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Bureau for Medical Services & Molina Medicaid SolutionsProvider Workshops

June 2011

Agenda

Welcome and Introductions

Healthcare Reform

Provider Incentive Program

5010 Electronic Transactions

Provider Enrollment & Screening

Provider Re-Enrollment

Policy & Program Updates

Managed Care Updates

BMS Website

General Billing Information

Innovative Resource Group (APS)

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BMS/Molina 2011 Provider Workshops

Healthcare Reform

What is Healthcare Reform?

Key areas of Reform

Purpose of PPACA (Patient Protection and Affordable Care Act)

PPACA and the States

PPACA provisions for Medicaid

PPACA funding opportunities


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What is Health Care Reform

This presentation provides a high-level overview of the purpose,

provisions, and related funding of the Patient Protection and Affordable

Care Act (PPACA, Act), as well as an overview of how the Act will

affect the West Virginia Department of Health and Human Resources

(DHHR) and Bureau for Medical Services (BMS).

The Act is also referred to as the Affordable Care Act (ACA).

The Obama Administration has stated that the intent of the Act is to “put

individuals, families, and small business owners in control of their

healthcare.”


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Key Areas of Reform

Much of the PPACA must be resolved through regulations. Many of the

provisions became effective upon enactment, and requirements of the

Act continue through 2019. Most of the reform activities will occur

between 2010 and 2014.

> Health Insurance Reform

> Employers offering health insurance to employees

> Public Programs including Medicaid, the Children’s Health

Insurance Program (CHIP), Medicare, and Public Health

> Healthcare workforce training

> Elimination of fraud, waste, and abuse in healthcare

> Improving the quality of healthcare


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The Purpose of PPACA

PPACA starts to change the way healthcare is delivered. PPACA deals in

great part with insurance reform. Among those reforms:

> Holding insurance companies accountable to keep premiums

affordable and prevent denials of care and coverage, including for

preexisting conditions

> Making health insurance affordable for middle class families and

small businesses with tax credits for health care, and reducing

premiums and out-of-pocket expenses.

PPACA creates powerful incentives so that more healthcare providers

can begin to deliver the kind of coordinated, patient-centered care that

has been shown to get best results.


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PPACA and the States

The critical role of State government is in managing and financing the

Medicaid and CHIP Programs. The PPACA creates new requirements for

expanded coverage and accountability mandates for those programs.

States must also create, manage, and regulate new insurance exchanges

for both individual residents and businesses.

The extensive new regulations for the health insurance plans must be

enforced by the States as well.


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PPACA Provisions for Medicaid

Continues Medicaid coverage to any individual who has been in foster

care under the age of 26.

Develops a core set of health care quality measures for Medicaid-eligible

adults.

Eliminates fraud, abuse and waste in the system which may require

outside vendor procurement and outside contracting meeting the federal

requirements.

Provides new options to States to provide Medicaid long-term care

services and support.


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PPACA Funding Opportunities

The Medical Home State Options offers states enhanced match of 90

percent FMAP (Federal Medical Assistance Program) for two years and

small planning grants may be available to promote the use of medical

homes for enrollees with chronic conditions. West Virginia has been a

leader in developing the medical home concept.

WV has applied and received a planning grant for this opportunity.

Health Homes for Members with Chronic Conditions.

WV has applied and received a Money Follows the Person grant.


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Provider Incentive Program (PIP)

The Electronic Health Records (EHR) Provider Incentive Program (PIP)

is a federal program offering financial support to assist eligible providers

to adopt, implement, or upgrade certified EHR technology.

The Medicaid EHR Incentive Program will provide incentive payments

to eligible professionals, eligible hospitals, and critical access hospitals

(CAHs) as they adopt, implement, upgrade, or demonstrate meaningful

use of certified EHR technology in their first year of participation and

demonstrate meaningful use for up to five remaining participation years.

Incentives will be available through both Medicaid and Medicare.

> Eligible healthcare professionals will be required to choose between

Medicaid and Medicare.

> Those in border counties should choose the state from which they

will receive the incentive payments. Hospitals may be able to

receive incentive funds from both programs.

> The Bureau for Medical Services (BMS) will administer the

Medicaid EHR Incentive Program for West Virginia.

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Providers eligible for payment are:

> Physicians, Dentists, Pediatricians, Nurse Midwives, Nurse

Practitioners, Physician Assistants who practice in a Federally

Qualified Health Center (FQHC), Critical Access Hospitals, Acute

Care Hospitals

Estimated Go-Live date is July 2011

Payments will be made through the claims processing system

Link for provider attestation will be available through Molina’s

webportal

> www.WVMMIS.com

Payment information will be reflected through provider’s remittance

advice

Questions related to PIP will be handled through Provider Relations

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http://www.wvmmis.com/


Key dates from Centers for Medicare and Medicaid Services (CMS):

> January 2011 - Medicaid providers can register with the Federal

National Level Repository (NLR).

> July 2011 - Attestations from Medicaid providers can be submitted

through state MMIS portal.

> Late July 2011 - WV State payments to Medicaid providers are

expected to start.

> September 30, 2011- Last day of the federal fiscal year. Reporting

year ends for eligible hospitals and CAHs.

> October 1, 2011 - Last day for eligible professionals to begin their

90-day reporting period for calendar year 2011 for the Medicare and

Medicaid EHR Incentive Program.

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Key Dates continued:

> November 30, 2011-Last day for eligible hospitals and CAHs to

register with NLR and attest to receive an incentive payment for

federal fiscal year (FY) 2011.

> December 31, 2011- Reporting year ends for eligible professionals.

> February 29, 2012 -Last day for eligible professionals to register with

the NLR and attest to receive an incentive payment for calendar year

(CY) 2011.

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5010 and D.0 Electronic Transactions

CMS is monitoring the States’ compliance with the regulatory

requirement to convert from Health Insurance Portability and

Accountability Act (HIPAA) Accredited Standards Committee (ASC)

X12 version 4010A1 to ASC X12 version 5010 and National Council for

Prescription Drug Programs (NCPDP) version 5.1 to NCPDP version

D.0.

All covered entities are targeted to be fully compliant on January 1,

2012.

The new HIPAA 5010 electronic transaction standard will drive billing,

reimbursement, and many administrative functions, as well as

accommodate the larger ICD-10 code sets. Version 5010 has more than

2,500 generic and 1,000 unique changes ranging from field size increases

to entire new segments of data, resulting in considerably more data than

its predecessor 4010A.

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Readiness of provider community

Testing process

> Providers will need to test with outside vendor (Edifecs) before

testing with Molina

> If the provider submits through clearinghouse, the individual

provider is not required to test

Testing schedule

> Once the provider/clearinghouse is certified from outside vendor, the

provider /clearinghouse will be required to have three successful tests

before submitting 5010 transactions

Companion guides and comparison XML will be posted on the web

portal

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The following transactions will be affected by 5010:

> 837 I/P/D Inbound

> 276/277

> 270/271

> 835 Outbound

Direct Data Entry (DDE) into the web portal will not be affected by

5010. All screens will remain the same.

Batch uploads via the web portal will need to be submitted in the new

5010 standard.

All real-time pharmacy transactions will be impacted by the new D.0

standard.

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General Policy Updates

National Correct Coding Initiative

New funding opportunities

> Money Follows The Person

> Health Homes for Members with Chronic Conditions

Revised BMS chapter changes

Assistant-at-Surgery

> Must be billed with appropriate modifier (-80) & operative report must reflect services

provided by assistant –at-surgery

Orthopedic update

> Effective 6/1/2011, CPT code 64455 (Nerve Block Injection, Plantar Digit) may now

be billed by physicians that have the specialty of Orthopedics.

Certified Nurse Midwife

> May bill for vaginal delivery in a hospital when facility has approved these services

via credentialing & delineation of services

Radiology services – CTs, MRIs or PET Scans in office setting

> Effective 1/1/2012, CMS requires accreditation by American College of Radiology,

Intersocietal Accreditation Commission or Joint Commission

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General Policy Updates (Target Effective Date 9/1/2011)

Anesthesia

> All anesthesia codes, except for 01996 must be billed with a modifier.

> Anesthesiologists must bill AA, AD, QK, QS or QY modifier; CRNAs must bill with

QS, QX or QZ.

> Anesthesia service with time units of 40+ requires paper claim and documentation

(anesthesia and operative reports)

• Reminder 1 time unit = 15 minutes

Mastectomy or related, covered, reconstructive procedures will not

require prior authorization (PA) with diagnosis of breast cancer

Occupational Therapy

> CPT Codes 97003 & 97004 will be restricted to Revenue code 0434

Physical Therapy

> CPT codes 97001 & 97002 will be restricted to Revenue code 0424

Speech Therapy

> CPT codes 92506, 92507 and 92508 must be billed by the speech therapist on a CMS

1500 or 837P

> If employed by hospital or CAH, pay-to must be facility


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Managed Care Updates

Effective July 1, 2011, when a Managed Care (MCO) member switches

to fee for service (FFS) while inpatient, the MCO will be responsible

until discharge

You may contact Brandy Pierce at 304-558-1700 for questions related to

this change


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Diabetes Education Program Collaborative effort - Medicaid and Bureau for Public Health’s WV

Diabetes Prevention and Control Program

Web-based training program – access thru BMS (www.dhhr.wv.gov/bms) or

CAMC website (www.camcinstitute.org/education)

Based on American Diabetes Association’s Clinical Practice

Recommendations

Primary Care Providers and other health care professionals

> 2 courses

• Initial certification

• Recertification required every 2 years

Must complete/maintain certification to be reimbursed for providing

diabetes education sessions under program

> HCPCS codes for billing• Code S0315 - initial assessment & initiation of self management training session

• Code G0108 – 30 minute (individual) diabetes education session

• Code G0109 – 30 minute (group of 2 or more patients) diabetes education session

> Limited number of sessions per patient per year


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http://www.dhhr.wv.gov/bms

http://www.camcinstitute.org/education

Provider Enrollment

Provider enrollment application

> Current application with supplemental pages

> New paper application

> User Manual

Ownership Information

> Owners, managing employees, and agents

> Must provide information for each individual with 5% or more

ownership interest

> Must provide information for owners who are related to each other

> Must provide information if ownership is present in other

organizations that bill Medicaid

> Ownership information must be completed in its entirety


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Provider Enrollment

Application fee $505.00 for 2011

> Required for institutional providers

• ICF-MR, Hospitals, PRTFs

> Application fee waived if paid to Medicare or another State’s

Medicaid program or CHIP

> CMS has the authority to change the fee yearly

Hardship Exception Request

> Form must be requested from Molina

> Form and supportive documentation must be submitted with

enrollment application

> Request for hardship exception is sent to CMS by Medicaid

> CMS makes decision and notifies Medicaid

> Enrollment application on hold until CMS decision received

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Provider Screening

Risk Levels

> Apply to all providers

> Based on risk of fraud, waste or abuse

Database Checks

> Federal Office of Inspector General’s List of Excluded Individuals &

Entities (LEIE)

> General Services Administrations Excluded Parties List System

(EPLS)

> State Medicaid Exclusion Lists

> State Licensing Boards

Criminal background check

Fingerprinting

Site visits

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Risk Levels by Provider Types

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Each provider type has been designated as limited, moderate, or high risk

by CMS

> Limited - Physicians or non-physician practitioners and medical

groups or clinics

> Moderate - Community mental health centers, comprehensive

outpatient rehabilitation facilities, hospice organizations, independent

diagnostic testing facilities, independent clinical laboratories,

non-public, non-government owned or affiliated ambulance service

suppliers, and currently enrolled home health agencies and DMEPOS

suppliers

> High - Prospective (newly enrolling) home health agencies and

suppliers of DMEPOS

At State’s discretion, the risk level may change.

Provider Enrollment

Site visits are required for providers in moderate and high risk levels

> States are required to conduct pre-enrollment (unannounced) and

post enrollment (announced) site visits.

> Molina staff will conduct both visits.

> Failure to permit access for site visits would be a basis for denial or

termination of Medicaid enrollment.

> Site visits are waived if conducted by Medicare or another State’s

Medicaid program or CHIP.

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Provider Re-Enrollment

Provider enrollment and screening requirements and need for additional

information from providers

> Medicaid providers will need to be re-enrolled

Scheduled to begin in Fall of 2011

> Phased-in approach by provider type/risk level

> Schedule will be placed on the web portal and banner pages

> Providers will be notified by mail

Provider Re-Enrollment will be electronic through web portal

> Providers will receive letter with access code to re-enroll

> Providers will have 30 days to complete re-enrollment or provider

will be placed on pay hold

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New BMS Website

BMS has created a new website that provides new navigation features

> www.dhhr.wv.gov/bms

Providers and members may subscribe to feeds related to the changes

within Medicaid

Updated Provider Manual

MediWeb Portal

Mountain Health Choices

State Medicaid Plans

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BMS Website


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Helpful Websites

Bureau for Medical Services

> www.dhhr.wv.gov/bms

Molina Medicaid Solutions

> www.wvmmis.com

Centers for Medicare and Medicaid Services

> www.cms.gov


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http://www.wvmmis.com/

http://www.cms.gov/

Timely Filing

Claims must be received within one year from the date of service

If Medicare is primary, claims must be received within one year from the

Medicare paid date

> One additional year with proof of timely filing

Corrected claims with reversal-replacement form can be submitted within

two years from the date of service

Claims over two years old will not be processed without a back dated

medical card

Original claims and corrected claims with reversal-replacement form that

are over one year are to be sent to:

> Molina Provider Relations, PO Box 2002, Charleston, WV 25327

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Common Errors Resulting in Denied Claims

Rendering provider not approved for services billed

Missing/incomplete/invalid HCPCS code

> Validate code is keyed correctly

> Validate code is current for date of service

Missing/incomplete/invalid NDC code

> For resolution refer to the drug code/NDC information on the BMS

website, www.dhhr.wv.gov/bms

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Common Errors Resulting in Denied Claims (continued)

Primary payer information not provided with claim

> Paper & Electronic Claims

Charges are covered under capitation agreement or managed care plan

> For members who have a PAAS provider, PAAS approval is

required on the claim

> View member’s card to verify MCO or PAAS

> Utilize AVRS to verify MCO or PAAS

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Errors Resulting In Returned Claims

Member ID not 11 digits

NPI and Tax ID not in the appropriate fields

Missing Diagnosis Codes

Missing Dates of Service

Missing Place of Service

Print is not legible and data is not aligned within applicable blocks on the

claim form

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Molina’s Provider Relations Representatives

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