PROVIDERNewsletter

PROVIDER SATISFACTION SURVEYWellCare Health Plans continues to focus efforts on the experiences of both our members and providers. In order to better understand and remain well informed about our valued provider network, we conducted the Provider Satisfaction Survey again in 2013. The survey concentrated on a variety of subjects including call center/member services, provider relations, continuity/coordination of care, provider network, utilization and quality management, finance issues, pharmacy and drug benefits, and overall satisfaction and loyalty.

As in 2012, extensive reviews of our 2013 survey results are under way to ensure that our focus is aligned with the needs of our providers. Current areas of focus include enhancing provider services at the local level, claim processing and issue resolution, enriching administrative tools/capabilities, and continued emphasis on quality. The organization is continuously engaged with several cross-functional teams working on these initiatives, and others that are aimed at better serving our providers. We anticipate incremental gains on several initiatives in 2014 and continued improvement beyond. Stay tuned as these efforts will be further communicated as the year progresses.

Shortly, WellCare will again conduct a Provider Satisfaction Survey. This follow-up survey will be used to measure progress from last year’s effort to better evaluate how we can become more effective and productive business partners.

Your participation is encouraged and appreciated, as together we strive to positively impact our members’ overall quality of care.

NEW YORK | 2014 | ISSUE I

PROVIDER RESOURCES

WEB RESOURCESVisit www.wellcare.com (Medicare) or newyork.wellcare.com (Medicaid) to access our Preventive and Clinical Practice Guidelines, Clinical Coverage Guidelines, Pharmacy Guidelines, key forms and other helpful resources. Providers may also request hard copies of any of the above documents by contacting their Provider Relations representative. For additional information, please reference your Quick Reference Guide at www.wellcare.com/provider/quickreferenceguides.

PROVIDER NEWSRemember to check messages regularly to receive new and updated information. Visit the secure area of www.wellcare.com (Medicare) or newyork.wellcare.com (Medicaid) to find copies of the latest correspondence. Access the secure portal using the “Member/Provider Secure Sign-In” area on the right. You will see Messages from WellCare located in the right-hand column.

ADDITIONAL CRITERIA AVAILABLEPlease remember that all Clinical Coverage Guidelines, detailing medical necessity criteria for several medical procedures, devices and tests, are available on our website at www.wellcare.com/provider/ccgs.

AVAILABILITY OF REVIEW CRITERIAThe determination of medical necessity review criteria and guidelines are available to the providers upon request. Providers may request a copy of the criteria used for specific determination of medical necessity by calling Provider Services at the number listed on your state-specific Quick Reference Guide at www.wellcare.com/provider/quickreferenceguides.

Also, please remember that all Clinical Coverage Guidelines, detailing medical necessity criteria for several medical procedures, devices and tests, are available via the provider resources link at www.wellcare.com/provider/ccgs.

ACCESS TO UTILIZATION MANAGEMENT STAFFThe Utilization Management section of your Provider Manual contains detailed information related to the utilization management program. Your patient, our member, can request materials in a different format including other languages, large print and audio tapes. There is no charge for this service.

If you have questions about the utilization management program, please call Provider Services at the number listed on your state-specific Quick Reference Guide located at www.wellcare.com/provider/quickreferenceguides.

CLINICAL PRACTICE GUIDELINESClinical Practice Guidelines are best practice recommendations based on available clinical outcomes and scientific evidence. WellCare Clinical Practice Guidelines reference evidence-based standards to ensure that the guidelines contain the highest level of research and scientific content. Clinical Practice Guidelines are also used to guide efforts to improve the quality of care in our membership. The Clinical Practice Guidelines listed below are available on the WellCare Provider Resources website www.wellcare.com/provider/cpgs.

GENERAL CLINICAL PRACTICE GUIDELINES• Asthma• Cholesterol Management• Chronic Heart Failure• Chronic Kidney Disease• COPD• Coronary Artery Disease• Diabetes in Adults• Diabetes in Children• HIV Antiretroviral Treatment in Adults• HIV Screening• Hypertension• Imaging for Low Back Pain• Lead Exposure• Obesity in Adults• Obesity in Children• Osteoporosis• Pharyngitis

• Rheumatoid Arthritis

PREVENTIVE HEALTH GUIDELINES• Adult Preventive Health• Post-Partum Guidelines• Preconception and Interpregnancy• Pregnancy

• Preventive Health Pediatric

BEHAVIORAL HEALTH CPGs• ADHD• Depressive Disorders in Adults• Depressive Disorders in Children• Schizophrenia• Substance Use Disorders• Suicidal Behaviors

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MEDICARE

MEDICARE RISK ADJUSTMENT (MRA) PAYMENT SYSTEMS (RAPS): FAQS WHAT IS RISK ADJUSTMENT?Risk adjustment is a payment methodology developed by CMS that adjusts payments to Medicare Advantage (MA) plans, based on the health status of their enrollees. Risk adjustment is prospective, meaning ICD-9-CM diagnosis codes from the previous year and demographic information are used to predict future costs.

HOW DOES RISK ADJUSTMENT WORK?A risk-adjusted score is calculated for each beneficiary, based on a combination of their demographic data (i.e., age, gender, original reason for entitlement, Medicaid status, etc.) and their disease data (i.e., ICD-9-CM diagnosis codes).

WHAT ARE THE RESPONSIBILITIES OF PHYSICIANS AND PROVIDERS?Physicians must report ICD-9-CM diagnosis codes to the highest level of specificity and report these codes accurately according to the official ICD-9-CM coding guidelines. This requires accurate and complete medical record documentation.

Clinical specificity involves having a diagnosis fully documented in the source medical record instead of routinely defaulting to a general term for the diagnosis.

• Diabetes mellitus (DM) coding. Code 250.00 for Type II DM without mention of complication. However, if there is a manifestation/complication, use the appropriate fourth digit to identify the manifestation/complication, and fifth digit to identify the type of DM and whether the diabetes is controlled or uncontrolled. For example, code 250.42 for uncontrolled Type II DM with Stage I Chronic Kidney disease.

Physicians should code all documented conditions that co-exist at the time of the encounter/visit, and require or affect patient care, treatment or management.

• Co-existing conditions include chronic ongoing conditions such as DM, congestive heart failure, atrial fibrillation, or chronic obstructive pulmonary disease. Co-existing conditions also include ongoing conditions such as multiple sclerosis, hemiplegia or rheumatoid arthritis.

Health status situations described by “V” codes are common in physician documentation and should be reported. Examples include HIV status, transplant status, artificial opening status or maintenance, dialysis status or encounter, and amputation status.

WHEN IS THE FINAL CMS SUBMISSION?The final CMS submission deadline to submit diagnosis data for 2012 DOS is January 31, 2014.

Please feel free to email us at raps@wellcare.com should you have any questions regarding risk adjustment, coding or documentation.

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NEW PAPER PROFESSIONAL 1500 CLAIM SUBMISSION REQUIREMENTSOn June 16, 2013, the National Uniform Claim Committee (NUCC) published an updated version of the 1500 manual (v. 1.1) providing new billing guidelines. (Form OMB- 0938-1197)

NUCC announced the approval of the updated 1500 Claim Form that accommodates reporting needs for ICD-10 and aligns with requirements in the Accredited Standards Committee X12 (ASC X12) Health Care Claim Professional 837P Electronic Data Interchange (EDI) Version 5010 Technical reporting requirements.

The new guidelines detail various Strategic National Implementation Process (SNIP) edits which WellCare had not previously enforced for paper claims. As of November 1, 2013, WellCare began adhering to the newly published billing guidelines.

RESOURCE DOCUMENTSThe following links provide information about the revisions made to the CMS-1500 Claim Form:

1. Change log showing all changes between 8/05 version and 2/12 version of the CMS-1500:

• www.nucc.org/images/stories/PDF/1500_claim_form_change_log_2012_02.pdf2. User manual for the CMS-1500 Claim Form:

• www.nucc.org/images/stories/PDF/1500_claim_form_instruction_manual_2012_02.pdf

3. Mapping between CMS-1500 Claim Form to 837P transaction:

• www.nucc.org/images/stories/PDF/1500_claim_form_map_to_837P_2012_02.pdf

The new CMS-1500 Claim Forms can be ordered via File RX at the following link: www.filerx.com/catalog/category.aspx?c=24.

CLAIMS/ENCOUNTERS TO BE REJECTED TO PROVIDERSPaper claims submitters must adhere to the National Uniform Claim Committee (NUCC) and National Uniform Billing Committee (NUBC) standards. Additional guidance can also be found in the June 2013 Ingenix – Uniform Billing Editor.

WellCare will only accept typed original red and white forms (no black & white copies, faxes, hand-written claims). For more specific details on WellCare claims submission policies, please visit your state-specific WellCare website at www.wellcare.com/provider/claimsupdates (Medicare) or newyork.wellcare.com/provider/claims_updates (Medicaid).

It is important that you comply with these submission requirements in order for your claims/encounters to be processed in a timely manner and to avoid rejections.

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ICD-10 UPDATEOn January 16, 2009, the Department of Health & Human Services (HHS) published a rule adopting ICD-10 CM and ICD-10 PCS to replace ICD-9 CM for everyone covered by the Health Insurance Portability and Accountability Act (HIPAA) with an effective implementation date of October 1, 2013. On September 5, 2012, HHS published a final rule adopting a revised effective implementation date of October 1, 2014.

Per the Centers for Medicare & Medicaid Services (CMS), the transition is necessary due to the fact that current ICD-9 codes contain outdated terminology, lack clinical detail, and due to current structure and formatting, many categories have reached their code limitations. These deficiencies greatly affect the industry’s ability to analyze data and trend information such as health care utilization, performance measurements and population disease patterns. ICD-10 allows for greater specificity and detail in describing a patient’s diagnosis and in classifying inpatient

procedures, so reimbursement can better reflect the intensity of the patient’s conditions and diagnostic.

WellCare will be compliant with the CMS rule for ICD-10 readiness beginning October 1, 2014. The WellCare strategy for ICD-10 compliance is to configure systems and business processes to accept ICD-10 codes. General Equivalency Maps (GEMs) will be used along with WellCare custom clinical and coding mappings to address gaps in GEMs when transitioning to ICD-10. WellCare recommends health care providers look for specific ICD-10 training offered by societies and professional organizations, and to utilize the CMS website as a resource for ICD-10-related materials and guidance during this transition period.

Please refer to the www.wellcare.com/provider/resources/icd_general website for more information or contact your market representative with questions regarding the transition to ICD-10.

MAJOR CHANGE SUMMARY• New form provider information for box 17, 17a and 17b

– Box 17 – Referring, Ordering or Supervising provider’s name (First Name, Middle Initial, Last Name) and credentials of the provider. Place the two-digit qualifier to the left of the name.

◊ DN – Referring Provider

◊ DK – Ordering Provider

◊ DQ – Supervising Provider

– Box 17a – Other ID (not the NPI) of the Referring, Ordering or Supervising provider with the corresponding NUCC defined qualifier

◊ 0B – State License Number

◊ 1G – Provider UPIN Number

◊ G2 – Provider Commercial Number

– Box 17b – Referring, Ordering or Supervising provider’s National Provider Identifier (NPI)

• Additional Diagnosis Codes

– It is imperative that billers complete Box 21 with the value “9” or “0” to indicate whether you are sending ICD-9 or ICD-10 diagnosis codes. The revised form also allows for additional diagnosis codes, expanding from 4 possible codes to 12

WELLCARE TIMELINESBeginning January 6, 2014, through March 31, 2014, WellCare will allow the use of both the 08/05 version and 02/12 version of the CMS-1500 Claim Form when submitted on typed original (red and white) forms.

Beginning April 1, 2014, WellCare will only accept typed original (red and white) CMS-1500 Claim Forms on the 02/12 version.

For questions regarding this requirement, please email EDI-Master@wellcare.com.

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MEDICARE

HIGH-RISK MEDICATIONS: 2014 UPDATESThe Centers for Medicare & Medicaid Services (CMS) evaluates health plans alongside several core quality and performance measures. One such measure is the high-risk medications (HRM) measure, which calculates the percentage of Medicare Part D enrollees who turn 65 years or older in a plan year who received two or more fills of the same HRM.

KEY CHANGES FOR 2014:• Prior authorizations for high-risk medications will affect members who are 64 years and older.

• For non-benzodiazepine hypnotics (zolpidem, zaleplon, eszopiclone), the preferred agent is trazodone.

• Hydroxyzine, amitriptyline, Premarin and digoxin (at doses greater than 0.125 mcg/day) will now require a prior authorization.

2014 Q1 PROVIDER FORMULARY UPDATEMEDICAIDUpdates have been made to the WellCare of New York Preferred Drug List. Please visit newyork.wellcare.com/provider/pharmacy to view the current preferred drug list and pharmacy updates.

Please refer to your Provider Manual available at newyork.wellcare.com/provider/resources to view more information regarding WellCare’s pharmacy utilization management policy and procedures.

MEDICARE:Updates have been made to the Medicare Formulary. The most up-to-date complete formulary can be found at www.wellcare.com/medicare/medication_guide.

Please refer to your Provider Manual available at www.wellcare.com/provider/providermanuals to view more information regarding WellCare’s pharmacy utilization management policy and procedures.

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MEDICAID

DEVELOPMENTAL SCREENING AND THE NEW YORK STATE EARLY INTERVENTION PROGRAM (EIP)Infants and toddlers from birth through age 2, who have been diagnosed with physical or mental conditions that could result in a developmental delay or, who are suspected of having a developmental delay or disability, are entitled to a developmental screening or a comprehensive evaluation to determine eligibility for additional early intervention services.

To refer pediatric patients for a screening or for more information about early intervention services, call the Growing Up Healthy 24-hour hotline at 1-800-522-5006 or 311 in New York City.

Sources:

www.nyc.gov/html/doh/pregnancy/html/home/index.shtml www.health.ny.gov/community/infants_children/early_intervention

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MEDICAID

LEAD SCREENING Any level of lead in the blood poses a hazard.

At each routine well-child visit, or at least annually if a child has not had routine well-child visits, providers should assess each child who is at least 6 months old, but under 6 years of age, for high-dose lead exposure using a risk assessment tool.

Each child found to be at risk for high dose lead exposure shall be screened or referred for lead screening. Providers should provide or make reasonable efforts to ensure the provision of follow-up testing for each child with an elevated blood lead level in accordance with currently accepted medical standards and public health guidelines.

Provide the parent or guardian of each child less than 6 years of age anticipatory guidance on lead poisoning prevention as part of routine care and reasonable efforts to ensure the provision of risk reduction education and nutritional counseling for each child with an elevated blood lead level.

Results of blood lead analysis performed in a health care practitioner’s office must be reported to the Commissioner of Health and to the local health officer in whose jurisdiction the subject of the test resides.

Source: New York State Department of Health; www.medpagetoday.com

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MEDICAID

PRIMARY CARE RATE INCREASE The Affordable Care Act established a Medicaid Primary Care Rate Increase (PCRI) for specific primary care services furnished by certain qualified primary care providers. The increase will result in payment of primary care services at the Medicare rate to qualified Medicaid providers from January 1, 2013 through, December 31, 2014.

QUALIFIED PROVIDERSThe qualified providers defined as eligible to receive payment under the PCRI are:

1. Physicians holding board certification from the American Board of Medical Specialties, the American Board of Physician Specialties or the American Osteopathic Association in pediatrics, internal medicine and family medicine and associated subspecialties, or

2. Physicians who have furnished primary care services that equal at least 60 percent the Medicaid codes paid during the most recently completed calendar year, or for newly eligible providers, the prior month, or

3. Nurse Practitioners and Nurse Midwives practicing under the professional oversight and supervision of a qualified physician (#1 or #2 above).

The PCRI is applicable to procedure codes:

• Evaluation and Management (99201-99499)

• Vaccine Administration (90460, 90471, 90472, 90473 & 90474) – that are covered by Medicaid fee-for-service or managed care plans and paid to qualified physicians.

Two tracks or options for qualified physicians to verify:

• Board certified in a designated specialty or subspecialty or

• 60 percent paid Medicaid claims history for the designated primary care procedure codes

Eligibility for Advanced Practice Clinicians (APCs – Nurse Practitioners and Nurse Midwives)

• Supervising physician must qualify and attest to their eligibility and name the supervised APCs.

• Physician must accept professional responsibility and legal liability for the APC, providing personal supervision for the primary care services provided by the APC.

• The APC submits claims with their NPI.

WellCare has submitted a payment methodology to the Department of Health outlining how we intend to reimburse qualified providers.

• For non-capitated providers, WellCare will run an external query that would compare the Medicaid allowable for Q1, 2013 that we paid to the 2009 and 2013 Medicare Schedule. If the Medicaid allowable is greater than the 2009 and 2013 Medicare Schedule, WellCare would not pay an enhanced rate. If it is lesser, WellCare will pay the greater of the two schedules.

• For capitated providers, WellCare will pull all capitated encounters for all services (not just those that qualify for enhanced payment), and effectively reprice those encounters to 100 percent Medicare. Next, we would determine what percentage of the repriced amount is for qualifying services, and compare this to capitation amounts for PCP and specialty cap for the same time period. We then would apply the percentage we determined to be the repriced amount was out of the qualifying services, to the cap amounts and determine if payment should be issued.

Please contact our Provider Services Department with changes to your office’s schedule of patient-care hours and/or new providers affiliated with your practice.

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MEDICARE

PART B DEDUCTIBLEIn 2014, WellCare will be implementing a Part B Deductible, similar to Original Medicare, in the amount of $147 for its Special Needs Plans. The deductible only applies to a limited number of Part B services which are outlined below. This change will be transparent to the member, but it will impact how providers bill, as either WellCare or the state will be responsible for this amount. If the state is responsible and a member has not met their deductible for the year, WellCare will deny the claim or pay the applicable amount and send an explanation of payment (EOP) to you noting that the member has not yet met their deductible. Providers should send the EOP and a claim to the State Medicaid agency for payment. It is important to note that you must have a Medicaid number in most states in order to receive payment. If WellCare is responsible for this deductible on behalf of the member and state, you will receive payment for amounts after the deductible is satisfied.

Services that apply to the D-SNP Part B Deductible include:

• Ambulance Services

• Ambulatory Surgical Center (ASC) Services

• Cardiac Rehabilitation Services

• Chiropractic Services

• Diabetes Self-Management Training

• Diagnostic Radiological Services

• Durable Medical Equipment (DME)

• End-Stage Renal Disease

• Intensive Cardiac Rehabilitation Services

• Kidney Disease Education Services

• Mental Health Specialty Services

• Occupational Therapy Services

• Other Health Care Professional

• Outpatient Blood Services

• Outpatient Diagnostic Procedures/Tests/Lab Services

• Outpatient Hospital Services

• Outpatient Substance Abuse

• Outpatient X-Rays

• Partial Hospitalization

• Physical Therapy and Speech-Language Pathology Services

• Physician Specialist Services

• Podiatry Services

• Prosthetics/Medical Supplies

• Psychiatric Services

• Pulmonary Rehabilitation Services

• Therapeutic Radiological Services

If the provider or the member has proof that the member has met their deductible, we ask that you call Provider Services at the number listed on your state-specific Quick Reference Guide found at www.wellcare.com/provider/quickreferenceguides and provide best available evidence. Members may call Customer Service at the number listed on the back of their member ID card and provide best available evidence. If it is determined that the member did in fact meet their deductible, WellCare will re-process the claim and pay accordingly.

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MEDICAID

TOBACCO COUNSELING AT WELL-CHILD VISITS: OPPORTUNITIES FOR IMPROVEMENT Rates of tobacco counseling at well-child and illness visits for diagnoses directly affected by tobacco use and environmental tobacco smoke (ETS) are extremely low. Significant opportunities exist to improve counseling rates in primary care. Physicians who care for children have patients at vastly different stages of intellectual and social maturity. This offers unique opportunities to intervene at each stage and especially early on. Many physicians, however, are more likely to only ask older adolescents about their smoking status. They overlook opportunities to provide preventive advice to preadolescents who might benefit more from prevention messages because they are less likely to have started smoking.

National guidance includes some of the following recommendations:

• Include tobacco in all discussions of substances of abuse and risky behaviors. Discussion and anticipatory guidance about tobacco use should ideally begin by 5 years of age. Both parents and children should be counseled that it is not safe to “experiment” with tobacco, because nicotine is highly addictive and there is no safe way to use tobacco.

• Ask about and document tobacco use and second-hand smoke (SHS) exposure at all clinical encounters, including prenatal visits, nursery visits, and well- and sick-child visits, whether inpatient or outpatient. Responses should be prominently recorded in the patient’s record. You can find a Tobacco Dependence Treatment Record available at newyork.wellcare.com/provider/forms_and_documents.

• Code for tobacco use and SHS exposure and bill for treatment. Consider SHS exposure a risk factor when justifying immunizations, respiratory syncytial virus prophylaxis and other care. The additional time needed to counsel families about tobacco use should be documented and billed as the appropriate counseling.

• Clinicians in a pediatric setting should offer smoking cessation advice and interventions to parents to limit children’s exposure to SHS. Whenever possible, proactively enroll tobacco users in cessation programs, using the Refer-to-Quit fax form for the New York State Smokers’ Quitline located at www.nysmokefree.com/Fax/Refer-to-QuitReferralForm2-11.pdf.

Each day in the United States, more than 3,800 young people under age 18 smoke their first cigarette. More than 80 percent of adult smokers began smoking by age 18. Prevention is the key. If physicians provide messages about tobacco use that are appropriate to the patient’s age and developmental stage, the potential for broad public health impact is great.

Source: New York State Smokers’ Quitline; www.nysmokefree.com

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NY024669_PRO_NEW_ENG©WellCare 2013 NY_10_13 Internal Approved 12042013

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IN THIS ISSUE

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WellCare of New York, Inc.

Medicare: 1-800-278-5155 www.wellcare.com

Medicaid:1-800-288-5441newyork.wellcare.com

WellCare of New York, Inc.110 Fifth Ave., 3rd FloorNew York, NY 10011

• Provider Satisfaction Survey

• Provider Resources

• Access to Utilization Management Staff

• Availability of Review Criteria

• Clinical Practice Guidelines

• Medicare Risk Adjustment (MRA) Payment Systems (RAPS): FAQs

• New Paper Professional 1500 Claim Submission Requirements

• ICD-10 Update

• High Risk Medications: 2014 Updates

• 2014 Q1 Provider Formulary Update

• Developmental Screening and the New York State Early Intervention Program (EIP)

• Lead Screening

• Primary Care Rate Increase

• Part B Deductible

• Tobacco Counseling at Well-Child Visits: Opportunities for Improvement