MassHealth Provider Services Update
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1 MassHealth Provider Services Update Executive Office of Health & Human Services April, 2017
2 AGENDA Ordering, Referring and Prescribing Updates Entity PCC Referrals POSC Provider Search Tool Fingerprint Based Criminal Background Check Contact Resources Directory 2
3 Ordering, Referring and Prescribing Update 3
4 Ordering and Referring (O&R) Requirements Background 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, Final Rule (42 CFR (b) and 42 CDR ) was published in the Federal Register on Feb. 2, Subregulatory guidance was given to states on December 23, MassHealth is continuing its implementation efforts. In March 2016 we began providing informational messaging on certain impacted claims. 4
5 O&R Requirements Provider Types (including interns and residents in those provider types) authorized to be included on a claim as the ordering, referring or prescribing provider Certified Nurse Midwife Certified Registered Nurse Anesthetist Clinical Nurse Specialist Dentist Licensed Independent Clinical Social Worker Nurse Practitioner Optometrist Pharmacist (if authorized to prescribe) Physician Physician Assistant Podiatrist Psychiatric Clinical Nurse Specialist Psychologist 5
6 O&R Requirements (continued) MassHealth is implementing the O&R requirements in several phases. On 2/26/16 MassHealth posted Provider Bulletin 259 for billing providers regarding the ordering, referring and prescribing provider requirements and the implementation phases. Phase 1A MassHealth began providing informational messages on certain claims for dates of service on or after March 7, 2016 that do not meet the O&R requirements listed below: - The ORP provider s NPI must be included on the claim. - The ORP provider must be one of the provider types listed on the previous slide. - The ORP provider must be enrolled with MassHealth, at least as a nonbilling provider. 6
7 O&R Requirements (continued) Claims impacted in Phase 1B (informational messaging is anticipated to begin in spring 2017). All claims (professional and institutional - 837P, 837I, CMS 1500 and UB-04) that currently require a PCC referral, regardless of billing provider. All professional claims (837P and CMS 1500) from certified Independent Labs and Diagnostic Testing Facilities. Phase 2 In Phase 2, effective date TBD, the claim types impacted in Phase 1 will not be payable if they do not meet O&R requirements. 7
8 O&R Requirements (continued) Phase 3 Phase 3A (Informational Messaging is anticipated to begin in spring 2017, claims denial date TBD) will impact the following claims: - Institutional claims (837I and UB-04) for home health services - Professional claims (837P and CMS 1500) for certain PCA related procedure codes. Phase 3B (Informational Messaging begin date TBD) - Institutional claims (837I & UB-04) for labs and diagnostic testing - All professional claims (837P and CMS 1500) for labs and diagnostic testing codes(such claims were included in Phase 1 only when billed by Labs and Diagnostic testing facilities). 8
9 O&R Requirements (continued) Next Steps Providers that order, refer or prescribe services for MassHealth members will need to include their NPI on and written orders, referrals and prescriptions. Effective June 1, 2017 MassHealth will update the process for entity PCC referrals to ensure they meet the O&R requirements. See Provider Bulletin #265 for more information. MassHealth will implement Phase 1B and 3A (informational messaging on claims for services that require a PCC referral, claims from labs and diagnostic testing facilities, institutional claims for home health services and certain PCA claims) during the spring of
10 O&R Requirements (continued) Entity PCCs referrals ORP providers included on a claim must be individual providers The POSC referral panel has been updated so that entity PCCs can identify an individual provider within the PCC entity as the PCC plan referring provider when entering a referral. All Provider Bulletin #265 about this update was posted on March 3, Effective June 1, 2017, entity PCC referrals will not go through unless an affiliated, enrolled individual provider has been selected The PCC referral letter has been updated to include the name and NPI of the individual referring provider within the PCC entity The customer service team has been reaching out to entity PCCs to collect lists of their individual referring providers in order to add them to the entity PCC s list on the POSC panel Entity PCCs should ensure that their individual referring providers are enrolled with MassHealth, at least as nonbilling providers, so that their PCC referrals can go through and so that claims based on their PCC referrals can be payable 10
11 O&R Requirements (continued) 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. 11
12 O&R Requirements (continued) POSC Provider Search Function You can search using a combination of criteria. 12
13 O&R Requirements (continued) 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 EHR only or could be in a provider type that is not authorized to Order, Refer or Prescribe. 13
14 Fingerprint Based Criminal Background Checks 14
15 Fingerprint Based Criminal Background Checks Section 6401 of the Affordable Care Act requires a fingerprint-based criminal background check as part of new screening requirements for all high risk providers and all persons with a 5% or greater direct or indirect ownership interest in such providers. The following is a list of the provider types that have been classified as high risk. Adult Foster Care Providers Group Adult Foster Care Provider New enrollees in the following provider types: o Durable Medical Equipment Providers & Personal Emergency Response System (PERS) Providers (newly enrolling on or after August 1, 2015 only) o Home Health Agencies (newly enrolling between August 1, 2015 and February 10, 2016) Due to the moratorium, we haven t enrolled any since that date 15
16 Fingerprint Based Criminal Background Checks (continued) New enrollees in the following provider types: (continued ) o Orthotics Providers (newly enrolling on or after August 1, 2015 only) o Oxygen & Respiratory Therapy Equipment Providers (newly enrolling on or after August 1, 2015 only) o Prosthetics Providers (newly enrolling on or after August 1, 2015 only) Any provider that meets one of the following criteria: o Have a payment suspension based on a credible allegation of fraud, waste, or abuse on or after August 1, 2015; o Excluded by OIG or another state Medicaid program within the past 10 years; o Had a qualified overpayment and is enrolled or revalidated on or after August 1, 2015; or o In a provider type that was previously subject to an enrollment moratorium who applies to enroll during the first six months after the moratorium is lifted. 16
17 Fingerprint Based Criminal Background Checks (continued) Notification and Process MAXIMUS has been outreaching to all affected providers during March. Providers will receive written notification from MassHealth that they and/or their owners are required to be fingerprinted through the Statewide Fingerprint Identification Services (SAFIS) for a fingerprint-based check of state and national criminal history databases. We are targeting to send letters out prior to implementation. Each person is required to schedule an appointment and have their fingerprints scanned within 30 days of notification. Providers must ensure that each of their qualifying owners have an appointment within this timeframe. The notification letter will include information on how to schedule an appointment by visiting the MorphoTrust USA IdentoGo The website contains information about the fingerprint services, locations, hours of operation, and acceptable forms of identification. 17
18 Fingerprint Based Criminal Background Checks (continued) Notification and Process Continued The appointment has been scheduled when the individual receives a registration ID number from MorphoTrust. Each individual should bring this ID number to the appointment. Failure to have the fingerprints of each individual on the notification letter scanned within thirty (30) days may result in denial of an enrollment application or termination of enrollment with MassHealth. To avoid a denial or termination, providers may be required to remove any owners who fail to have their fingerprints scanned within 30 days, or are found to have a criminal history unacceptable to the MassHealth agency. 18
19 Contact Resource Directory 19
20 Resources MassHealth Customer Service Center: by at or by phone at O&R Application/Contract enrollment-information.html All Provider Bulletins MassHealth Provider Library MassHealth Job Aids for including eligibility and referral verification 20
21 Questions? 21
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