Fall 2018 Molina Provider Workshop

LARC Updated Billing Procedure for

Facilities and Providers

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Separate reimbursement for long acting reversible contraceptive (LARC)

intrauterine device (IUD) in inpatient setting:

• Submit separate claim specific to the LARC

• A LARC device from inpatient pharmacy stock

• Bill on UB form using Bill Type 0111

• A LARC device from out-patient pharmacy stock

• Bill on UB form with a Bill Type 0131

• A LARC device from 340B stock

• Bill on UB form with a Bill Type 0131 w/modifier UD

• Date of service (DOS) for LARC must correspond with date span on

inpatient claim for delivery

• Excludes discharge date

LARC Updated Billing Procedure for

Facilities and Providers Cont’d

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• Practitioners may bill for service associated with insertion of LARC• Separate CMS 1500 claim form

• Use appropriate CPT code

• Bill place of service (POS) 21

Medicaid Urine Drug Testing

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• Presumptive drug screens (80305, 80306, and 80307) limited to 24 in

combination per calendar year

• Definitive drug screens (G0480, G0481, and G0482) limited to 12 in

combination per calendar year

• Definitive drug testing for 22 or more drug classes (G0483) requires prior

authorization from the INITIAL (DOS)

• Definitive drug testing to identify drugs that do not have a specific test

available (G0659) requires prior authorization from the INITIAL DOS

• To exceed the benefit limit, providers must contact The Health Plan (THP)

to obtain a prior authorization

Pro-Rated Medicaid Urine Drug Testing

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• Urine drug testing will be pro-rated for remainder of

calendar year 2018

• Up to 12 presumptive drug screens and 6 definitive drug

tests (testing under 22 drug classes) covered without prior

authorization

• Contact THP for prior authorization to exceed this benefit

limit prior to payment

• Note: All definitive drug testing for over 22 drug classes

requires prior authorization prior to payment unless it is the

result of an emergency room visit

Fluoride Varnish

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• Fluoride varnish is reimbursable to both medical and

dental providers:

• May be billed two times/year for each type of

provider = four fluoride varnish treatments/year

• Patient must be less than 21 years old

• Code may only be billed once within a six month

period per each type of provider

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• Medical Providers

• Bill procedure code 99188

• Apply during time of well-child visit or health screening

• Oral health risk assessment should be conducted prior to

application

• Dental Providers

• Bill procedure code D1206

• Provide service at a dental visit

• Topical application of fluoride (excluding fluoride varnish)

• Bill procedure code D1208

• CANNOT bill D1206 with D1208

Fluoride Varnish

Medicaid Prior Authorization

Prior authorization required before a service is rendered

• Includes outpatient and inpatient services

• Authorization required next business day for after-hours,

weekend or holiday services

• Authorization requests received after next business day

will not be processed

• Failure to follow prior authorization guidelines will result in

denied claims

Non-par providers are required to receive prior authorization

for all services to receive reimbursement

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Prior Authorization and

Elective Admission

• Elective admissions always require prior authorization

• Urgent/emergent admissions require authorization within

48 hours

• Census number assigned when admission demographics

and clinicals are received

• The census number will be different than the prior

authorization number

Failure to obtain a census number will result in a denied claim

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Non-Participating Laboratories

• Use of participating laboratories is required

• SERVICES MUST BE PRE-AUTHORIZED if services rendered with

a non-participating laboratory

Contact Medicaid Customer Service Department at

1.888.613.8385 for a list of participating laboratories

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Cultural Competency Requirement

• CMS requires ALL providers complete cultural competency

training

• THP tracks network providers to ensure compliance

• Training materials and an attestation form are available on

THP’s website: www.healthplan.org/providers

• Attestation from another MCO’s website or proof of

attendance at a seminar is acceptable

• For specific requirements and expectations, refer to our

website at www.healthplan.org/providers11

Coding Software Implementation

• Implementation of Edifecs has begun

• New auditing software to enforce quality claim submission

• Supports:

• Front-end processing of electronic claims

• Faster claim rejections

• 835 Electronic remittance

• Coming soon through Edifecs:

• 270/271 eligibility files

• 276/277 claim status files

• 278 pre-authorization files

• Phase II: paper claims and claims via provider portal

• Share w/office manager, billing staff, billing vendor

• Email hpecs@healthplan.org to schedule transition 12

Rebateable J Codes/NDC Codes

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Per BMS contract and CMS, MCOs are required to only

reimburse rebateable J codes/NDC codes

• THP is following the same processing guidelines as fee-

for-service

• Providers are encouraged to view CMS website to

ensure the NDC code that is being administered is

rebateable

• FAQs are located on the BMS website:

https://dhhr.wv.gov/bms/BMS%20Pharmacy/Documents

/FAQsNDC_HCPCS_012712_v.%208.pdf

Follow-Up Care After Behavioral Health

Admission

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• Goal for timely follow-up care is within seven days after

discharge

• Ensures continuous care

• Encourages wellness

• Prevents repeat hospitalizations

• Request practitioners communicate to hospital discharge

planners and office staff to schedule appointment

Continuity and Coordination of Care

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• Continuity and coordination of care important between behavioral and medical providers

• Important for delivery of quality health care

• THP expects information to be shared within federal and state confidentiality laws

• Continuity of care consultation sheet is available on THP’s website: www.healthplan.org

Home Health Prior Authorization

Requirement

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• Home health prior authorization is required only if services extend past

the first certification period

• The first 60 days of care

• THP requires claims submitted with:

• Start of care date

• Note the current certification period on each claim submitted

• Box 80 on the UB04 paper claim

• The free text box for an electronic claim

• To pre-authorize home health services for Medicaid members, call

1.888.613.8385

Referrals and Member Rosters

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• THP receives calls when PCPs receive referrals for members they’ve never seen

• Member may have chosen PCP and isn’t established yet

• PCP may have been auto-assigned to Medicaid member

• Grow your practice

• THP encourages you to contact member to schedule appointment to get acquainted

• Rosters available on THP’s secure provider website

• Rosters contain keys to line of business

• Send letter of explanation to THP if you can’t accommodate member as a patient

The Health PlanAttn: Customer Service1110 Main St, Wheeling, WV 26003

Forwarding Order Expiring

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• Postal forwarding order expires November 1, 2018

• Claims and correspondence mailed to former St.

Clairsville address will be returned

• Inform billing staff, billing service, clearinghouse of mailing

address:

The Health Plan

1110 Main Street

Wheeling, WV 26003

Network Services

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• Network Services division restructured

• Provider Engagement Team formed for servicing and

educating providers

• More visibility and accessibility to providers

• Valerie Ogilbee, Director of Provider Engagement

• Barbara Good, Regional Manager Charleston

Office

• Kayla Shreve, Regional Manager Wheeling

Office & Interim Manager Morgantown Office

Population Health Management

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• Shift from treating illness to interventions for wellness and prevention

• Resulting in value-based care and reimbursement

• THP uses CCGroup Marketbasket System™ to develop performance reports

• Builds episodes of care

• Develops predictive scores for patient risk

• Provides comparisons with peers on efficiency of care

• Targets services responsible for inefficiency in care patterns

• Education will be provided by provider engagement

representatives

• Deciphering performance reports

• Closing care gaps

Practice Information

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• Contact THP if you’ve made changes that include:

• Practice location

• Phone/fax number(s)

• Restrictions (accepting/not accepting new patients, age, etc.)

• Termed/new providers

• Send these changes in writing

• Fax: 740.699.6169

• Email: hpecs@healthplan.org

• Verify your provider information on our website:

www.findadoc.healthplan.org

Q&A

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