Department of Medical Assistance Services

1. Department of Medical Assistance Services Medicaid 101 www.dmas.virginia.gov

2. This presentation is to facilitate training of the subject matter in Virginia Medicaid Hospital Manual. • This training contains only highlights of the manual and is not meant to substitute for or take the place of the manual. • Providers are responsible for reviewing and adhering to all Medicaid manual requirements. 2

3. Agenda 1. DMAS Website 2. Excluded Individuals/Entities 3. Medicaid Eligibility Verification Options 4. Medicaid Programs and Benefit Packages 5. UB-04 Billing Guidelines

4. DMAS Websitewww.dmas.virginia.gov • Current, most up-to-date information on Virginia Medicaid programs • Provider memos available for review • Access to Medicaid manuals • 50 Common Error Reason Codes with Resolutions • Numeric Insurance Code List • Primary Carrier Coverage Code List

5. DMAS Websitewww.dmas.virginia.gov • Financial Reason Code Description List • Hospital DRG Rates • Medicaid Forms • 2010 Medicaid/FAMIS-PLUS Handbook

7. Excluded Individual/Entities • No payment can be made for any items or services ordered or prescribed by an excluded physician when the furnishing party either knew or should have known of the exclusion • Medicaid providers may be subject overpayment liability and civil monetary penalties when they do not abide by this Federal Regulation

8. Excluded Individual/Entities • This ban includes payment for administrative and management services not directly related to patient care • Providers are required to identify excluded individuals and entities • This ensures that DMAS is not paying any excluded individuals or entities for services rendered

9. How to Ensure Program Integrity • Screen all employees and contractors to determine whether they have been excluded • Search HS-OIG List of Excluded Individuals/Entities (LEIE) website monthly • Immediately report to DMAS any exclusion information discovered

10. Reporting • Discoveries are to be sent in writing to the address below and should include the: • individual or business name • provider identification number • State action, if any, has been taken DMAS Attn: Program Integrity/Exclusions 600 E. Broad St. Ste 1300 Richmond, VA 23219

11. Accessing the LEIE • HHS-OIG maintains the LEIE • Provides information about parties excluded from participation in Medicare, Medicaid and all other Federal healthcare programs • The online database is located at http://www.oig.hhs.gov/fraud/exclusions.asp

12. As A Participating ProviderYou Must- • Determine the patient’s identity. • Verify the patient’s age. • Verify the patient’s eligibility. • Accept, as payment in full, the amount paid by Virginia Medicaid. • Bill any and all other third-party carriers.

13. COMMONWEALTH OF VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES 002286 999999999999 VIRGINIA J. RECIPIENT DOB: 05/09/1964F CARD# 00001

14. Medicaid Verification Options • MediCall • Medicaid Web Portal

15. MediCall/Medicaid Web Portal Information Available • Medicaid member eligibility/benefit verification • Service limit information • Claim status • Service authorization • Provider check log • Primary Payer Information • Medallion Participation • Managed Care Organization Assignment

16. Copay Indicators • Code A • Under 21- No copay exists • Code B • Long Term Care, Home or Community Based Waiver Services, Hospice-No copay • Code C • All other members – collect any/all applicable copays

17. Copay Exemptions • Members in managed care may not have copays • Pregnancy related/family planning services • Emergency services

18. Copay Amounts Inpatient hospital $100.00 per admission Outpatient hospital clinic $3.00 per visit Clinic visit $1.00 per visit Physician office visit $1.00 per visit Other physician visit $3.00 per visit 18

19. General Exclusion • Payment cannot be made under the Medicaid Program for certain items and services, and Virginia Medicaid will not reimburse providers for these non-covered services. • Medicaid members have been advised that they may be responsible for payment to providers for non-covered services.

20. General Exclusion - Directive • Prior to the provision of service, the provider must advise the Medicaid member that he or she may be billed for a non-covered service. • A directive signed by the patient, meets Virginia Medicaid’s requirement of patient notification of financial responsibility for non-covered services.

21. MediCall • 800-884-9730 • 800-772-9996 • 804-965-9732 • 804-965-9733

22. Medicaid Web Portal • Web-based eligibility verification option • Free of Charge. • Information received in “real time”. • Secure • Fully HIPAA compliant

23. Changes- • A new enhanced web portal will allow providers to transact all Medicaid business via one central location. • The web portal will provide access to: • Member Eligibility Status • Payment History • Remittance Advices • Service Authorization

24. Registration Process • First Time Users • Go to www.virginiamedicaid.dmas.virginia.gov • Establish an user ID and password • By registering you are acknowledging yourself as a staff member with administrative rights for the organization • Established Users- Delegated Administrators • will receive a letter containing their NPI and instructions on accessing the Web Portal • must access the Web Portal and change their temporary password no later than June 27, 2010 • will be able to add new users beginning June 28, 2010. 24

25. ACS Web Registration Support Call Center • Questions regarding new user registration, existing user access letter, or temporary password • 1-866-352-0496 • Available after June 8, 2010 • 8 am – 5 pm Monday thru Friday • No holidays

26. Key Dates and Times • May 26th • New registration to FHS/UAC discontinued • Through June 27th • Current FHS/UAC users can continue to request password resets, routine maintenance, or access information as normal • June 27th • Access to ARS via FHS/UAC will be discontinued

27. Key Dates and Times • June 28th • new registration and users can be added via the new Virginia Medicaid Web Portal • access to eligibility and claims information will be available in the new Virginia Medicaid Web Portal at 7:01 am www.virgniniamedicaid.dmas.virginia.gov

28. Provider Call Center Claims, covered services, billing inquiries: 800-552-8627 804-786-6273 8:30am – 4:30pm (Monday-Friday) 11:00am – 4:30pm (Wednesday)

29. Provider Enrollment NPI enrollment, EFT sign-up, update facility contact and email, change of address or phone number: Provider Enrollment Unit P. O. Box 26803 Richmond, VA 23261 888-829-5373 804-270-5105 804-270-7027 - Fax

30. Medicaid Programs/Benefit Packages

31. Medicaid Fee-for-Service No Primary Care Physician (PCP) No mandatory referral from the PCP. Medallion Primary Care Physician who directs all care. PCP referral required for all non-emergency services. Medicaid Programs

32. Medicaid Programs • FAMIS • Medicaid program for children under age 19 • First 30 days coverage provided under the FAMIS fee-for-service program • Mandatory Managed Care Organization assignment (where available) after the initial 30 days of coverage

33. Medicaid Programs • FAMIS MOMS • For pregnant women with incomes above the Medicaid income guidelines • Managed Care Organization assignment rules same as FAMIS • Apply thru local Department of Social Services or Central Processing Unit • Baby is not covered until application submitted and approved

34. Medallion II MCO ID Cards • Issued by the Managed Care Organizations • Medicaid member will have both MCO and Medicaid cards • Eligibility verification is a REQUIREMENT • Each verification option will give the MCO enrollment information if applicable

35. Medallion II MCO ID Cards • The Anthem card for Medicaid members indicates Anthem Health Keepers Plus (PLUS identifies the Medicaid plan). • The Optima Card for Medicaid members indicates Optima Family Care (FAMILY CARE identifies the Medicaid plan). • Virginia Premier - anyone presenting a VA Premier Card is a Medicaid client.

36. Medallion II MCO ID Cards • CareNetidentifies the Southern Health Services card for Medicaid members. • AMERIGROUP of Virginia is for Medicaid members.

37. Virginia Medicaid MCO Contacts 37

38. Member Choice - MCO Selection(Areas Where MCO is Available) • Member will be enrolled in Medicaid fee-for-service plan for the first 30 days. • Member will then have 90 days to select an MCO plan. • During the 90 day period, a member can select a new MCO for the upcoming month as long as the request is received by the 15th of the current month. • At the end of the 90 day period, the member will be enrolled in the chosen MCO until the next open enrollment period.

39. Managed Care Helpline 1-800-643-2273 TDD# 1-800-817-6608 Monday – Friday 8:30 a.m. – 6:00 p.m. (Translation Services Available)

40. Client Medical Management- CMM • Mandatory Primary Care Physician (PCP) and Pharmacist who directs all care • Responsibilities: • coordinating routine medical care • making referrals to specialists as necessary • arrange 24 hour coverage when not available • explain to members all procedures to follow when office is closed or there is an urgent or emergency situation

41. Client Medical Management - CMM • Services received by a CMM member not provided by the PCP will be reimbursed only: • in a medical emergency/delay in treatment may cause death, lasting injury or harm • on written referral from PCP using the Practitioner Referral Form (DMAS-70), includes covering physicians • covered services excluded from CMM program requirements • If not a medical emergency or no referral form is attached, hospital emergency room CMM claims will be denied, not paid at a reduced rate • CMM patient can be billed for these non-emergency services 41

42. Aliens • Section 1903v of the Social Security Act requires Medicaid to cover emergency services for specified aliens when the services are provided in an emergency room or inpatient hospital setting. • Hospital outpatient follow-up visits or physician office visits are not included in the covered services.

43. Aliens • Emergency medical treatment only • Eligibility requests should be sent to the local DSS • Emergency Medical Certification form required for claim submission

44. Aliens Covered services must meet emergency treatment criteria and are limited to : • Emergency room care • Physician services • Inpatient hospitalization not to exceed limits established for other Medicaid recipients • Ambulance service to the emergency room • Inpatient and outpatient pharmacy services related to the emergency treatment

45. Early Periodic Screening Diagnosis and Treatment - EPSDT • The EPSDT Program is Medicaid’s comprehensive and preventative child health program for individuals under the age of 21. • Federal law requires a broad range of outreach, coordination, and health services under EPSDT distinct from general state Medicaid requirements. • The goal of EPSDT is to identify and treat health problems as early as possible. • EPSDT provides examination and treatment at no cost to the individual.

46. Early Periodic Screening Diagnosis and Treatment - EPSDT • For individuals under age 21, EPSDT must include the services listed below- • Screening services, which encompass all of the following services: • Comprehensive health and developmental history • Comprehensive unclothed physical exam • Appropriate immunizations according to age and health history • Laboratory tests (including blood lead screening) • Health education

47. Qualified Medicare Beneficiaries- QMB • Eligible only for Medicaid payment of Medicare premiums, deductibles, coinsurance and Medicare Advantage Plan copays. • Medicaid will consider the Medicare deductibles, coinsurance and copays for benefits. • If Medicare does not cover the service, the service cannot be billed to Medicaid.

48. Qualified Medicare Beneficiaries- QMB Extended • This group is eligible for Medicaid coverage of premiums, deductibles, coinsurance and Medicare Advantage Plans copays, plus all other Medicaid-covered services. • Medicaid will consider the Medicare deductibles, coinsurance and copays for benefits. • Members are also eligible for all Medicaid covered services.

49. Medicare Advantage Plans • VA Medicaid handles and processes Medicare Advantage Plans the same way as traditional Medicare. • DMAS does not process the Medicare Advantage Plans as Third Party Liability (TPL) • Advantage Plan deductible, copay or coinsurance amounts submitted, will be considered by VA Medicaid for payment

50. Special Low-Income Beneficiaries- SLMB • This group is only eligible for Medicaid coverage of the Medicare Part B premium only. • The member will have a Medicaid number, but will not received a Medicaid card. • Medicaid will not cover any medical services for this member.