West Virginia Children’s Health Insurance Program

1. West Virginia Children’s Health Insurance Program (WVCHIP) Jennifer J. Myers, Benefit and Enrollment Manager Fall 2016 Provider Workshop

2. Annual Income Guidelines for WVCHIP

3. Coverage

4. PERM Audit Payment Error Rate Measurement (PERM): Measures improper payments in Medicaid and CHIP and produces error rates for each program • The current PERM cycle is reviewing Medicaid and CHIP FFS payments made by states October 1, 2015–September 30, 2016. • Requests for provider medical records associated with the sampled FFS claims began in May/June 2016 and will continue through July 2017. • Providers will have 75 calendar days from the date of the request letter to submit the record to CNI. • CNI will conduct reminder phone calls and send written requests to providers if records are not received. If the records are not received within 75 days, an error is assessed for lack of documentation.

5. PERM Audit (cont) In the 2013 FY PERM audit our two largest errors were: • No Documentation and Insufficient Documentation • Provider Enrollment guidelines not established/followed CMS PERM Website: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicaid-and-CHIP-Compliance/PERM

6. Medical Home • Eligible Medical Home Provider Types are General Practice, Family Practice, Internal Medicine, and Pediatricians. Any PA or NPs practicing under these specialtiesis 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.

7. 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. Provisional enrollment ended June 30, 2016. Any provider not fully enrolled in the WVCHIP Plan was terminated effective 9/26/16 and claims are no longer paid. If you would like to enroll in WVCHIP contact Molina at 1-888-483-0793, or 304-348-3360or online at www.wvmmis.com.

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 after by calling the provider enrollment department at Molina. • WVCHIP uses the Public Employees Insurance Agency’s fee schedules.Go to www.peia.wv.govto see PEIA fees. • Dental fees can be found at: http://www.dhhr.wv.gov/bms/FEES/Pages/default.aspx • You may also send an inquiry to WVCHIPProvider@Outlook.com.

9. 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 2 Hale Street, Suite 101 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

10. Updates WVCHIP is removing the PA requirement for frenulectomy (D7960) and will reprocess claims retro to 1/1/16. September resolved claims issues/reprocessing include: • APC • Vision • Missing codes • Well-care copays corrected

11. ABA Updates Applied Behavior Analysis Treatment for Autism Spectrum Disorder children: Revised Policy 2.0 WVCHIP/WVPEIA ABA billing and payment policy effective 7/1/16 is located at the WVCHIP website at www.chip.wv.gov. • Clarification of required qualifying diagnostic assessments for service initiation and continuing services. • Expectation of BCBA/BCaBA professional standards as identified by the National Certifying Body. • Updated combination coding limitations. • Interpretation of treatment plan expectations which should be data-driven and include baseline of behaviors, goals, objectives, strategies, activities and progress reviews.

12. Upcoming Claim Resolutions FQHC/RHC payments APC explanation at the line detail Medical Home copays Pre-determination letters for Orthodontic claims will be mailed in addition to posting on the Provider Portal Prior Authorizations: • All PA numbers should begin with CH0 (the number zero) • All PA numbers should be entered in box number 25 of the HCFA • If PA is not required, leave box 25 blank; please do not enter any information as your claim will deny

13. 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: HealthSmartat 1-800-356-2392 Prescription drug benefits: CVS at 1-800-241-3260 Provider enrollment: Molina at 1-888-483-0793

14. Contact Jennifer J. Myers HHR Program Manager WVCHIP 2 Hale Street Charleston, WV 25301 Phone: 304-957-7864 Fax: 304-558-2741 Email: Jennifer.J.Myers@wv.gov Follow DHHR on Facebook and Twitter for WVCHIP related announcements and information.