WVCHIP Program Guidelines and Provider Updates - Spring 2018

1. West Virginia Children’s Health Insurance Program (WVCHIP) Crystal Fox, Benefit and Eligibility Specialist Spring 2018 Provider Workshop

2. Monthly Income Guidelines for WVCHIP

3. Coverage 2

4. PERM Audit Payment Error Rate Measurement (PERM) measures improper payments in Medicaid and CHIP and produces error rates for each program. Of the error cited, the following are considered provider errors: • No Documentation (records not received): 15 • Incorrect documents received, or missing: 5 • Incorrect date of service billed: 4 Our goal for the next review is zero errors! The next PERM cycle will review WVCHIP payments made July 1, 2018 – June 30, 2019.

5. Medical Home • Eligible Medical Home provider types are General Practice, Family Practice, Internal Medicine, and Pediatricians. Any Physician Assistant (PA) or Nurse Practitioner (NP) practicing under these specialties is considered a “back-up” Medical Home provider and will not be assessed a copay when the supervising physician is the named Medical Home provider. • Please note: the physician group/facility must also select to be a Medical Home provider along with the rendering provider. • To become a Medical Home provider, please contact Molina Provider Enrollment at 1-888-483-0793. • Encourage your patients to enroll in the Medical Home program; WVCHIP will waive the copay for sick visits and increase your reimbursement by the copay amount! • WVCHIP should not be confused with the Public Employees Insurance Agency (PEIA) who increased their Medical Home copays effective July 1, 2017.

6. Provider Enrollment • The Affordable Care Act requires all providers to enroll or revalidate their enrollment information under new enrollment screening criteria. Enrollment and revalidation is mandatory for both Medicaid and WVCHIP providers. Enrollment in Medicaid does not fully enroll the provider in WVCHIP. • Provisional enrollment has ended. If you are not fully enrolled, you will no longer be eligible to receive payment from WVCHIP. To enroll in WVCHIP, contact Molina at 1-888-483-0793, or 304-348-3360, or online at www.wvmmis.com.

7. Provider Enrollment (cont.) • WVCHIP does not enroll Health Departments as rendering providers. We enroll the individual provider under their own specialty. • Example: Dr. Smith, Pediatrician, provides services at Mingo County Health Department. WVCHIP will enroll Dr. Smith, with a pay-to for Kanawha Health Department. • When enrolling, make sure documentation is sent for each specialty if there are multiple specialties. The contract assigned to the provider’s file will be determined by all of their specialties.

8. Out-of-State Providers • WVCHIP will waive the out-of-state prior authorization requirement if the provider agrees to accept WVCHIP in-state fees as payment in full with no balance billing to the member. • This agreement can be made during provider enrollment or any time thereafter by calling the provider enrollment department at Molina. • WVCHIP uses the PEIA fee schedules (medical).  Go to www.peia.wv.gov to see PEIA fees. • Dental fees can be found at: http://www.dhhr.wv.gov/bms/FEES/Pages/default.aspx

9. Dental Services • The 2017 Dental Provider Guide is available for review at www.chip.wv.gov. This guide contains a complete list of codes covered by WVCHIP, billing and Prior Authorization guidelines, service limits, as well as copay information for CHIP Premium Dental services. If you do not see a code listed in the guide, the code is not covered. • Crowns do not require Prior Authorization with WVCHIP. Codes D2390, D2751, D2791, and D2930-D2933 are covered by WVCHIP and do not require review prior to payment. • Frenulectomies, D7960, do not require Prior Authorization with WVCHIP effective January 1, 2016.

10. Orthodontic Treatment Comprehensive orthodontic treatment is payable once per lifetime. • Coverage is not automatic and must be prior authorized to be covered. Information should be mailed to: WVCHIP – Orthodontic PA Request 350 Capitol Street, Room 251 Charleston, WV 25301 Information required for review: • Panoramic film • Cephalometric x-ray • A standard series of 5 Intra and 3 Extra Oral photographs that meet the American Board of Orthodontic standards • Treatment plan including findings, prognosis, length of treatment, and phases of treatment

11. Procedures Requiring Prior Authorization Abortion Nonemergency ambulance transport and hospital-to-hospital transport All inpatient admissions to hospitals/facilities (in-state and out-of-state) All admissions to rehabilitation or skilled nursing facilities Any potentially experimental/investigational procedure, medical device, or treatment Applied Behavioral Analysis treatment Chelation therapy Chiropractic services for children under age 16 Continuous glucose monitors Cosmetic/reconstructive surgery as a result of accident or birth defects CT scan of sinuses or brain - outpatient CTA (CT angiography) - outpatient Dental ridge reconstruction DEXA scans (dual energy x-ray absorptiometry) Dialysis services - outpatient

12. Procedures Requiring Prior Authorization (cont.) Durable medical equipment purchases of $1,000 or more, or rental more than 3 months Endoscopic treatment of Gastro-esophageal Reflux Disease (GERD) Hearing aids Heart Perfusion Imaging Home health care: exceeding 12 skilled nursing visits Hospice care IMRT (intensity modulated radiation therapy) - outpatient Hyperbaric Oxygen Therapy (HBOT) IV therapy in the home MRI scan of the breast, knee or spine (cervical, thoracic, and lumbar) Orthotics/prosthetics over $1,000 Oral surgeries including orthognathic surgery Outpatient therapy services including occupation, physical, speech, and vision therapy beyond 20 visits PET Scans Sleep apnea services and equipment

13. Procedures Requiring Prior Authorization (cont.) SPECT (single photon emission computed tomography) of brain and lung Stereotactic Radiation Surgery and Stereotactic Radiation Therapy All inpatient surgical procedures Outpatient surgeries as listed below: • cataract • cochlear implants • colonoscopy • hysterectomy • implantable devices including, but not limited to: implantable pumps, spinal cord stimulators, neuromuscular stimulators, and bone growth stimulators • knee arthroscopy • septoplasty or submucous resection • spinal surgery including artificial disc, laminectomy, and/or fusion • uvulopalatopharyngoplasty

14. Procedures Requiring Prior Authorization (cont.) Transplants and transplant evaluations (including, but not limited to: kidney, liver, heart, lung and pancreas, small bowel, and bone marrow replacement or stem cell transfer after high dose chemotherapy) (TTE) Transthoracic Echocardiogram Submit Prior Authorization Requests to: • HealthSmart PO Box 2451 Charleston, WV 25329-2451 1-800-356-2392 www.healthsmart.com

15. Helpful Reminders When submitting a claim that does not require or have Prior Authorization, please do not put anything in the Prior Authorization box; this will cause the claim to be rejected. Claims must be filed within 6 months for both dental and medical services. Claims not submitted within this time period will not be paid, and WVCHIP will not be responsible for payment. Appeals must be initiated within 60 days of receiving a denial of service. Initiate the appeal process of services by contacting Molina at 1-800-479-3310. Initiate the appeal process of Prior Authorizations by contacting HealthSmart at 1-800-356-2392.

16. Resources Eligibility, application status, renewals and general information: WVCHIP HelpLine at 1-877-982-2447 Claims, benefits, and eligibility: Molina at 1-800-479-3310 Prior Authorizations: HealthSmart at 1-800-356-2392 Prescription drug benefits: CVS at 1-800-241-3260 Prescription drug Prior Authorization: RDTP 1-800-847-3859 Provider enrollment: Molina at 1-888-483-0793

17. Contact Crystal Fox Benefits and Eligibility Specialist WVCHIP West Virginia Department of Health and Human Resources 350 Capitol Street, Room 251 Charleston, WV 25301 Phone: 304-957-7862 Fax: 304-558-2741 Email: Crystal.D.Fox@wv.gov Follow DHHR on Facebook and Twitter for WVCHIP related announcements and information.