masshealth pcdi provider education & communication reso… · 25/4/2018 · whitney moyer,...

Proprietary & Confidential 1

Executive Office of Health & Human Services

Provider Education and Communication

Provider Association Forum

April 25, 2018

2Proprietary & Confidential 2

Agenda

1. Welcome and Agenda Review - Felicia Clements, Manager, Provider Relations

2. Ordering, Referring and Prescribing Requirements - Alison Kirchgasser, Director of Federal Policy Implementation

3. Office of Long Term Services and Supports Updates – Whitney Moyer, Interim Director of Fee for Services and Supports

4. APEC Methodology (Hospital Billing) – Steve Sauter, Director, Acute Hospitals, MassHealth

5. MassHealth Payment and Care Delivery Innovations – Stephen Cairns, Director, Provider Services

6. Community Partners – Sophie Jones, Director of Community Partners and Social Integration

7. MassHealth Updates - Marilyn Thurston, Sr. Provider Relations Specialist• MassHealth Bulletins


Ordering, Referring & Prescribing (ORP) RequirementsBackground

ACA Section 6401 (b) States must require:

All ordering or referring physicians and other professionals be enrolled under the State [Medicaid] Plan…as a participating provider; and

The NPI of any ordering or referring physician or other professional…be specified on any claim for payment that is based on an order or referral of the physician or other professional

These requirements were effective March 25, 2011. Final Rule (42 CFR 455.410(b) and 42 CDR 455.440) was published in the Federal Register on Feb. 2, 2011. Subregulatory guidance was given to states on December 23, 2011

MassHealth is continuing its implementation efforts. In March 2016 and August 2017 we began providing informational messaging on certain impacted claims


ORP RequirementsProvider Types (including interns and residents in those provider types) authorized to be included on a claim as the ordering, referring or prescribing provider and who must enroll as at least a nonbilling provider

Certified Nurse Midwife Certified Registered Nurse

Anesthetist Clinical Nurse Specialist

Dentist Licensed Independent

Clinical Social Worker Certified Nurse Practitioner

Optometrist

Pharmacist (if authorized to prescribe)

Physician

Physician Assistant

Podiatrist Psychiatric Clinical Nurse

Specialist Psychologist

Fillable nonbilling provider applications and contracts are available on the MassHealth website:

http://www.mass.gov/eohhs/provider/insurance/masshealth/aca/aca-section-6401enrollment-information.html

http://www.mass.gov/eohhs/provider/insurance/masshealth/aca/aca-section-6401enrollment-information.html


ORP Requirements State law (Chapter 118 of the Acts of 2012 and Chapter 10 of the Acts of 2015)

requires that these provider types must apply to enroll with MassHealth for at least the purposes of ORP (i.e., at least as a nonbilling provider) in order to obtain and maintain state licensure, regardless of practice location (private practice, hospital, CHC, CMHC, etc.) The legislation applies to physician interns and residents but not other types of interns and residents.

This law went into effect in November 2017 upon promulgation of MassHealth regulations on ORP enrollment and claims. These regulations:

Define a new provider type – nonbilling providers

Clarify that for Group Practices, only those providers that see MassHealth patients must fill out a fully participating application. Providers in Group Practices that do not see MassHealth patients may choose to fill out either a fully participating application or a nonbilling application.

Authorize MassHealth to deny claims that do not meet the ORP requirements.

Specify requirements for making referrals in order to facilitate claims submission by billing providers.


ORP Requirements

The services below must be ordered, referred or prescribed. O&R requirements apply to fee for service, crossover (where Medicare requires O&R) and third party liability claims but not to claims submitted to MassHealth contracted managed care entities.

Any service that requires a PCC referral

Adult Day Health

Adult Foster Care

Durable Medical Equipment

Eyeglasses

Group Adult Foster Care

Home Health

Independent Living

Independent Nurse

Labs and Diagnostic Tests

Medications

Orthotics Oxygen/Respiratory

Equipment Certain Personal Care

Attendant services * Prosthetics

Psychological Testing

Therapy (PT, OT, ST)

Transitional Living

* T1019 billed by Fiscal Intermediary and T1020 billed by Transitional Living


ORP Requirements

On 2/26/16 MassHealth posted Provider Bulletin 259 for billing providers regarding the ordering, referring and prescribing provider requirements and the implementation phases. On 2/18/18 MassHealth posted Provider Bulletin 274 with additional information regarding billing requirements related to ordering/referring/prescribing.

MassHealth is providing informational edits on most types of claims impacted by the ORP requirements. Impacted claims that do not meet all of the requirements listed below receive informational edits. These are the claims that will deny once MassHealth begins to deny claims that do not meet the requirements.

The ORP provider’s NPI must be included on the claim

The ORP provider must be enrolled with MassHealth, at least as a nonbilling provider

The ORP provider must be one of the provider types listed on slide 6


ORP Requirements• Informational messages if the NPI of the ORP provider is not

included on the claim:

835 Electronic Remittance Advice (log into the POSC to see the applicable detailed edit from the list below)

HIPAA Claim Adjust Reason Code (CARC) HIPAA Remark Adjust Reason Code (RARC)206 – National Provider Identified – missing N265 – Missing/incomplete/invalid ordering

provider primary identifier

• POSC version of the remittance advice1080—Ordering Provider Required1081—NPI required for Ordering Provider1200—Referring Provider Required 1201—NPI of Provider Required—HDR1202—NPI of Referring Provider Required 2—HDR *1204—NPI of Referring Provider Required 2—DTL *

• According to federal guidance, Ordering and Referring rules do not require a secondary referring provider identifier on claims. However, there may be circumstances where the HIPAA V5010 Implementation Guide situationally requires a second referring provider identifier. In those circumstances, if the second referring provider’s NPI is included on the claim, but that provider is not enrolled with MassHealth or is not an authorized ORP provider, relevant informational edits will be included on the remittance advice.


ORP Requirements• Informational messages if the ORP provider on the claim is not actively enrolled with

MassHealth, at least as a nonbilling provider:

• 835 Electronic Remittance Advice (log into the POSC to see the applicable detailed edit from the list below)

HIPAA Claim Adjust Reason Code (CARC) HIPAA Remark Adjust Reason Code (RARC)208 – National Provider Identified – N265 – Missing/incomplete/invalid ordering Not matched. provider primary identifier

• POSC version of the remittance advice1082—Ordering Provider NPI not on file1083—Mult Sak Prov Locs for Ordering Provider +1084—Ordering Provider not actively enrolled1205—Referring Provider NPI not on file – HDR 1206—Referring Provider 2 NPI not on file – HDR *1207—Referring Provider NPI not on file – DTL1208—Referring Provider 2 NPI not on file – DTL *1209—Mult Sak Prov Locs for Referring Provider – HDR +1210—Mult Sak Prov Locs for Referring Provider 2 – HDR * + 1211—Mult Sak Prov Locs for Referring Provider – DTL +1212—Mult Sak Prov Locs for Referring Provider 2 – DTL * +1213—Referring Provider not actively enrolled – HDR1214—Referring Provider 2 not actively enrolled – HDR *1215—Referring Provider not actively enrolled – DTL1216—Referring Provider 2 not actively enrolled – DTL *

This informational edit indicates that there is more than one Provider ID/Service Location listed in the MassHealth MMIS for the NPIof the ORP provider. As a result, the MMIS is unable to confirm enrollment of the ORP provider. If you receive this message, please contact the MassHealth Customer Service Center for assistance.


ORP Requirements

• Informational messages if the ORP provider on the claim is not an eligible ORP provider type:

• 835 Electronic Remittance Advice (log into the POSC to see the applicable detailed edit from the list below)

HIPAA Claim Adjust Reason Code (CARC) HIPAA Remark Adjust Reason Code (RARC)183 – The referring provider is not eligible to N574 – Our records indicate the ordering/refer the service billed . referring provider is of a type/specialty that

cannot order or refer. Please verify that the claim

ordering/referring provider information is accurate or contact the order/referring provider.

184 – The prescribing/ordering provider is N265 – Missing/incomplete/invalid ordering not eligible to prescribe/order the service provider primary identifierbilled.

184 – The prescribing/ordering provider is N574 – Our records indicate the ordering/not eligible to prescribe/order the service referring provider is of a type/specialty that billed. cannot order or refer. Please verify that the claim

ordering/referring provider information is accurateor contact the order/referring provider.

• POSC version of the remittance advice1085—Ordering Provider Not Authorized to Order Services1217—Referring Provider Not Authorized to Refer - HDR 1218—Referring Provider 2 Not Authorized to Refer – HDR *1219—Referring Provider Not Authorized to Refer - DTL1220—Referring Provider 2 Not Authorized to Refer – DTL *


ORP Requirements

Prescribing related denial and informational edits for claims submitted to the Pharmacy Online Processing System (POPS)

Under HIPAA billing rules, pharmacies are to continue to enter the NPI of the individual prescriber on each claim submitted to POPS and claims submitted to POPS without a prescribing NPI are not accepted.

Under HIPAA rules, if an NPI is submitted, but is not known to POPS, then NCPDP reject code 42 – ‘Plan's Prescriber data base indicates the Prescriber ID Submitted is inactive or expired’ is posted.

To implement the ORP requirements, claims submitted to POPS with the NPI of a

prescriber who is not enrolled with MassHealth receive an NCPDP reject code: 71 – Prescriber is not covered with a corresponding text message

‘PRESCRIBER OF THIS CLAIM IS NOT MASSHEALTH PROGRAM ELIGIBLE. CLAIMS WILL DENY IN FUTURE IF PRESCRIBER DOES NOT ENROLL. PLEASE INFORM MEMBER AND/OR PRESCRIBER OF THAT FACT. SEE ALL-PROVIDER BULLETIN 259 FOR MORE INFO.

When MassHealth begins to deny claims due to the prescriber not being enrolled

with MassHealth, the NCPDP reject code will be changed to: 662 – Prescriber has not enrolled.


ORP Requirements Certain types of billing providers are currently receiving

significant numbers of informational edits, particularly those noting that the NPI of the ORP provider is not on the claim.

Acute Outpatient Hospital Adult Day Health Adult Foster Care Certified Independent

Laboratories Chiropractors Chronic Outpatient Hospitals Community Health Centers Durable Medical Equipment Early Intervention Fiscal Intermediaries in the

Personal Care Attendant Program

Group Adult Foster Care Group Practice

Organizations Home Care Home Health Agencies Hospital Licensed Health

Centers Pharmacies Renal Dialysis Clinics Special Programs Volume Purchaser

(eyeglasses)

Billing providers receiving these informational denial edits should update their billing procedures to avoid future claims denials.


ORP Requirements

Billing Instructions:

Enter the ORP NPI in the Referring Provider field if the claim is for a service that requires a PCC referral (such claims will also

continue to require the PCC referral number); or is for a laboratory service or a diagnostic testing service; or is submitted on an 837I or UB-04 (such claims only have a

Referring Provider field)

Enter the ORP NPI in the Ordering Provider field for all other impacted claims for services listed on slide 5

Batch Claims – Report the Referring Provider in Loop 2310A for Professional claims or Loop 2310F for Institutional claims and the Ordering Provider in Loop 2420E. Please adhere to ASCX12 HIPAA V5010 Implementation Guide regarding the inclusion of the referring and ordering provider Loops and Segments.

POPS – Submitters should follow the instructions in the POPS Billing Guide related to populating prescriber information


ORP Requirements

Direct Data Entry (DDE)• Institutional (837I)

• ORP NPI location is Referring Provider field on the Billing and Service Tab. Referring provider is allowed only at the header level in DDE. If multiple referring providers apply to the claims, services for each referring provider must be billed separately.

Professional (837P) PCC Referral/Labs/Tests

• ORP NPI location is Referring Provider field on the Billing and Service Tab. Referring provider is allowed only at the header level in DDE. If multiple referring providers apply to the claims, services for each referring provider must be billed separately.

• All other impacted services• ORP NPI location is Ordering Provider Field on the

Procedure Tab.


ORP Requirements POSC Provider Search Function

• In response to provider requests, Mass Health developed a provider search tool

• In order to use the Provider Search Function you must be logged into the POSC. The Provider Search Option is in the left navigation list.


ORP Requirements POSC Provider Search Function

• You can search using a combination of criteria


ORP Requirements

POSC Provider Search Function

• Results will return PROVIDER NAME, ADDRESS, NPI and ACTIVE Y or N

• Please note that a response of ACTIVE Y does not definitively confirm that the provider is eligible to be an Ordering, Referring or Prescribing provider. For example, facilities and entities (e.g., hospitals, health centers, group practices) are not authorized ORP providers. Also, individual providers could be in a provider type that is not authorized to Order, Refer or Prescribe


Questions?


Office of Long Term Services and Supports UpdatesPresented by – Whitney Moyer, Interim Director of Fee for

Services and Supports


OLTSS Program PA Enhancement and Implementation

Steps in the Enhancement and/or Implementation of Prior Authorizations for OLTSS services• Update the program regulations and program guidelines (where applicable)• Build the necessary IT infrastructure – LTMS & Provider Portal• Develop or update medical necessity guidelines, approval forms and align processes with regulations

and program guidelines• Design and test each program-specific PA portal• Train providers

Enhancement Features:

• Home Health o PA form enhancements o Time-to-task tools for HHAs and nursing services o Implementation February 2018

• DME o PA submission on Provider Portal with guided assistanceo Updated PA forms o Development Spring 2018 o Implementation Summer 2018

• PCAo PA submission on Provider Portal with guided assistanceo Electronic PCA Time-to-task tool o Development Spring 2018o Implementation Summer 2018

New PA Current Working Timelines:

• AFC & ADHo Development

Spring/Summer 2018o Implementation Fall 2018

• Day Hab & GAFCo Development Summer/Fall

2018o Implementation Winter

2018/Spring 2019


LTSS Program Regulation Updates (1/2)

AFC• Regulation update completed 5/5/2017• FAQ will released in Jan 2018• Guidance regarding accreditation requirements released in March 2018• Further guidance on financial solvency to be released in Spring 2018

Adult Day Health• Proposed program regulation drafted and hearings took place in September • Robust stakeholder engagement between draft and final regulation• Piloted new clinical criteria, 20 ADH providers participated• Anticipated promulgation in July 2018• Provider trainings to be scheduled July 2018

Day Habilitation • Proposed program regulation drafted and hearing took place in December • Robust stakeholder engagement between draft and final regulation• Anticipated promulgation in June 2018• Provider trainings to be scheduled for beginning of June 2018

GAFC • Proposed program regulations are beginning development• Planning to hold field visits with consumers to better inform the regulation process• Engagement with stakeholder community on a proposed draft anticipated for Fall 2018• Anticipated promulgation in Spring 2019


DME Program Regulations• Proposed program regulation being finalized• Robust stakeholder engagement has occurred prior to draft • Public hearing not yet scheduled• Anticipated promulgation in November 2018• Provider trainings to be scheduled for November/December 2018

Orthotics Program Regulations• Proposed program regulation drafted; public hearing not yet scheduled. • Met with industry to develop draft, will continue on an on-going basis through the reg process• Anticipated promulgation in December 2018• Provider trainings to be scheduled for December 2018 / January 2019

CDRH Program Regulations• Proposed program regulations are still in development• Met with industry to develop draft, will continue on an on-going basis through the reg process• Anticipated promulgation in Spring 2019

Nursing Facility Program Regulations• Proposed program regulations are still in development• Robust stakeholder engagement ongoing• Anticipated promulgation in Spring 2019

LTSS Program Regulation Updates (2/2)


LTSS Program Audits

• MassHealth is continuing with efforts to increase program integrity across all programs including LTSS programs

• Beginning in January, 2018 MassHealth, through its third party administrator, Optum, began conducting audits of certain fee-for-service LTSS providers to determine compliance with applicable regulations and guidanceo 13 on-site audits conducted, to dateo MassHealth program staff accompany Optum program integrity staff to

onsite visit and exit conferences

• MassHealth’s LTSS audits generally consist of a member records review, an operational records review and, where appropriate, member home visits

• MassHealth communicates all relevant findings, recommendations, and observations to providers

• The providers selected are notified 24 hours in advance of the audit. • The review team communicates with each selected provider regarding the

extent of the review and any preparations that the provider should make


Adult Foster Care Bulletin 14 Re: MassHealth Accreditation Requirements for Adult Foster Care (AFC) Providers MassHealth amended the Adult Foster Care (AFC) program regulation at 130 CMR 408.000 effective May 5, 2017, to revise and clarify certain AFC program requirements. This bulletin provides guidance about the accreditation requirement provided at 130 CMR 408.404(A)(11). AFC providers are required to provide evidence of accreditation to MassHealth by June 30, 2019Adult Foster Care Bulletin 14 link: https://www.mass.gov/files/documents/2018/03/30/AFC-14.pdf

Long-Term-Care Facility Bulletin 112Re: Annual Review of Personal Needs Allowance AccountMassHealth requires that nursing facilities and chronic disease and rehabilitation inpatient hospitals account for the balances of personal needs allowance (PNA) account funds (see www.mass.gov/regulations/130-CMR-456000-nursing-facility).Long-Term-Care Facility Bulletin 112 link: https://www.mass.gov/files/documents/2018/03/22/ltc-112.pdf

Adult Foster Care Bulletin 13Re: Frequently Asked Questions About Adult Foster Care ServicesMassHealth amended 130 CMR 408.000: Adult Foster Care (AFC), effective May 5, 2017, to revise and clarify certain AFC program requirements. As part of the outreach efforts to support these amendments, MassHealth staff conducted a series of training sessions throughout the Commonwealth to educate providers about the revisions to the updated AFC program requirements. This bulletin provides additional guidance about certain regulatory requirements of the AFC program, based on the feedback that we received during the training sessions. Adult Foster Care Bulletin 13 link: https://www.mass.gov/files/documents/2018/01/24/afc-13.pdf

Office of Long Term Services and Supports- Bulletin Releases Jan-March 2018

https://www.mass.gov/files/documents/2018/03/30/AFC-14.pdf

https://www.mass.gov/files/documents/2018/03/22/ltc-112.pdf

https://www.mass.gov/files/documents/2018/01/24/afc-13.pdf


Adjudicated Payment per Episode of Care (APEC) Overview and UpdatePresented by: Steve Sauter, Director,

Acute Hospitals


Key Definitions

APEC = MassHealth’s hospital-specific, episode-specific, all-inclusive (mostly) facility payment. Implemented 12/30/16.

Episode = outpatient services to one MassHealth member on a single calendar day. Exception: episode for emergency department or observation services can cross midnight(s)

Note: These exclude (1) professional services (2) labs except certain Surgical Pathology codes, and (3) (new, 3/1/18) “Outpatient Carve-Out Drugs”


The “chassis” for payment is the 3M Corporation’s product, Enhanced Ambulatory Patient Grouping (EAPG) System

MassHealth’s 3M EAPG grouper is a classification system that groups outpatient services with similar resource use in order to determine an episode’s relative resource intensity, which impacts payment (i.e., APEC)

APEC Basics


MassHealth’s APEC and EAPG are applicable to all in-state and out-of-state hospital outpatient settings, including hospital’s OPD, amb surg, ED, clinics, diagnostic centers; i.e., MassHealth Provider Types 80 (Acute Outpatient Hospital) and 81 (Hospital Licensed Health Center)

Approximately $600M (pre-ACO) in annual payment to 61 in-state contracted acute hospitals

Not applicable to these settings: Freestanding, non-hospital, separately contracted ambulatory surgery (Provider Type 84), diagnostic testing facility (PT 45), dialysis centers (PT 25), Community Health Centers (PT 20), etc.

APEC Basics – Provider Settings


Applicable to acute outpatient hospital services paid via fee-for-service (including Primary Care Clinician Plan members.)

Excludes PCC Plan’s Behavioral Health vendor services

Not applicable to hospital services to members in a MassHealth MCO or an ACO Model A (Accountable Care Partnership)

Does apply to hospital services for members in a Model B (Primary Care ACO), consistent with Acute Hospital RFA and Contract

APEC Basics – Provider Services


Better link at hospital’s episode level between resources required (i.e., case weight, service types, cost) and payment

EAPGs (with weights) determined for specific episode - not 1 single, average weight and PAPE per hospital per episode for entire year

EAPG weights can be updated more frequently Outlier add-on calculated (> or = $0) using episode’s costs

Increased transparency to providers

Improved ability to track costs for comparisons, efficiency improvements, etc.

The refinements above can facilitate movement to ACOs, total of cost care, etc.

*Payment Amount per Episode of Care

Impetus for Replacing PAPE* with APEC

31

APEC Compared to Payment Amt per Episode of Care (PAPE)

PAPE (past) APEC (present)Based on EAPG codingEpisode = calendar day of services

Separate claims for separate episodes (including extra ICN to generate PAPE payment)

Hospital had 1 average weight per all episodes, based on 1 full, prior year (base year, 2 years old) of paid claimsHospital’s PAPE for current year was based on statewide standard and hospital’s average EAPG weight

Coding did matter (eventually)Breaks in coverage – not applicableLate charges – minimally applicable

Based on EAPG codingEpisode = typically calendar day of related services, except that ED (Rev Code 45x) and Observation/Trtmnt Rm (Rev Code 76x) can cross midnight.One claim can convey multiple episodes (useful for PT/OT/SLP)

Statewide standard from base year cost report. Includes efficiency standard and outlier set-aside EAPG(s) determined for each episodeOutlier $ is episode-specific; based on pre-outlier payment vs. cost ( cost = charges x outpatient CCR)Episode’s APEC is based on statewide standard, episode’s EAPG weights, and episode’s outlier (if any)Coding matters immediatelyBreaks in coverage – recognized and handled via DOS on claim lineLate charges: TOB 135 pays $0


EAPG uses HCPCS Level 1 (CPT) and Level 2 procedure codes and (primarily for medical visits) ICD-10-CM diagnosis codes.

Each EAPG is assigned to one EAPG Type – Per Diem, Significant Procedure, Medical Visit, Ancillary, Incidental, Drug, DME, or Unassigned

Each EAPG has a MassHealth relative weight EAPG recognizes and encourages efficiencies within a visit –

specifically, an adjustment to EAPG weight via EAPG grouper’s logic. Types of “bundling” within an episode:

Discounting (e.g., multiple unrelated significant procedure EAPGs, terminated procedure)

Consolidation (e.g., multiple identical or related significant procedures) Packaging (e.g., ancillary services present with medical visit EAPG or

significant procedure EAPG)

APEC Basics


1 Per Diem Significant Procedure 2 Significant Procedure 21 Physical Therapy and Rehab 22 Mental Health and Counseling 23 Dental Procedure 24 Radiologic Procedure 25 Other Diagnostic Procedure

3 Medical Visit 4 Ancillary 5 Incidental 6 Drug 7 DME 8 Unassigned

APEC Basics – EAPG Types


3 Major Classes of Procedures Significant Procedures – Normally scheduled procedures;

constitute the reason for the visit and dominate the time and resources E.g.: excision of lesion; biopsy; colonoscopy; CT scan

◦ Ancillary Tests and Procedures – Ordered by the primary physician to assist in diagnosis or treatment Includes pathology, some chemotherapy and pharmacotherapy,

certain ancillary tests, plain film ◦ Incidental Procedure - Integral part of a medical visit and usually

associated with professional services (“incident to”) E.g., ROM, Category II CPT codes for performance measurement

Medical EAPGs◦ Describe patients who receive medical treatment but no significant

procedure◦ Primary or principal diagnosis in ICD-10 is the driver

APEC Basics – EAPG Types (cont’d)


EAPG payment at claim detail line, based on “adjusted” EAPG weight. (Note: Payment of $0 does not mean “not covered”)

Total EAPG payment (which excludes outlier payment, if any) = sum of payments from the detail lines of the episode

APEC Basics - Payment


“APEC outlier component” equals marginal cost factor (currently 80%) x [episode specific case cost* less episode-specific outlier threshold**]

*=Payable charges x hospital’s outpatient cost-to-charge ratio

**=Total EAPG payment (previous slide) + fixed outpatient outlier threshold (was $2,100, increased to $2,750 as of 3/1/18)

APEC = Total EAPG payment + Outlier Component

APEC Basics - Payment (cont’d)


Divided into two periods (1st Period =10/1/17 – 2/28/18 and 2nd Period = 3/1/18 – 9/30/18)

Purpose: to implement changes coincident with 3/1/18 ACO rollout, although (as noted earlier) methodology applies to hospital services to Primary Care ACO members, not Accountable Care Partnership or MCO members.

No changes in 1st Period vs. RY2017; all changes are effective with 2nd Period

No major changes for RY2108 2nd Period, except for implementation of “APEC Carve-Out Drugs”:

Update for Rate Year 2018 (10/1/17 – 9/30/18)


“APEC Carve-out Drugs” effective 3/1/18

◦ Excluded from APEC payment methodology

◦ To be designated by EOHHS/MassHealth and identified within the MassHealth Drug List (MHDL) Currently, no drugs are designated

◦ Definitions, prior authorization and billing requirements, and payment methodology are described in Acute Hospital RFA as amended, MHDL, and/or MassHealth billing instructions

◦ Similar approach for inpatient (Adjudicated Payment Amount per Episode (APAD)) payment methodology

Update for Rate Year 2018 (10/1/17 – 9/30/18) (cont’d)


Acute Hospital RFA – contract is for in-state acute hospitals only, not out-of-state; but very similar payment methods Includes links, e.g., list of the Rate Year’s EAPGs and their MassHealth EAPG

weights Hospital regulations and other components of Acute Outpatient Hospital

Manual on state website (mass.gov) Administrative and Billing Instructions Service Codes (“Subchapter 6”) Includes 105 CMR 450.233 “Rates of Payment to Out-of-State Providers”, which

generally follows in-state Acute Hospital RFA Bulletins for interim policies, announcements, and descriptions; Transmittal Letters

for changes to regulations APEC “Billing Tips”

Informal guidelines, instructions, in-service materials (e.g., 3M’s description of Observation Services, 3M’s overview of EAPG, Trading Partner Testing Questions and Resolutions

Notices of Preliminary/Final Agency Action (to comply with CMS) MassHealth’s Customer Service Center (CSC)◦ E-mail: [email protected] (For non-member-specific questions only.

This e-mail is not secure. DO NOT SEND US PERSONAL INFORMATION.)Phone: 1-800-841-2900

Useful Sources of Information (cont’d)

mailto:[email protected]


Payment and Care Delivery Innovation (PCDI)

Presented by – Stephen Cairns, Director of Provider Services


Agenda

1.MassHealth Payment and Care Delivery Innovation (PCDI)

a. Member Assignment Timeline

b. MassHealth Plan Types 2018

c. Continuity of Care (CoC)

d. Eligibility Verification System (EVS)

e. Common Questions


• After March 1, 2018, a new managed care member’s Plan Selection Period will be the first 90 days after the effective date of

enrollment to a new Plan, and Fixed Enrollment will be the remaining 275 days of the year

• For example, a new managed care eligible member who enrolls into a new Plan effective 6/1/18, will be

in their Plan Selection Period from 6/1/18 to 8/29/18, and their Fixed Enrollment Period from 8/30/18 to 5/31/19

• All managed care members have a new plan selection and fixed enrollment period every year

• Member enrollment changes made during the Plan Selection Period will take 2 to 3 days to process

11/13/17 – 2/28/18: During this time, members can choose to prospectively

enroll in a new plan effective March 1, 2018

11/13/17-12/22/17 3/1/18 7/1/18Member Mailing

Start of Plan Selection PeriodMembers can change health plans

for any reason for 120 days

Start of Fixed Enrollment Period Members enrolled in an ACO or

MCO can only change their health plans for certain reasons

Important Member Choice Dates

Below are important dates for managed care eligible members with enrollments effective March 1, 2018

Update: The fixed enrollment period extended to July 1st


New Service Area Exceptions Process Effective April 9, 2018, MassHealth is implementing a process to allow members, under certain specific circumstances, to join an Accountable Care Partnership Plan that does not cover the service area in which the member lives. MassHealth will allow current and future members to request a service area exception to enroll in an out-of-area Accountable Care Partnership Plan by contacting the MassHealth Customer Service Center.

Service area exceptions may be granted for the following reasons: The member has an established relationship with a PCP who

participates in an Accountable Care Partnership Plan that does not cover the service area in which the member resides;

The member is homeless and a specific Accountable Care Partnership Plan can better accommodate the member’s support needs; or

The member’s enrollment in the Accountable Care Partnership Plan significantly supports language, communication, or cultural needs; specialized health care needs; or other accessibility needs


Primary Care Participation and Exclusivity

• Primary care practices and ACO-participating PCPs will be exclusive to their contracted ACO—they will exclusively provide primary care to MassHealth managed care members enrolled in their ACO.

• ACO-participating PCPs cannot participate as primary care providers in MCOs or the PCC Plan or any other ACO.

• This exclusivity is enforced at the practice or entity level rather than at the individual doctor level.

• Exclusivity does not apply to other programs, such as MassHealth fee-for-service, Senior Care Options (SCO), One Care, or the Program of All-inclusive Care for the Elderly (PACE).

• PCPs can continue to provide services to members in the above-mentioned plans including fee-for-service members regardless of their contracts with ACOs.

• PCPs who are also specialists can continue to provide specialty services across managed care plans.


Specialist, Hospital, and Other Provider Participation

• Specialists, hospitals, and other providers may contract with multiple health plans at the same time and can provide services to members in any of the health plans with whom they are contracted. The managed care assignment of the member to an MCO, ACO, or PCC Plan is crucial for specialists to understand. This will ensure that specialists provide services to members of plans that they are contracted with.

• A specialist may see MassHealth members enrolled with the PCC Plan or a Primary Care ACO if the specialist is a MassHealth participating provider. For members enrolled in an Accountable Care Partnership Plan or MCO, specialists will need to contract with each of these health plans to provide services to members enrolled in these plans.

• This information can be found in All Provider Bulletin 272.

http://www.mass.gov/eohhs/docs/masshealth/bull-2017/all-272.pdf


• A network of PCPs who have exclusively partnered with an MCO to use the MCO’s provider network to provide integrated and coordinated care for members

• Accountable Care Partnership Plans cover a set of service areas where they will operate. Members must live in the service areas covered by the ACO to enroll in that plan

• MassHealth has contracted with13 Accountable Care Partnership Plans

Accountable Care Partnership Plans (Model A)

MCO Provider NetworkPCP Network


• A network of PCCs who contract directly with MassHealth to provide integrated and coordinated care for members

• Primary Care ACOs work with the entire MassHealth provider network of specialists and hospitals, and may have certain providers in their “referral circle” that will not require a MassHealth referral for the service

• Primary Care ACOs will use the Massachusetts Behavioral Health Partnership (MBHP) for behavioral health services

• MassHealth has contracted with 3 Primary Care ACO Plans

Primary Care ACOs (Model B)

MassHealth Provider NetworkPCC Network


• A network of PCPs who may contract with one or multiple MCOs, and use the MCO provider networks to provide integrated and coordinated care for members

• MCO-Administered ACOs are not presented as an enrollment option for members because they will be attributed through their relevant MCO

• There is one MCO-Administered ACO, Lahey Clinical Performance Network, which is participating with both MCOseffective March 1, 2018: Boston Medical Center (BMC) HealthNet Plan, and Tufts Health Together

MCO-Administered ACOs (Model C)

MCO Provider Network

ACO PCP Network


Primary Care Clinician (PCC) Plan

• The Primary Care Clinician (PCC) Plan is a statewide plan run by MassHealth that uses the MassHealth provider network

• Behavioral health services for the PCC Plan are provided by the Massachusetts Behavioral Health Partnership (MBHP)

• Members must choose a PCC in order to enroll in a PCC Plan

MCOs and the PCC PlanIn addition to ACOs, members will continue to have the following managed care options effective March 1, 2018:

Managed Care Organizations (MCOs)

• MCOs are health plans run by insurance companies that provide care through their own provider network that includes PCPs, specialists, behavioral health providers, and hospitals

• There are two MCO options: Boston Medical Center (BMC) HealthNet Plan, and Tufts Health Together

• BMC HealthNet Plan will operate statewide, and Tufts Health Together will operate in every region except Southeast, MA

All Service Areas Southeast Region


Accountable Care Partnership Plans (Model A)

Be Healthy Partnership - Baystate Health Care Alliance with Health New England

Berkshire Fallon Health Collaborative - Health Collaborative of the Berkshires with Fallon Health

BMC HealthNet Plan Signature Alliance - Signature Healthcare with BMC HealthNet Plan

BMC HealthNet Plan Community Alliance - Boston Accountable Care Organization with BMC HealthNet Plan

BMC HealthNet Plan Mercy Alliance - Mercy Medical Center with BMC HealthNet Plan

BMC HealthNet Plan Southcoast Alliance - Southcoast Health with BMC HealthNet Plan

Fallon 365 Care - Reliant Medical Group with Fallon Health

My Care Family - Merrimack Valley ACO with Neighborhood Health Plan (NHP)

Tufts Health Together with Atrius Health - Atrius Health with Tufts Health Plan (THP)

Tufts Health Together with BIDCO - Beth Israel Deaconess Care Organization (BIDCO) with Tufts Health Plan (THP)

Tufts Health Together with Boston Children's ACO – Boston Children’s ACO with Tufts Health Plan (THP)

Tufts Health Together with CHA - Cambridge Health Alliance (CHA) with Tufts Health Plan (THP)

Wellforce Care Plan - Wellforce with Fallon Health

MCO-Administered ACO (Model C)

Lahey Clinical Performance Network (Participating with Boston Medical Center

HealthNet Plan and Tufts Health Together)

MCOs

Boston Medical Center(BMC) HealthNet Plan

Tufts Health Together

PCC Plan

Primary care Providers in the MassHealth Network

Primary Care ACO Plans (Model B)

Community Care Cooperative (C3)

Partners HealthCare Choice

Steward Health Choice

MassHealth Health Plan Options Effective March 1, 2018


Payer of Claims Effective March 1, 2018

Plan Type Payer of Claims

PCC Plan MassHealth for non-BH services (MBHP for BH services)

Primary Care ACO MassHealth for non-BH services(MBHP for BH services)

MCO MCO*

MCO-Administered ACO MCO*

Accountable Care Partnership Plan Partnership Plan*

*If an MCO or Accountable Care Partnership Plan uses a Behavioral Health (BH) vendor, providers may be paid through the BH vendor for BH services.


Continuity of Care (CoC)

MassHealth is committed to working with all relevant parties to ensure continuity of care for the many members who are movingto new plans, whether they are going to or from an ACO Partnership Plan, a Primary Care ACO, an MCO, or the Primary Care Clinician (PCC) Plan.

Here are the most important things for you to know:

• These changes apply to MassHealth managed care members (generally, this includes members under age 65 who do not have another primary insurer, either commercial or Medicare, and are not in a long-term facility)

• All members have a minimum 30-day continuity of care period

• During the continuity of care period all existing prior authorizations for services and for provider referrals will be honored by the member’s new plan. Members can continue to see their existing providers for at least 30 days, even if those providers are not in their new plan’s network

• Providers who are not in the new plan’s network must contact the new plan to make appropriate payment arrangements

• In some cases, the continuity of care period may be extended. For example, members who are pregnant can continue seeing their existing OB/GYN providers throughout their pregnancy and up to six weeks postpartum

• We are asking all plans, providers, and assisters to support members in receiving all needed health care services during this transition

• Members can contact their new plan now to let them know of any ongoing treatments or scheduled appointments

• Providers will be able to see new plan information in the MassHealth Eligibility Verification System (EVS) starting March 1. They can contact the new plan at that time for new authorization requests, or with any questions or concerns about providing services

• MassHealth and all ACOs and MCOs have escalation protocols in place for continuity of care issues that may arise

Please make all efforts to ensure that members continue to have access to all needed health services during this transition.

Update:Continuity of care extended for medical care through May 31st.


MassHealth has created a Continuity of Care Homepage which features helpful information available to view and download for interested parties regarding Continuity of Care through transitions to new managed care arrangements.

• https://www.mass.gov/service-details/continuity-of-care

• Continuity of Care Memo

• Continuity of Care FAQ's

This information is also featured on the MassHealth Provider PCDI Resources Web Page at https://www.mass.gov/lists/provider-pcdi-resources

Continuity of Care (CoC)

https://www.mass.gov/service-details/continuity-of-care


https://www.mass.gov/files/documents/2018/02/21/Continuity%20of%20Care%20(02-21)_1.pdf

https://www.mass.gov/files/documents/2018/03/26/ContinuityofCare-FAQs_0.pdf

https://www.mass.gov/lists/provider-pcdi-resources



• Providers should continue to check member enrollment and eligibility using EVS* on the Provider Online Service Center (POSC)

• Providers reduce the risk of denied claims by using EVS to verify member enrollment and eligibility prior to providing services to MassHealth members

• There are two types of Restrictive Messages that appear on EVS: • Eligibility Restrictive Messages (No Changes)

• Managed Care Data Restrictive Messages (Enhanced)

• The Managed Care Data Restrictive Messages have been enhanced to identify which type of health plan a member is enrolled in, and their contact information for inquiries regarding:

• Billing (medical and behavioral health claims)

• Service authorizations (medical and behavioral health services)

• Behavioral Health vendors

Eligibility Verification System (EVS)

• Visit the Provider PCDI Resources page at https://www.mass.gov/lists/provider-pcdi-resources to view and download the MassHealth Quick Reference Guide and screenshot examples of EVS codes and restrictive messages for all 2018 managed care health plans.

• If you have questions about how to check a member’s eligibility, please refer to the Verify Member Eligibility Job Aid to learn how to access and check member eligibility using EVS on the POSC (URL: https://www.mass.gov/how-to/check-member-eligibility)

*Note: EVS only displays a member’s current eligibility, not future eligibility.


http://www.mass.gov/eohhs/docs/masshealth/provlibrary/pocs-job-aids/eligibility-verification-verify-member.pdf

https://www.mass.gov/how-to/check-member-eligibility


EVS – Eligibility Tab

2. Click on the hyperlink of the Date Range* entered for details regarding the member’s coverage.

1. To verify the coverage type a member has, click on the Eligibility tab.

*Note: EVS only displays a member’s current eligibility, not future eligibility.


Screenshot Examples of New EVS Restrictive Messages for 2018 Managed Care Health Plans

1. BeHealthy Partnership – Accountable Care Partnership Plan

Note: EVS only displays a member’s current eligibility, not future eligibility.


• If I am a specialist or hospital contracted with MassHealth can I see members enrolled with a Primary Care ACO or PCC Plan? o Yes, Primary Care ACOs and the PCC Plan use the MassHealth fee-for-service (FFS) network of

specialists and hospitals.o For more information please refer to the PCDI for Specialist Fact Sheet.

• Who is responsible for paying claims during the 30 day continuity of care period? o The plan that the member is enrolled with on the date of service is responsible for paying the

claim for the services rendered. o For more information please refer to the Continuity of Care Homepageo https://www.mass.gov/service-details/continuity-of-care

Who should providers contact about joining a plan?o Providers should contact the plan directly. o MassHealth has created a 2018 Health Plan Contact Matrix that lists the medical and behavioral

health contact information, member ID card images, and web links for all 2018 MassHealth managed care health plans.

o Visit the Provider PCDI Resources page to view and download this document and other helpful resources.

Common Questions

https://www.mass.gov/files/documents/2017/11/10/PCDI-FS-SPC%20(11-17)_0.pdf



https://www.mass.gov/files/documents/2018/03/14/MassHealth%20Contact%20Matrix%20%E2%80%93%202018%20Managed%20Care%20Health%20Plans_0.pdf



Community PartnersPresented by – Sophie Jones, Director of

Community Partners and Social Integration


Overview: Community Partners Program

• Community Partners (CPs) are paid, contracted, and managed by MassHealth.

• There are two types of Community Partners:

Behavioral Health Community Partner (BH CP)• Responsible for care management and coordination for populations with significant BH

needs

• May support up to 35,000 members

Long Term Services and Supports Community Partner (LTSS CP)• Provide LTSS care coordination and navigation to populations with complex LTSS needs

• May support up ~20,000 – 24,000 members

• MCOs and ACOs must partner with an adequate number of CPs, per MassHealth requirements, to support members with high BH and complex LTSS needs.

• MassHealth is conducting a structured, mandatory readiness process with ACOs, MCOs and CPs to ensure timely readiness for CP Program implementation.

• The CP Program will begin supporting members as of July 1, 2018


Who will Community Partners serve?

needs.

embers of all ages

Members with physical disabilities, members with brain injury, members with intellectual or developmental disabilities,

and older adults eligible for managed care (ages 60-64)

Focus population will be inclusive of members with co

LTSS CPs will serve a population with complex LTSS needs and include:

ACO and MCO-enrolled members age 3 and older

Members with complex LTSS and behavioral health needs; members with brain injury or cognitive

impairments; members with physical disabilities; members with intellectual or developmental disabilities,

including Autism; older adults eligible for managed care (up to age 64); and children and youth with

LTSS needs

BH CPs will serve a population with high BH needs and include:

ACO and MCO-enrolled members age 21 and older with Serious Mental Illness and/or addiction treatment

needs and high service utilization

For members < 21 years of age with Serious Emotional Disturbance (SED), existing CSAs under CBHI1 will

continue to provide ICC services for such members

o Members 18-20 with addiction treatment needs and high utilization will be eligible for BH CP supports if

requested

Members with co-occurring BH and LTSS needs will be offered BH CP supports. Only assignment to a

single CP is permitted

1 CSA = Community Service Agency; CBHI = Children’s Behavioral Health Initiative; ICC = Intensive Care Coordination


What will Community Partners do for members?

BH CP Functions

1. Outreach and engagement;

2. Comprehensive assessment and person-

centered treatment planning;

3. Care coordination & care management,

including across

1. Medical

2. Behavioral Health

3. Long Term Services and Supports;

4. Support for transitions of care;

5. Medication reconciliation support;

6. Health and wellness coaching; and

7. Connection to social services and

community resources, including Flexible

Services

LTSS CP Functions

1. Outreach and engagement;

2. LTSS care planning including choice

counseling;

3. Care team participation;

4. LTSS care coordination;

5. Support for transitions of care;

6. Health and wellness coaching; and

7. Connection to social services and

community resources, including Flexible

Services

Comprehensive Care Management LTSS Component of Care Coordination


Contracted Community Partners (1/2)▪ EOHHS executed contracts with 18 BH CPs and 9 LTSS CPs

▪ Entities listed below are those with which ACOs and MCOs will enter into ACO/MCO and CP Agreements. Many are comprised of multiple components.

▪ CP organizational configurations include:– Single legal entities– Single legal entities comprised of Consortium Entities, which operate as part of the legal structure – Single legal entities with Affiliated Partners, which operate jointly under a management agreement

▪ The contracted BH CPs are as follows:

Behavioral Health Community Partners

1. Behavioral Health Network, Inc. 10. Eliot Community Human Services, Inc.

2. Behavioral Health Partners of Metrowest, LLC 11. High Point Treatment Center, Inc.

3. Boston Health Care for the Homeless Program 12. Innovative Care Partners, LLC

4. The Bridge of Central Massachusetts, Inc. 13. Lowell Community Health Center, Inc.

5. The Brien Center for Mental Health and Substance Abuse Services, Inc.

14. Northeast Behavioral Health Corporation d.b.a Lahey Behavioral Health Services

6. Clinical Support Options, Inc. 15. Riverside Community Care, Inc.

7. Community Counseling of Bristol County 16. Southeast Community Partnership

8. Community Healthlink, Inc. 17. South Shore Mental Health Center, Inc.

9. Community Care Partners, LLC 18. Stanley Street Treatment and Resources (SSTAR), Inc.


Contracted Community Partners (2/2)

Long-Term Services and Supports Community Partners1. Alternatives Unlimited, d.b.a Central Community Health Partnership

2. Boston Medical Center d.b.a Boston Allied Partners

3. LTSS Care Partners, LLC

4. Elder Services of Merrimack Valley, d.b.a Merrimack Valley Community Partnership

5. Family Service Association

6. Innovative Care Partners, LLC

7. Seven Hills Family Services, Inc.

8. WestMass Elder Care, d.b.a Care Alliance of Western Massachusetts

9. Greater Lynn Senior Services d.b.a North Region LTSS Partnership

The contracted LTSS CPs are as follows:


CP Program Timeline

4/18-6/18 7/18-12/18 1/19 and beyond

• ACO/MCO and CP Agreements Executed

• MassHealth Readiness Review

• ACO/MCO Fixed Enrollment Period Begins (7/1)

• CP Program Go-Live (soft launch) (7/1)

• MassHealth identifies eligible members and assigns members to CP

• ACO/MCO begins accepting referrals for CP Program from providers, members, etc.

• ACO/MCO assigns members to CPs

• Planned improvements to MMIS

• Continued growth of CP capacity


MassHealth UpdatesPresented by-Marilyn Thurston, Sr. Provider Relations Specialist

6


This bulletin lists the Eligibility Verification System (EVS) restrictive message codes and text for MassHealth managed care health plans effective March 1, 2018. Providers accessing EVS through the Provider Online Service Center (POSC) to verify the eligibility of a MassHealth managed care member before providing medical services will receive one or more of the restrictive messages listed below.

Appendix Y of all MassHealth provider manuals is being updated to include the complete list of active EVS codes and messages. To sign up for email notifications when MassHealth publishes new provider bulletins and transmittal letters, send a blank email to [email protected].

For a complete listing Eligibility Verification System (EVS) restrictive message codes and text for MassHealth managed care health plans please refer to All Provider Bulletin 275.

Online ResourcesMassHealth provider bulletins are available to view and download at https://www.mass.gov/masshealth-provider-bulletins

MassHealth provider appendices are available to view and download at https://www.mass.gov/guides/masshealth-provider-manual-appendices.

MassHealth Provider PCDI Resources webpagehttps://www.mass.gov/lists/provider-pcdi-resources

All Provider Bulletin 275 link: https://www.mass.gov/files/documents/2018/03/16/pb-all-275.pdf

All Provider Bulletin 275Re: MassHealth EVS Codes and Restrictive Messages for 2018 Managed Care Health Plans


https://www.mass.gov/masshealth-provider-bulletins

https://www.mass.gov/guides/masshealth-provider-manual-appendices


https://www.mass.gov/files/documents/2018/03/16/pb-all-275.pdf


This bulletin transmits additions and updates to the vaccine service codes payable for MassHealth’ s limited services clinics (LSCs). These changes are effective for dates of service on or after January 1, 2018. The Massachusetts Department of Public Health (DPH) is authorized to license LSCs under M.G.L. c. 111, sec. 51J and 52, and regulations at 105 CMR 140.1000. Pursuant to these regulations, LSCs are licensed to provide a limited set of medical services and may not serve as a member’s primary care or provide treatment to children younger than the age specified by statute and regulation. See M.G.L. c. 111, Section 51J, and 105 CMR 140.1000, as amended.

LSC Service CodesFor a complete list of service codes payable for for MassHealth LSC providers, please refer to Limited Services Clinic Bulletin 5.

Limited Services Clinic Bulletin 5 link: https://www.mass.gov/files/documents/2018/03/22/lsc-5.pdf

Limited Services Clinic (LSC) Bulletin 5Re: Updates to Vaccine Service Codes and Descriptions

https://www.mass.gov/files/documents/2018/03/22/lsc-5.pdf

https://www.mass.gov/files/documents/2018/03/22/lsc-5.pdf


The purpose of this bulletin is to clarify and consolidate previous communications between MassHealth and its ACPPs and MCOs concerning recent changes to the MassHealth Supplemental Rebate/Preferred Drug List in the MassHealth Drug List (MHDL) (available at https://masshealthdruglist.ehs.state.ma.us/MHDL/) and corresponding actions that must be taken by MassHealth ACPPs and MCOs pursuant to Section 2.6.B.4 of their respective ACPP and MCO contracts with MassHealth. Effective March 1, 2018, all MassHealth ACPPs and MCOs must update their respective drug lists or formularies within the therapeutic classes listed in the table below to align the preferred drugs within those categories with the preferred drugs set forth in the MHDL. Specifically, MassHealth ACPPs and MCOs must utilize the following preferred drugs in the following therapeutic classes: (Please refer to Bulletin 3 for a complete list )

Beginning March 1, 2018, MassHealth ACPPs and MCOs must also utilize the utilization management criteria set forth in the MHDL for the evaluation and adjudication of prior authorization requests for the preferred drugs and non-preferred drugs within these designated therapeutic classes. These criteria have been previously distributed to the ACPPs and MCOs and provided guidelines for the implementation of this policy and any conditions or exceptions to the preferred drug status within the therapeutic class.

Finally, effective March 1, 2018, MassHealth ACPPs and MCOs must also terminate any plan-specific rebate agreements (or similar arrangements) the plan may have with its Pharmacy Benefit Manager (PBM) or the manufacturer(s) of the preferred drugs listed above (or any competing products where the terms of the arrangement would preclude alignment with the MHDL). MassHealth is requiring these actions in order to maximize value to the Commonwealth. In the event any ACPP or MCO believes an alternative arrangement would better maximize value to the Commonwealth, the ACPP or MCO must, NO LATER THAN February 23, 2018, contact in writing Dr. Paul Jeffrey, MassHealth Pharmacy Director: [email protected].

Managed Care Entity Bulletin 3 link: https://www.mass.gov/files/documents/2018/02/16/mce-3.pdf

Managed Care Entity Bulletin 3Re: MassHealth Accountable Care Partnership Plan (ACPP) and Managed Care Organization (MCO) Coverage of Drugs Subject to MassHealth Supplemental Rebate Agreements

https://www.mass.gov/files/documents/2018/02/16/mce-3.pdf


https://www.mass.gov/files/documents/2018/02/16/mce-3.pdf


The information in this bulletin is intended to continue to help billing providers prepare their processes and systems for compliance with ordering, referring, and prescribing requirements, and reduce the impact on them once claim denials take effect. MassHealth is preparing for, but has not yet established a date to begin denying claims that do not meet the ordering, referring, and prescribing requirements described below. MassHealth will communicate the start date for claim denials prior to beginning such denials.

Enrollment of ORP ProvidersMassHealth has been working to outreach to and enroll authorized ORP providers to reduce the impact on billing providers submitting claims to the MassHealth agency for services that require an order, referral or prescription. In addition, state law requires that the providers listed below as authorized ORP providers apply to participate in MassHealth at least as a nonbilling provider in order to obtain and maintain state licensure. The state law requirement went into effect on November 3, 2017, when MassHealth regulations that define the new nonbilling provider type were promulgated (see 130 CMR 450.212).

All Provider Bulletin 274 link: https://www.mass.gov/files/documents/2018/02/08/all-274.pdf

All Provider Bulletin 274Re: Continued Implementation of Ordering, Referring, and Prescribing Provider Requirements

https://www.mass.gov/files/documents/2018/02/08/all-274.pdf


Starting March 1, 2018, MassHealth will require acute inpatient hospitals to use an updated Notification of Birth (NOB-1) form. This form, which is available at https://www.mass.gov/lists/masshealth-provider-forms-by-provider-type-h-l , will include streamlined submission instructions that simplify the process for providers.

Changes to the NOB-1 Form

• Section 1: Mother’s Information box fields have been added for the newborn’s “Primary Insurer or Guardian … ” along with the mother’s or the primary insurer’s “Primary Commercial Insurance” plan. Instructions on the back of the form provide guidance on how to complete these new fields. Also, the “Mother’s Plan” box has been removed.

• Section 2: Child’s Information box, the “Child’s Birth Weight,” Gestational Age,” and “Race Code” fields have been removed.

Changes to the NOB-1 Submission Process

There are several changes regarding submission of the NOB-1 form. Effective March 1, 2018, (or sooner if the provider is ready to do so), NOB-1 forms must be submitted via fax (617)887-8777. This is the fastest and most complete way to get information on newborns to us. It allows us to add newborn information into our systems and to track and archive the request. We will not accept NOB-1 forms via mail, and providers should not mail forms that they have already faxed to MassHealth. We hope to eliminate confusion and save providers time and postage by eliminating this mailing step. Please note, we will not mail eligibility or enrollment information to providers. Providers should check the Eligibility Verification System (EVS) in the Provider Online Service Center (POSC) for this information.

Acute Hospital Inpatient Bulletin 161 link: https://www.mass.gov/files/documents/2018/02/08/aih-161.pdf

Acute Hospital Inpatient Bulletin 161Re: Changes to Notification of Birth (NOB-1) Form and Filing Process

https://www.mass.gov/lists/masshealth-provider-forms-by-provider-type-h-l

https://www.mass.gov/files/documents/2018/02/08/aih-161.pdf


As of October 1, 2014, the Centers for Medicare & Medicaid Services (CMS) provided an update regarding, among other changes, new editing instructions for diagnoses that are not appropriate for reporting on hospice claims.

• CMS Transmittal 3032, available at https://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R3032CP.pdf, provides the following guidelines:

Hospices are to report diagnosis coding on the hospice claim, as required by ICD-10- CM Coding Guidelines. The principal diagnosis reported on the claim is the diagnosis most contributory to the terminal prognosis. ICD-10-CM Coding Guidelines state that codes listed under the classification of Symptoms, Signs, and Ill-defined Conditions are not to be used as principal diagnoses when a related definitive diagnosis has been established or confirmed by the provider. Hospice providers may not report diagnosis codes that cannot be used as the principal diagnosis according to ICD-10-CM Coding Guidelines and require further compliance with various ICD-10-CM coding conventions, such as those that have principal diagnosis code sequencing or etiology/manifestation guidelines.

Hospice Bulletin 12 link: https://www.mass.gov/files/documents/2018/02/06/hos-12.pdf

Hospice Bulletin 12Re: Changes to MassHealth Policy on Diagnoses That Are Not Appropriate for Reporting as Principal Diagnoses on Hospice Claims

https://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R3032CP.pdf

https://www.mass.gov/files/documents/2018/02/06/hos-12.pdf


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