Provider Workshops March 2012

1. Provider WorkshopsMarch 2012

2. Agenda • Welcome and Introductions • BMS Policy & Program Updates • National Correct Coding Initiative (NCCI) • Medicaid Programs • Health Homes • Take Me Home WV (Money Follows the Person) • Traumatic Brain Injury (TBI) Waiver Program • Program Integrity • Provider Enrollment & Screening • Risk Levels & Site Visits • Provider Re-Enrollment • Web-Based Provider Enrollment Application • Provider Application Demonstration BMS/Molina 2012 Provider Workshops

3. Agenda (continued) • 5010 Electronic Transactions & Updates • One NPI to Multiple WV Medicaid Provider IDs (One to Many) • WV Health Information Network (WVHIN) –Health Information Exchange and WVDirect • Health Information Technology (HIT) • APS Healthcare • Eligibility Verification of Prior Authorization (PA) Requests • Out-Of-Network Requests • Denials and Reconsiderations • Provider Registration with APS Healthcare • Provider Automated Capabilities • Automated Voice Response System • Web Portal Electronic Transactions • WV Medicaid Training Center BMS/Molina 2012 Provider Workshops

4. General Policy Updates • Updates to BMS Provider Manual Chapters • Proposed changes posted on BMS website • 30 Day Public Comment Period • Recent updates to Chapters for Partial Hospitalization Program, PRTF, Pharmacy, Hospice, Nursing Facility • Devices – pacemakers, implantable defibrillators, nerve stimulators • Policies for coverage; some devices require PA • OT, PT, Speech Therapy • If employed by hospital or CAH, facility may bill for therapist’s services; pay-to must be facility BMS/Molina 2012 Provider Workshops

5. General Policy Updates (continued) • Transperineal Stereotactic Template-Guided Saturation Prostate Biopsy • CPT code 55706 • Coverage limited to specific diagnoses • Requires Prior Authorization • CTs, MRIs or PET Scans in Office Setting • Effective 1/1/2012, CMS requires accreditation by American College of Radiology, Intersocietal Accreditation Commission or Joint Commission • Radiologic Guidance for Needle Placement by Different Modalities • Effective 03/01/12, WV Medicaid will allow one unit of service per day for CPT codes 76942, 77002, 77003, 77012 and 77021 regardless of the number of needle placements performed. BMS/Molina 2012 Provider Workshops

6. General Policy Updates continued • Fluoride Varnish – coverage for children at high risk of dental caries • Effective 01/16/12, for children age 6 months to 36 months • Primary care providers (physicians, APRNs, physician assistants) • Limited to 4 applications per year • 2 applications by dentist and 2 by medical professional • Must complete training through WVU School of Dentistry • Information about course at www.hsc.wvu.edu/sod/oral-health • Reminder: HRSA’s 340 B Program Participants • For WV Medicaid members provided drugs from 340B inventory, billing must be based on 340B-acquisition cost • Reminder: Documentation Retention • Required by WV Medicaid policy (Chapter 320) to retain all documentation supporting medical necessity for a period of not less than 5 years from date of service BMS/Molina 2012 Provider Workshops

7. Coding Updates • National Correct Coding Initiative (NCCI) • Mandated by the Affordable Care Act of 2010 to incorporate NCCI into Medicaid claims processing • All Medicaid NCCI edits with Molina system upgrade • Applies to CMS 1500 and outpatient hospital claims • Testing continues • Changes in claims processing • Column 1, Column 2 Code Pairs • Medically Unlikely Edits • For more information, go to http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/Medicaid-Nation-Correct-Coding-Initiative.html BMS/Molina 2012 Provider Workshops

8. Coding Updates • ICD 10 • Implementation delayed per Centers for Medicare and Medicaid Services • Modifiers • Assistant-at-Surgery • Must be billed with appropriate modifier (-80,-81,-82,-AS ) • Operative report must reflect services provided by assistant–at-surgery • Transportation • Must use modifiers to indicate origin and destination • Documentation must support codes billed • Functional or Bypass • Examples: Modifier -25or -59 • Documentation must support codes billed BMS/Molina 2012 Provider Workshops

9. Medicaid Programs – Health Homes • Health Homes for Members with Chronic Condition • Program is intended to improve the health of Medicaid members who may need a variety of services to address primary and acute care, behavioral health care, and long-term care services. • BMS has been working with stakeholders across the state • WV Health Improvement Institute to develop State Plan Amendment (SPA) • SPA has been reviewed by Substance Abuse and Mental Health Services Administration (SAMHSA) as required by CMS • Draft SPA at http://www.wvhealthimprovement.org/Portals/0/documents/GEN-001%20WV%20draft%20HH%20SPA%20Template%202-15.pdf • Next stakeholder call – April 12, 2012 • Register at WV Health Improvement Institute’s website www.wvhealthimprovement.org/ BMS/Molina 2012 Provider Workshops

10. Medicaid Programs – Health Homes (cont’d) • To be eligible, Medicaid member must have 2 conditions among those listed below: • Diabetes • Cardiovascular disease • Asthma/COPD • Alzheimer’s Disease • Serious Mental Illness • Schizophrenia spectrum disorder • Bipolar disorder • Major depression • Anxiety • Attention Deficit Hyperactive Disorder • Pervasive Developmental Disorder • Substance abuse • OR one condition listed above and one of the following risk factors: • BMI > 25 • Tobacco use • High utilization of ED & hospitalization • Living in foster care • Residence in a long term care facility BMS/Molina 2012 Provider Workshops

11. Medicaid Programs – Health Homes (continued) • Provider Infrastructure • Designated primary care physician or advanced practice nurse providers working with multidisciplinary teams in a variety of possible settings • primary care and solo medical practices • comprehensive community behavioral health centers with a primary care service base • providers who serve special populations • academic medical centers • other entities meeting established qualifications • Health Homes Team works together to Integrate Medical and Mental Health BMS/Molina 2012 Provider Workshops

12. Medicaid Programs – Health Homes (continued) • Six defined health home services • Comprehensive Care Management • Care Coordination • Health Promotion • Comprehensive Transitional Care • Individual and Family Support Services • Referral to Community and Social Support Services • Health Information Technology • Standards for Monitoring and Evaluation BMS/Molina 2012 Provider Workshops

13. Medicaid Programs – Take Me Home WV • Money Follows the Person Rebalancing Demonstration Project • Federal grant to enhance services and supports for Medicaid members who wish to receive services in a home-based or community setting • Will transition at least 600 individuals from institutional to community living over 5 year grant period • Builds on successful Transition Navigator Pilot Program initiated by WV Olmstead Office • Opportunity for improvement of home and community-based services through quality monitoring via consumer and stakeholder participation BMS/Molina 2012 Provider Workshops

14. Medicaid Programs - TBI Waiver Program • Traumatic Brain Injury (TBI) Waiver Program • Started February 1, 2012 • Available to assist individuals to return home following a TBI, rather than receiving nursing home care • Covered services include: • Case Management • Personal Attendant Services (direct care support and transportation) • Cognitive Rehabilitation Therapy (CRT) • Participant-Directed Goods and Services • Chapter 512 in BMS Provider Manual • APS Healthcare serves as the Administrative Services Organization BMS/Molina 2012 Provider Workshops

15. TBI Waiver Program (continued) • In order to be determined eligible for the TBI Waiver program, applicants must: • Be 22 years of age or older • Be a permanent resident of West Virginia • Have a TBI caused by an external force resulting in total or partial functional disability and/or psychosocial impairment • TBI cannot be degenerative or congenital in nature • Be approved as medically eligible for nursing home level of care • Score at a Level VII or below on the Rancho Los Amigos Levels of Cognitive Functioning Scale • Be inpatient in a licensed nursing facility, inpatient hospital or licensed rehabilitation facility to treat TBI at the time of application • Meet Medicaid Waiver financial eligibility requirements, as determined by DHHR or SSA, if they currently receive SSI • Choose to participate in the TBI Waiver Program as an alternative to nursing home care BMS/Molina 2012 Provider Workshops

16. Program Integrity • CMS visit in May 2012 • Recovery Audit Contractor (RAC) • Mandated by Affordable Care Act • Contract to be awarded by late summer 2012 • All claims and provider types open to review • Review methodology • Data abstraction • Desk review of medical records • On-site visits • RAC will communicate requests/findings to providers • Recovery by BMS • Appeal process via BMS • For more info: http://www.cms.gov/Recovery-Audit-Program/ • Reminder: Failure to submit medical records for Program Integrity review may result in payhold by BMS BMS/Molina 2012 Provider Workshops

17. Provider Enrollment & Screening • Provider enrollment and screening requirements mandated by ACA • Additional guidance released December 23, 2011 • Guidance pending on Criminal Background Check and Fingerprinting • BMS currently accepting paper enrollment application + supplemental pages • Updates to Supplemental Pages Required • Practice Location Information • All future enrollment will require copy of most recent Medicare approval letter • BMS now has access to information in Medicare’s Provider Enrollment System (PECOS) BMS/Molina 2012 Provider Workshops

18. Provider Enrollment & Screening (continued) • Application fee of $523.00for CY 2012 • Required for institutional providers • Application fee waived if paid to Medicare or another State’s Medicaid program or CHIP • Hardship Exception Request available • Form letter and supportive documentation must be submitted with enrollment application • Request for hardship exception is sent to CMS by Medicaid • CMS makes decision and notifies Medicaid • Enrollment application on hold until CMS decision received • Ordering/referring providers • Required to enroll BMS/Molina 2012 Provider Workshops

19. Provider Enrollment & Screening (continued) • Risk Levels • Apply to all providers • Based on risk of fraud, waste or abuse • Database Checks • OIG’s List of Excluded Individuals & Entities (LEIE) • GSA’s Excluded Parties List System (EPLS) • National Practitioner Data Bank (NPDB) • SSA Death Match File (SSA DMF) • State Medicaid Exclusion Lists & centralized MCSIS • State Licensing Boards • Provider enrollment site visits to begin soon • Unannounced • Failure to allow site visit is basis for denial of enrollment or disenrollment BMS/Molina 2012 Provider Workshops

20. Provider Re-enrollment • All WV Medicaid providers must be re-enrolled by 2015. • Phased-in approach by provider type/risk level. • Schedule will be placed on the web portal and banner pages. • Providers will receive general notice 60 days prior to re-enrollment start date. • Then 30 days prior to re-enrollment start date, providers will receive letter that includes re-enrollment access code . • Provider will have 30 days to complete re-enrollment or BMS may place provider on pay hold. • Re-enrollment for specific provider types will be limited to paper. BMS/Molina 2012 Provider Workshops

21. Web-Based Provider Enrollment Application (PEA) • Available in 2012 • Dependent on Molina system upgrades • Will accommodate newly enrolling and re-enrolling providers • Need provider volunteers for testing phase • Process for web-based re-enrollment • Phased-in approach by provider type/risk level • Schedule will be placed on the web portal and banner pages • Providers will receive general notice 60 days prior to re-enrollment start date • Then 30 days prior to re-enrollment start date, providers will receive letter that includes re-enrollment access code • Provider will have 30 days to complete re-enrollment or BMS may place provider on pay hold • Process for newly enrolling providers • Must contact Molina for information and access code level, if applicable BMS/Molina 2012 Provider Workshops

22. Online Application Demo BMS/Molina 2012 Provider Workshops

23. 5010 and D.0 Electronic Transactions • CMS’s regulatory requirements to convert from HIPAA (ASC) X12 version 4010A1 to ASC X12 version 5010 effective 1/1/2012. • The Centers for Medicare & Medicaid Services (CMS) extended the HIPAA 5010 deadline for • compliance – enforcement will begin • June 30, 2012. • The new HIPAA 5010 electronic transaction • standard will drive billing, reimbursement, • and many administrative functions, as well as accommodate the larger ICD-10 code sets. BMS/Molina 2012 Provider Workshops

24. 5010 and D.0 Electronic Transactions (cont’d.) • Molina became 5010 (Medical & Dental), and D.0 (Pharmacy) capable, and began accepting 5010 electronic transactions on 12/27/2011. • 837 I/P/D Claims Submissions Inbound • 276 (Inbound)/277 (Outbound) – Claim Status • 270 (Inbound)/271 (Outbound) – Member Eligibility • 835 Paid Claims Outbound/Upload File • DDE (Direct Data Entry) to the Web portal is not impacted. BMS/Molina 2012 Provider Workshops

25. 5010 and D.0 Electronic Transactions (cont’d) • 72% of WV Medicaid electronic claims submitters have been production certified to submit claims in the 5010 format. • Electronic Submitters are required to pass testing requirements to become production certified to submit 5010 electronic transactions. • 3 Successful test files of not less than 15 transactions per file. All transactions claims must pass! > WV Medicaid 5010 Companion Guides are available on Molina’s website at: www.wvmmis.com • Molina will be refreshing its claims payment system to expedite claims processing and response times in support of 5010 & ICD10 Federal Requirements. BMS/Molina 2012 Provider Workshops

26. One NPI to Multiple WV Medicaid Provider IDs • Referred to as ‘One to many’ provider records • This means one NPI to multiple Medicaid provider ID numbers. • Separate NPI number can be obtained by NPESS https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do. • CMS expects BMS/Molina to use NPI numbers on all transactions. Benefits • Eliminates the use of taxonomy. • Reduces delay of claims processing. • Facilitates electronic enrollment. BMS/Molina 2012 Provider Workshops

27. Automated Voice Response System (AVRS) Advantages to using AVRS: • Automated response • No long hold times – Save Your Time! • Can be used at your convenience: • Available 24 hrs per day 7 days per week Use AVRS for: • Member Eligibility • Payment Information • Claim Status Access to AVRS: 1-888-483-0793 Providers 1-888-483-0797 Members 1-888-483-0801 Pharmacy BMS/Molina 2012 Provider Workshops

28. How To Use AVRS • Voice response will prompt caller to press 1 to use NPI or 2 to use Medicaid Provider ID > Use Rendering NPI/ ID for claim status > Use Pay To NPI / ID for accounts payable It is important to choose the correct option to avoid being transferred or hold times. BMS/Molina 2012 Provider Workshops

29. Molina’s Web Portal - www.wvmmis.com Advantages of Having a Web Portal Account • Eliminate paper claim forms • Saves time and money • Updates and Important Billing Information • Bulletins and Forms • Molina’s contact information • User Guides • Access to submit all claims free of charge through DDE (Direct Data Entry) • Capability to Upload Multiple Claim(s) in 1 file (837 Transactions) • Receipt of Electronic Remit 835 transactions with ability to auto-post payments in provider systems (dependent on provider’s system capabilities) • Receipt of Electronic version of Paper Remittance Advices • Access to submit Member Eligibility Requests free of charge • Capability of uploading up to 99 members for eligibility verification in 1 file (270 Transactions) & receive electronic response in 1 file (271 Transactions) • Access to Provider’s Medicaid Training Center currently in development BMS/Molina 2012 Provider Workshops

30. Registering For Web Portal Account • Complete Trading Partner Agreement (TPA) with EDI Transaction form • TPA & EDI Transaction form is located on the Molina website, www.wvmmis.com. • Health PAS Online Registration After receipt of completed TPA forms, Molina’s EDI staff will contact you by email with a link to set up username and password through the Health PAS Online Registration. For assistance, contact EDI at 888-493-0793, Option 4. BMS/Molina 2012 Provider Workshops

31. Molina Web Portal Welcome Page BMS/Molina 2012 Provider Workshops

32. Web Portal Training & Provider Field Representatives Beth Roach Beth.Roach@molinahealthcare.com 304-348-3291 Carrie Blankenship Carrie.Blankenship@molinahealthcare.com 304-348-3292 BMS/Molina 2012 Provider Workshops

33. West Virginia Medicaid Training Center • The Provider Medicaid Training Center is currently under revision and development. • Registration is required to access WV Medicaid Training Center. • Access Training Center through www.WVMMIS.com web portal. • First time registration use default password as WV-Provider. • Training Center can be used for trainings, webinars, and scheduled classes provided by Molina. BMS/Molina 2012 Provider Workshops

34. Molina Web Portal – WV Provider Medicaid Training Center BMS/Molina 2012 Provider Workshops

35. BMS/Molina 2012 Provider Workshops