west virginia children’s - wvmmis.com provider workshops/wv... · wvchip – out-of-state...
TRANSCRIPT
West Virginia Children’s Health Insurance
Program (CHIP)
Jennifer J. Myers, Benefit and Enrollment Specialist, Fall 2015 Provider Workshop
WVCHIP - Eligibility
Children are eligible if they:
Reside in West Virginia
Are under age 19
Are not eligible for West Virginia Medicaid and are not covered under any other creditable coverage
Income and family size fall within qualifying Income Guidelines
Are United States citizens or qualified aliens
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WVCHIP – Income Guidelines
Annual Income Guidelines for WVCHIP:
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Family Size Medicaid Max
WVCHIP Gold
WVCHIP Blue
WVCHIP Premium
2 $21,186 $23,895 $33,613 $47,790
3 $26,719 $30,135 $42,390 $60,270
4 $32,252 $36,375 $51,168 $72,750
5 $37,785 $42,615 $59,946 $85,230
6 $43,318 $48,855 $68,723 $97,710
WVCHIP - Coverage
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WVCHIP - PERM
PERM (Payment Error Rate Measurement)
The purpose of this audit is to produce a national level error rate for Medicaid and CHIP in order to comply with the requirements od the Improper Payments Elimination and Recovery Improvement Act (IPERIA).
West Virginia – PERM CHIP FY 2013 Findings:
WVCHIP error rate = 13.2%
National error rate = 4.8%
Provider did not submit documentation = 5
Provider submitted insufficient documentation = 7
Non-covered service = 60
Other = 5
Our next cycle begins with dates of service 10/1/2015.
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Pharmacy claims will continue to be processed by ESI.
Medical/Dental claims date of service current – 12/31/2015 submit to:
HealthSmart Benefit Solutions
All Claims: PO Box 2451 Charleston, WV 25329-2451
Medical/Dental claims date of service 1/1/2016 and after submit to:
Molina Medicaid Solutions
UB04: PO Box 3766 Charleston, WV 25337
CMS 1500: PO Box 3767 Charleston, WV 25337
ADA: PO Box 3768 Charleston, WV 25337
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WVCHIP – Claim Submissions
WVCHIP – Provider Enrollment
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.
Providers that are currently enrolled and have revalidated with Medicaid will not need to go through a full enrollment with WVCHIP.
Molina will provide an abbreviated form for WVCHIP enrollment.
These forms are located in your packet and can also be found at the CHIP table.
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WVCHIP – Out-of-State Providers
Out-of-State Providers
WVCHIP does not cover services provided out-of-state that are available from in-state providers, except for emergencies and office visits to primary care physicians (family and general medicine physicians, internists, and pediatricians) in counties bordering West Virginia in surrounding states. (Routine childhood vaccines from out-of-state providers, including border providers, are not covered – routine childhood vaccines are covered when received from in-state Vaccine for Children’s program (VFC) providers.)
There are exceptions for medical necessity and emergencies. To meet the criteria as a covered benefit, the service must be medically necessary, and the type of care must not be available within the State of West Virginia, as determined PRIOR to the service.
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WVCHIP – Out-of-State Providers, cont.
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.
WVCHIP uses the Public Employees Insurance Agency’s fees. These can be found on their website, http://www.peia.wv.gov.
Dental fees can be found at http://www.dhhr.wv.gov/bms/Documents/Fee%20Schedule/DentalFeeSchedule.
You may also send an inquiry to [email protected].
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WVCHIP – Orthodontic Treatment
Comprehensive orthodontic treatment is payable once per lifetime. Coverage is not automatic and must meet certain criteria and 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 Xray
Photographs – A standard series of 5 Intra and 3 Extra Oral photographs that meet the American Board of Orthoditic standards
Treatment Plan including findings, prognosis, length of treatment, and phases of treatment
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WVCHIP
For eligibility, application status, renewals and general information: WVCHIP HelpLine at 1-877-982-2447
Health claims and benefits, and eligibility prior to 1/1/2016: HealthSmart at 1-800-356-2392
Health claims and benefits, and eligibility after 1/1/2016:
Molina at 1-800-479-3310 or 304-348-3390
Prior-authorizations: HealthSmart at 1-800-356-2392
Prescription drug benefits: Express Scripts at 1-877-256-4689
Provider enrollment: Molina Medicaid Solutions at 1-888-483-0793
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Contact
Jennifer J. Myers Benefit and Enrollment Specialist 2 Hale Street, Charleston, WV 25301 Phone: 304-957-7864 Fax: 304-558-2741 Email: [email protected]
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