Long Term Care Updates: Attention Long Term Care Providers Effective dates of service 3/1/12, coding was implemented to deny LTC claims when the resource amounts billed from the providers do not match the resource amounts housed within the claims processing system. It was brought to our attention that there may be some confusion as to which documentation LTC providers should use when determining the resource amounts to bill. In light of this issue, the coding has reverted back to the WARN message when there is a resource mismatch, instead of DENY. If you have received a denial on a March 2012 LTC claim based upon the resource mismatch, please resubmit that claim on Monday, April 16, 2012. Once the issue has been resolved and communicated to the stakeholders, the coding to DENY the resource mismatches will resume. Please continue to watch the web portal for updated communication regarding this issue.
Attention: It has come to our attention that nursing homes are either placing their Medicare ID provider number in the A0100C block of the MDS 3.0 or leaving the item blank. A0100C is for the State Provider Number (Medicaid 10 digit provider ID number) and is not optional per the WV Medicaid guidelines. It must be included on each MDS assessment, or we will be unable to pick up the MDS assessment and load nursing home authorizations into the claims processing system.
Regarding Nursing Home Authorizations Created from MDS Assessments The information within the document linked below regard to MDS assessments for authorizations and provide example issue to solution scenarios.
Document link provided below:Provider Information Regarding Nursing Home Authorizations Created from MDS Assessments
Provider Alert: Arthrodesis Codes Added Effective 9/1/11 CPT codes 22551 and 22552, arthrodesis procedures, are covered procedures for orthopedic surgeons as well as neurosurgeons.
Optometrist Reimbursement for CPT Code 66982 Effective 9/1/11, Optometrists can be reimbursed for providing post-operative care for a surgeon that performed extracapsular cataract removal, 66982, by appending modifier 55. Denied claims are to be reprocessed.
CPT Codes 11400 - 11406 Now Covered For Podiatrists CPT codes 11400-11406 are covered to podiatrists for procedures of the ankle effective 4/1/12. These procedures require prior authorization in an ASC or outpatient hospital setting.
Specialty Restrictions Removed from Skin Substitute Grafting BMS has removed specialty restrictions on 2012 CPT codes 15271 – 15278, skin substitute grafting, and they may be performed by all MDs, DOs and DPMs effective 1/1/12.
Changes to Drug Screening Services Reimbursement Effective with dates of service May 1, 2012, WV Medicaid will no longer reimburse drug screen service codes 80100, 80101 or 80104. Drug screening services will be reported using service codes G0431 (Drug Screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter) or G0434 (Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter).
G0431 and G0434 are reimbursed at a maximum of one unit of service per day. Any intent to screen members at a frequency exceeding that requirement will require prior authorization. Prior authorization may be obtained at the Utilization Management Contractors’ website (wvmi.org or apshealthcare.com).
Please note: All drug screening must be medically necessary and ordered by a physician.
Attention Anesthesia Providers It is BMS’ policy that anesthesia time MUST be billed in units of 15 minute time increments, NOT in minutes. Beginning May 1, 2012 electronic claims with MJ qualifier indicating minutes will be rejected to the submitter. This includes claims crossed over from Medicare so Medicare primary claims must be submitted by the provider electronically or on paper and must be billed in units. See the Practitioner Services Manual concerning rounding units to whole integers. Also note that anesthesia modifiers AA, AD, QK, QX, QY or QZ must be billed and QS must be billed when appropriate.
Expanded Coverage for Implantable/Wearable Cardiac Device Evaluation BMS has expanded coverage to Cardiac and Thoracic surgeons for Implantable and Wearable Cardiac Device Evaluation procedure codes 93279, 93280, 93281, 93282, 93283, 93284, 93288, 93293, 93294, 93295, 93296 previously covered to cardiologists, pediatric cardiologist and internal medicine specialties. If you have any issues with these Evaluation codes, call Provider Relations.
Policy Revision for CPT 55706 Policy revision for CPT 55706 – Biopsies, prostrate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance. As of 1/1/12 the procedure requires prior authorization and may be performed by radiation oncologists as well as urologists. As of 4/1/12 the procedure is restricted to specific diagnosis codes.
Fluoride Treatment Coverage Effective 1/16/12, WV Medicaid will cover fluoride treatment provided by certain eligible medical practitioners for high risk children under 3 years of age. See Attachment 18 of Chapter 519, the Practitioner Services manual on the BMS website for coverage policy.
Click on the link below to access the BMS web page.
www.dhhr.wv.gov/bms
Coverage Expanded for Cardiology Procedure Codes Coverage has been expanded for cardiology procedure codes 37224 - 37235 to allow Thoracic and Cardiac surgeons in addition to General and Vascular surgeons effective 1/1/11. Denied claims will be reprocessed.
Service Limits Applied Procedure codes 76942, 77002, 77003, 77012 and 77021 will have a service limit of one per day effective 3/1/12. Payment consideration over the service limit requires Prior Authorization from WVMI.
Sanctioned/Excluded Providers Pursuant to Section 1128 and Section 1902(a)(39) of the Social Security Act, the West Virginia Medicaid Program will not reimburse a provider for any services or items that were rendered or ordered/prescribed by a sanctioned (e.g., suspended, excluded) provider. The effect of the provider's sanction precludes them from furnishing, ordering, or prescribing services or items to a Medicaid member. Claims for services/items rendered/ordered/prescribed by a sanctioned provider with dates of service or dispensing after the effective date of the sanction, will be rejected or disallowed if discovered during a post-payment review.
In accordance with the Patient Protection and Affordable Care Act (Pub. L. 111-148, enacted on March 23, 2010, as revised by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152), enacted on March 30, 2010, together known as the Affordable Care Act (ACA), the West Virginia Medicaid Program is required to terminate enrollment of any provider that is excluded under Medicare or any other state Medicaid Agency. Excluded individuals and entities prohibited from participating in the West Virginia Medicaid Program are identified in the following list. Excluded individuals and entities are listed according to the type of provider they were at the time of exclusion; however, they are excluded from participating in providing services in the Medicaid program in all categories of services and in any capacity. The exclusion remains in effect until they are removed from this list.
Any provider participating or applying to participate in the West Virginia Medicaid program must search this list and the Federal Office of Inspector General's List of Excluded Individuals and Entities (LEIE) at http://oig.hhs.gov/fraud/exclusions.asp on an annual basis to determine if any existing employee, contractor, owner or board member has been excluded from participation in the Medicaid program. Also, any provider participating or applying to participate in the West Virginia Medicaid program must search both lists prior to hiring staff to ensure that any potential employees, contractors, owners or board members have not been excluded from participating in the Medicaid program.
Document link provided below:Sanctioned/Excluded Provider List
A Tip When Billing Secondary Claims When mailing your paper secondary claims to Molina you need to have an EOB/EOMB with each claim. Molina's mailroom is getting mail packs where the EOBs are separated from the claims so the mail room has been trying to match them up. We are also receiving multiple claims for one member with only one EOB/EOMB attached causing the mailroom staff to make copies to add to the other claims. In order for your claims to process more efficiently, please attach the EOB/EOMB with each claim. In the future, when large volumes of claims are submitted in this manner the claims will be returned unprocessed to the provider for correction.
Facilitating Payment for Sterilization and Hysterectomy Procedures In order to facilitate payment for these procedures, please attach the "Transmittal Letter" to all Consent to Sterilization forms, Hysterectomy Acknowledgement forms, and Hysterectomy Certification forms.
` Web Portal Updates: Member Validation: 5010 Transactions As part of the new 5010 HIPAA transactions and effective May 1st, 2012, ALL Submitted claims will be matched on the Member’s Medicaid ID and Date Of Birth as part of the Claim EDI validation. Claims will be rejected if the Member Medicaid ID and Date of Birth do not match what is in the Molina System.
WVMMIS Now Supports 5010 Transactions Effective 1/1/12, the Health PAS Online portal will support 5010 transactions for production processing. In order to submit 5010 transactions, successful testing is required for completion. Trading partners are required to submit a minimum of three files containing a minimum of fifteen transactions per file. All three files must pass validation. Please submit with the ISA15 set to “T” to avoid a corresponding TA1 rejection. The 5010 testing website, www.wvmmis5010.com, is no longer active. The correct website to test 5010 transactions is www.wvmmis.com.
Providers who currently only use direct data entry (DDE) into the web portal are not required to test.
Please contact Molina's EDI Helpdesk at 1-888-483-0793 option 6 or edihelpdesk@molinathealthcare.com for questions and to schedule your testing.
While 5010 compliance is legislatively mandated effective January 1, 2012, both the West Virginia Bureau for Medical Services and CMS are sensitive to the needs of the West Virginia provider community. At this time, Molina, the Bureau’s fiscal agent, will have the capability to accept both 4010 and 5010 HIPAA compliant submissions. You will be given advance notification when the 4010 format will no longer be accepted for West Virginia Medicaid.
5010 Electronic Submission Readiness West Virginia Medicaid along with the fiscal agent Molina Medicaid Solutions, is working on implementation activities to transition from the Health Insurance Portability and Accountability Act (HIPAA) Accredited Standards Committee (ASC) X12 Version 4010A1 to ASC X12 Version 5010. In order to determine web portal electronic submitter’s readiness, we are requesting all WV electronic submitter’s complete a 5010 Survey form. Please print and complete this form. Once completed, email the completed form to edihelpdesk@molinahealthcare.com, or fax to (304) 348-3380.
Document link provided below:5010 Molina Survey Molina 5010 (X12) 270 Companion Guide Molina 5010 (X12) 276 Companion GuideMolina 5010 (X12) 837 Companion Guide
Absent Diagnosis Codes Results In Rejection All transactions submitted without proper diagnosis codes will result in 824 rejection reports.
Pharmacy: Point of Sale NCPDP 5.1 and D.0 Acceptance While NCPDP D.0 compliance for the processing of pharmacy claims is legislatively mandated effective January 1, 2012, both the West Virginia Bureau for Medical Services and CMS are sensitive to the needs of the West Virginia provider community. At this time, Molina, the Bureau’s fiscal agent, will have the capability to accept both NCPDP 5.1 and D.0 HIPAA compliant submissions. You will be given advance notification where when the NCPCP 5.1 format will no longer be accepted for West Virginia Medicaid.
Provider Enrollment Updates: Change of Ownership Policy Effective June 1, 2008 A change of ownership requires that all parties involved shall collaborate to ensure that services are billed and paid to the correct owner using the correct provider number. The new provider must obtain an enrollment number to participate in the West Virginia Medicaid Program. The effective date of the new owner's enrollment is determined when the enrollment application is approved by Molina. Providers are required to submit a complete and accurate enrollment packet 10 days prior to the change of ownership date and inform Molina of the exact change of ownership to ensure a seamless transition. Services rendered prior to the effective date will not be payable through Medicaid.
Federally qualified health centers (FQHC), rural health centers (RHC), home health providers, hospice, independent diagnostic testing facilities (IDTF), renal centers, ambulatory surgical centers, and critical access hospitals (CAH) are the only exceptions to this policy. These provider types will have their enrollment date correspond with their Medicare approval letter.
Revised License Maintenance Policy Health care providers, who, under the State Plan and/or State statute are required to be licensed in West Virginia (WV) or the state in which they practice, must maintain and ensure that a current license is on file at all times with West Virginia Bureau for Medical Services (BMS) Provider Enrollment Unit, Molina. A provider's participation in the WV Medicaid Program may be terminated if Molina cannot verify the current status of a provider's license.
Document link provided below:License Lapse Policy
WV Medicaid EHR Incentive Payment: West Medicaid is now ready for registered Medicaid Providers to complete their EHR Incentive Attestations Effective July 4th, 2011, providers eligible for the Provider Incentive Program (PIP) may register with the National Level Repository (NLR). Providers will be notified when attestation can occur with WV Medicaid.
Providers are required to have an active web portal account with a user name and password on file with Molina prior to attesting for their incentive payment. In orderto obtain your user name and password, you must first complete a Trading Partner Agreement (TPA) and an EDI Transaction form. Mail these forms to Molina Medicaid Solutions, Attn: EDI Helpdesk, P.O. Box 625, Charleston, WV 25322-0625. You can obtain detailed instructions for obtaining web portal access at: Molina Web Portal Account Instructions. If you need further assistance on obtaining a web portal account, you may contact our EDI Helpdesk at 1-888-483-0793, option 6.
For those providers who have already registered with CMS' National Level Repository (NRL) for incentive payment, the transition from the CMS NLR Incentive Registration to the WV Medicaid EHR Incentive solution can take 48 hours. You will be notified by the email you provided to the CMS NRL Incentive Registration when we receive and process this information. At that time, providers may proceed with their attestations by logging into the web portal at https://www.wvmmis.com/layout_login.jsp and look for the WV EHR Incentive solution on the left hand panel of the screen.
If you believe you are an eligible provider under the ARRA regulations and you are not registered yet with the CMS NLR system, click here to receive the CMS Incentive Users Guide for Professionals, or CMS Incentive Users Guide for Hospitals. Use these guides to start your Registration CMS Incentive Registration System (https://ehrincentives.cms.gov/hitech/login.action).
WV EHR Incentive Solution Provider Training Materials West Virginia has created user manuals and companion worksheets for providers to utilize while they are using the system to complete their attestation. The workbooks have detailed instructions to the provider on what data they need to pull prior to attesting and how to complete their attestation online.
Overview - West Virginia EHR Provider Incentive Program The Electronic Health Records (EHR) Provider Incentive Payment (PIP) is a federal program offering financial support to assist eligible providers to adopt (acquire and install), implement (train staff, deploy tools, exchange data), or upgrade (expand functionality or interoperability) certified EHR technology.
The program goals are to improve outcomes, facilitate access, simplify care, and reduce costs of health care nationwide by:
Enhancing care coordination and patient safety
Reducing paperwork and improving efficiencies
Facilitating information sharing across providers, payers, and state lines
Enabling communication of health information to authorized users through state Health Information Exchange (HIE) and the National Health Information Network (NHIN).
WV Provider Newsletter 2nd Quarter 2011: Exclusively Published to the Web Portal The 2nd quarter 2011 Molina WV Provider Newsletter is now available and published exclusively to the portal. The bulletin contains WV Medicaid general billing tips, policy updates, and other important information/announcements.
Document link provided below:Molina 2nd Quarter 2011 WV Medicaid Provider Newsletter
Friendly Reminders: Call Center Information Hours: 8:00 am - 5:00 pm (EST)
Pharmacy: 1-888-483-0801
Provider Services: 1-888-483-0793
Medicaid Members: 1-888-483-0797
Provider Services Options:
Login Session Inactivity Expiration Reminder Please keep in mind that extended inactivity during a login session will result in the session to expire. All DDE (Direct Data Entry) data not submitted will be lost with the expiration.
Email Information Request for Molina For EDI Agreements, TPAs, or electronic billing questions:
edihelpdesk@molinahealthcare.com
Charging for Duplicate RA Requests Effective July 1, 2006, Molina will be charging $10.00 per remit for duplicate remit requests for paper copies. Paper remits that are less than 25 pages will be mailed. Paper remits that are over 25 pages will be placed on a CD ROM and mailed to the provider. Providers will not be charged for the first 90 days after the original remit has been mailed.
WV Medicaid Training Center Updates: Molina WV Medicaid Providers Online Training Molina will be implemented a web-based e-learning system referred to as the West Virginia Medicaid Training Center. This training center will be available 24 hours a day, 7 days a week to all WV Medicaid Providers. The WV Medicaid Training Center will assist with claims processing information as well as offer various training sessions that can benefit providers participating in the WV Medicaid Program. Molina will be providing notices as to when this training center will be online.
Useful Links: WV Casemix Workbook for MDS 3.0
Step-By-Step procedures for manually determining a resident's case-mix class using the MDS 3.0 assessment.
Registration
