West Virginia Medicaid Provider Workshops June 2007

Transcription

1 West Virginia Medicaid Provider Workshops June 2007 West Virginia Medicaid - Provider Workshops June 2007 Page 1

2 Topics of Discussion National Provider Identifier (NPI) Top Billing Issues Mental Health/HMO Issues WVMMIS Clinical Auditing Solution National Drug Code (NDC) Billing Requirement Medicaid Cost Reporting Requirement (handout) Billing Instructions when COB is involved (handout) Questions & Answers West Virginia Medicaid - Provider Workshops June 2007 Page 2

3 National Provider Identifier (NPI) Monthly mailings are still occurring to provider s who have not submitted their NPI. New Billing Instructions have been posted on the BMS and Unisys website Old claim forms will be accepted until If billing on the new claim form, follow the new billing instructions Providers can still submit claims with their Medicaid ID# s until notified. Taxonomy letters will be mailed to providers indicating the appropriate taxonomy code to use when billing West Virginia Medicaid - Provider Workshops June 2007 Page 3

4 Provider Billing Errors on the CMS 1500 (8/05) Providers are not billing their Medicaid Number prior to Submitting NPI s that are not listed in our system Submitting individual NPI in group NPI field or vice versa Submitting tax identification number in place of the NPI and Medicaid number Not placing 1D in front of the Medicaid Provider Number West Virginia Medicaid - Provider Workshops June 2007 Page 4

5 Mental Health/HMO Billing Issues Responsibility of WV Medicaid Office visits when performed by a Psychiatrist or Psychologist Inpatient claims when related to a psychiatric stay and all associated claims with place of service 21 Inpatient Psychiatric Facility, and all associated claims with place of service 51 School Based Services, place of service 03 Outpatient Electro-Shock Therapy RHC/FQHC Encounter rates for code T1015 HE West Virginia Medicaid - Provider Workshops June 2007 Page 5

6 Mental Health/HMO Billing Issues Responsibility of The HMO Outpatient services, such as labs and x-rays regardless of the diagnosis Office visits with a mental health diagnosis, place of service 11, unless performed by a Psychiatrist or Psychologist Inpatient acute care claims when related to a medical condition and all associated claims with place of service 21 RHC/FQHC Encounter rates for code T1015 Emergency Room Visit West Virginia Medicaid - Provider Workshops June 2007 Page 6

7 Clinical Auditing Solution Effective with dates of service 07/01/2007 the clinical auditing will include 90 days of historical auditing. The pre/post operative auditing will not include any dates of service prior to 07/01/2007. At this time clinical auditing will only apply to services submitted on a CMS 1500 claim form or services submitted via 837 transactions. CPT Manual, HCPCS Manual and CCI Coding ( sp#topofpage) guidelines should be utilized for service codes and for modifier usage. Claims will be reviewed for appropriate CPT/Modifier combinations. Code pairs in the DME manual that are not reimbursed together will be reviewed effective with dates of service 07/01/2007. West Virginia Medicaid - Provider Workshops June 2007 Page 7

8 Clinical Auditing Solution Ambulance services will be audited for oxygen usage based on policy represented in the transportation manual under attachment 3. Blood drawing fees will be included in the laboratory service on the same date of service. When billing for a repeat lab on the same date of service, a modifier 59 is required with the subsequent service submitted. Post payment review will be conducted to ensure proper usage of modifiers. If providers do not agree with a clinical audit denial, they should contact provider relations and plan to submit documentation for review. West Virginia Medicaid - Provider Workshops June 2007 Page 8

9 National Drug Code (NDC) Effective on dates of service July 1, 2007 and after If billing for a drug, you must bill with the appropriate NDC number Not Required for Inpatient Services Not Required for Immunizations Not Required for Radiopharmaceuticals The NDC number being submitted must be the actual NDC number on the package or container from which the medication was administered. Unit of Measurement is also required when billing the NDC number West Virginia Medicaid - Provider Workshops June 2007 Page 9

10 Unisys/ BMS Provider Workshops 2007 PROVIDER ENROLLMENT TIPS Licensure updates should be kept current to avoid payments being placed on hold. FAX to Provider Enrollment as soon as received Providers will be placed on pay hold if updated license is not received by expiration date. Provider will be terminated from WV Medicaid if updated license is not received within 30 days of expiration date. Change of address must be MAILED can result in important communication break down i.e. notification of licensure, receiving RA s, receiving updates on provider information CLIA Certifications-must be kept current FAX any updates or changes to provider Enrollment If enrolling more than two providers on same TAX ID, you must request a Group Medicaid number Enrollment Representatives will walk you through the process and assist you in the completion of all necessary forms. Update MEDICARE numbers (Linked to Medicaid Provider numbers) Failure to do so will result in crossover payments paying incorrectly. -May pay to wrong pay to provider or group provider -May not find correct provider to pay when crosses over Notify Provider Enrollment when you receive your National Practitioner Identifier (NPI) Provider Enrollment Address PO Box 625 Charleston, WV Page 1

11 Unisys/ BMS Provider Workshops 2007 CLAIMS PROCESSING TIPS Signature is required on claim. However, original Signature on Claim is not required. A Computer Generated or Stamp Signature is Acceptable Billing a continuing (multiple page claim) the claim total field on first page must read continuing and total line on final page should have the total of all charges. In addition to this, you may also write the following on the claim: Page 1 of 2, Page 2 of 2, etc. Multiple lines/dates on CMS 1500 or 837P earliest date on the claim becomes the header date. If this date is over one year, the entire claim will deny for timely filing. Span Date-If the date on the claim is a span date, the earliest date on the claim becomes the header date---if this date is over one year, the claim will deny for timely filing. Example: 1/1-1/31/06. Timely filing edit/denial will hit after 1/1/07 not 1/31/07. TIMELY FILING-Allow mail time and processing time Billing for immunizations under the Vaccine for Children (VFC) program If provider does not participate in the VFC program, they should not bill for immunizations. VFC immunization stock should be provided only to Medicaid eligible members (including those with primary insurance and Medicaid) If member has Primary insurance, you are not required to bill to the primary payer first as long as the diagnosis code is on the approved Pay Chase diagnosis codes. Pediatric Codes V01.0 thru V07.9 V20.0 thru V21.9 V70.0 V72.0 thru V72.3 V73.0 thru V75.9 V77.0 thru V78.9 V79.1 thru V79.9 V80.0 thru V80.3 V82.3 thru V82.9 Page 2

12 Unisys/ BMS Provider Workshops 2007 CODING TIPS Did you know that familiarizing yourself with coding and documentation requirements can reduce the number of denied and PEND claims? Types of documentation needed on unlisted codes: o Unlisted surgical codes-operative report and a brief description of why an unlisted code was used. o Unlisted Drugs/Vaccinations-description of service and cost invoice o Unlisted Laboratory service-name of test performed o Unlisted lesion removal-the documentation should include the size of all lesions removed. o Any other physician service not listed should include the physician s notes and a brief description of why an unlisted code was used A surgical history and physical does not provide adequate information for unlisted surgical services. All documentation needs to be legible. When required, all documentation needs to be the submitting physician s documentation. (Example team surgeon: Dr. Smith should submit his report and Dr. Jones should submit his report). Assistant and co-surgeons can use the primary physician s operative report; however, the need for an assistant or co-surgeon and his/her participation should be documented in the report. Examples: Unlisted Procedures or RBRVS indicates a requirement for documentation When a provider received a remit message of A1 (Claim Denied Charges) and no other remit message, the provider should call Provider Relations. When a provider submits a claim for procedure code 80299, the claim must have the following information: 1. Method by which the level is determined (i.e.: gas, chromatography) 2. Reference lab where the test was performed is pertinent 3. Request for Medical Director review. Page 3

13 Unisys/ BMS Provider Workshops 2007 COORDINATION OF BENEFITS TIPS Did you know that Secondary Claims can be submitted electronically? Did you know that secondary claims have special rules as it relates to PA requirements and payment methodology? Secondary claims can be submitted electronically through the Web Portal. Also, certain software applications are approved to upload secondary claim. When submitting electronically, you are not required to submit an EOB or EOMB. (keep on file) However, TPL Explanations of Benefits (EOB) are requested as a courtesy by BMS. These should be mailed to PO Box 3767 where they will be used to update member information. The receipt of the EOB will not hold up the processing of an electronic secondary claim. When sending these EOB s, attach a cover letter or note indicating that the claims have been filed electronically. Paper Secondary Claims when filing Medicare or TPL claims, do not enter payment information on the face of the claim---information will be taken from the attached EOB. PA Requirement--If a service requires PA and primary payer approves services, you are not required to submit claim to Medicaid with PA. If primary payer denies claim, request retro PA. (must provide EOB with denial when requesting retro PA) Payment methodology on TPL and Medicare claims is explained in Chapter 600 of WV Medicaid Provider Manuals Billing Denied Secondary Claims--Denied secondary claims should not be submitted electronically. These claims should be submitted on paper with EOB attached. If the EOB does not clearly summarize the explanation of the denial code, the provider must also attach a summary or key that clearly explains the reason for denial. These codes are not uniform and vary from one payer to another. Medicaid is not able to consider payment of a claim unless they can confirm why the primary payer denied the claim. (Note: Denied Medicare claims require only the EOMB as an attachment) Page 4

14 Unisys/ BMS Provider Workshops 2007 CLAIM IDENTIFIERS, REMITTANCE ADVICES, AND DEFINITION TIP SHEET Did you know that claim and claim submissions have identifiers that can assist you in knowing the history of a claim? Claim Number 07002E12345 Breakdown of claim number 07- Year in which claim was received 002- Day in the year claim was received, AKA Julian Date E- Claim was submitted electronically or paper claims that have been data scanned System generated number (numbering scheme from computer, no relative value to the provider) This information can be a useful tool to determine submission date and how long the claim has been in the system. What are the other identifiers and what do they mean? R within a claim number---reversed A within a claim number---adjusted by Unisys E in a claim number submitted electronically OR submitted as paper claim, scanned creating an electronic claim for processing. Claim number without alpha/letter-paper claim keyed and processed at Unisys Claim Status Definitions When calling into Provider Relations, you may hear some of these terms. Open, Adjudicated, or Pend Claim is currently being processed by Unisys, but has not yet been finalized. Denied-Claim is finalized and has been denied for a series of specific reasons/remarks To Be Paid Wait Pay the claim is currently in the payment process, but has not been released by BMS (check). When released by BMS, the status will then become PAID and will acquire a paid date, will appear on RA and have corresponding check number. Reverse-Original claim has been processed and PAID, but a payment error has been identified by either the provider or by Unisys. A reversal creates a negative dollar Page 5

15 Unisys/ BMS Provider Workshops 2007 amount equal to the original payment and will be retracted from future paid claims. (In some cases, these issues are Resolved by the provider writing a check but this should only be done with assistance to avoid a double take back of funds) In Process-Used when a claim is currently in our database, but not yet in a determined finalized status not yet determined to pay or deny. Reading Remittance Advices (RA) Tips Note both Billed Amount Column and the Paid Amount Column Reversal Remarks 125 and MA67- Provider initiated the reversal A7 if Unisys performed the replacement Note PA numbers, member numbers, internal account numbers Conflicting Claim Number-is the claim number that caused the current claim to deny as a duplicate. Status is the RA date the original claim paid or if the claim paid or if the claim is not yet paid but in a Wait Pay status. *note a duplicate claim can result as a previous claim submitted has paid, or is in the system approved for payment. (Can hit against a PAY, WAIT PAY, OR PAID Claim. Remit Date is located in upper right hand corner not the run date at bottom of page If member has HMO coverage, RA will reflect the name of the HMO. Page 6

16 Unisys/ BMS Provider Workshops 2007 WEB PORTAL & EDI TIPS WEB PORTAL Internet Access Required Free Transactions One on One Training Available (free) Functions Available Claim Status Reports Eligibility Reports Claims Submission Secondary Claims (for approved claims) Reversal/Replacements Resources HIPAA Codes Crosswalk Reports Received Faster CLAIMS IN PROCESS REPORT (CIP) Additional Reports available (CIP, Check Report) ELECTRONIC REPORT All electronic transactions (including secondary claims, reversals, and reversal/replacements are subject to 824 editing process and 824 Rejection reports must be monitored. If a claim rejects, the claim is never processed in the system and will never appear on a Remittance Advice. If you are submitting claims electronically and call for claim status and find that a high number of claims are not in our system, you most likely need to check the 824 Rejection Report If you are submitting claims electronically, and call for claim status or check your CIP report and find that a high number of claims are not in the system, you will need to check your 824 rejection reports. Claim Status Report-denied claim will indicate check date vs. the RA date...back up the date by 3-5 days to determine the RA date To check status by means of a 276, the claim status inquiry must be submitted on the rendering or servicing provider number-not group number. If you request on the Group #, the result on the report will read No Encounter Found When verifying eligibility by means of a 270, a span of dates can now be entered as well as a single date. If Member has Medicaid, all information will be reported including TPL, HMO, Medicare, QMB Page 7

17 Unisys/ BMS Provider Workshops 2007 FINANCE TIPS Change Banking Information-fax to (304) attention Finance Department Electronic Funds Transfers (EFT s) require Financial Institution Signature OR Voided Check OR Letter from Bank stating Account # and routing #. A deposit slip is most usually not acceptable (does not include routing #) EFT form must have ALL information completed don t leave blanks EFT must list name of bank, bank s phone number, bank s address, and contact information. EX: Bank One national chain of banks information varies from state to state as it relates to routing information Payments received-if you receive payment for services not provided notify PR immediately determine the issues early and work towards resolution. Need a Check Trace-Contact PR Need back up for posting (i.e. RA s) Contact PR Check or payment received that does not say REG-MED is not a Medicaid payment. Unisys cannot provide any information regarding these payments. Provider would contact WV Treasury Department Reversing payments to correct a claim do not send BOTH CHECK AND REVERSAL FORM. Submit Reversal Form ONLY. Recommend that provider work closely with a representative on these issues. Page 8

18 Unisys/ BMS Provider Workshops 2007 PROVIDER SPECIALTY BILLING TIPS Long-Term Care Providers (LTC) MDS Authorization Data must be in to OFLAC per the dates on the published BMS schedule for the extraction of data. (usually around the 9 th or 10 th of the month) If the provider misses this window, claims submitted will deny. The extraction does not occur again until the following month. The denied claims are not automatically recycled and must be resubmitted by the provider. Dental Providers We recommend that dental providers not bill more than one unit per service line. When billing paper claims or Direct Data Entry claims on the Web Portal, this is not an issue as neither option will accommodate more than one unit per service line. However, if you are uploading claims through the Web Portal, VAN, Clearing House, etc., it is possible to submit more than one unit per line. This could affect the payment of claims and Provider Relations Representatives cannot view multiple units in the system when you inquire on claims. When billing secondary claims and only partial lines that are partially approved/paid by primary insurance, you need to split bill the claim. All lines that were paid or approved by the primary insurance must be billed on one claim and all lines denied on a separate claim. EOB s must be attached to both with applicable lines indicated. When split billing, make sure totals on each claim is correct. Tooth numbers should be single digits. Example #3 not 03 Page 9

19 BILLING INSTRUCTIONS WHEN OTHER INSURANCE IS PRIMARY Providers must follow all primary insurance requirements prior to billing Medicaid. If the provider is not enrolled in the primary insurance plan, he/she must inform the member to either see a provider in their primary plan network or be responsible for payment of the services if they choose not to use a provider in their plan network. Under no circumstances should the provider bill primary insurance and Medicaid at the same time: primary insurance must be billed first. If primary insurance pays on or approves a service, the provider does not have to obtain a PA from WVMI. An approved claim will include one or all of the following listed on the EOB: allowed amount, paid amount, co-insurance amount and/or deductible amount. Patient responsibility is considered co-insurance. Orthodontic and periodontal services will still require a PA from WVMI regardless of what the primary insurance does or does not approve. If the primary insurance denies a service, the service must be billed on paper with a copy of the EOB attached. The EOB must show all fields on the EOB include denial reasons and remark codes. The explanation of the remark codes and denial reasons must also be sent or the claim will be returned. If the EOB states the claim was previously considered, the original EOB must also be sent with the claim. If the EOB is the result of a claim adjusted by the insurance company, both the original and adjusted EOB should be attached to the claim. Because dental claims are paid at the header level instead of the line level, line items which are denied by the primary insurance should be billed separately with the EOB attached and the denied lines highlighted. The line items paid by the other insurance should also have the EOB attached and the paid lines highlighted. Unlike Medicare, all primary insurance claims are subject to the Medicaid timely filing regulations of twelve (12) months from the date of service not twelve (12) months from the date of the EOB. If the claim is Medicare and private insurance, the timely filing deadline is twelve (12) months from the date on the Medicare EOMB. Claims related to accidents or trauma, e.g., auto, slip and fall, etc., must be pursued for the possibility of a liable third party before Medicaid is billed. If, after a reasonable time and prior to the twelve (12) month timely filing requirements, payment has not been received or a settlement has not been reached, the provider may bill Medicaid with all pertinent information. Once Medicaid has been billed, the provider must accept the Medicaid payment as payment in full and cannot bill the patient for any remaining balance. In all instances, whether it is commercial insurance or payment received from a settlement, once Medicaid has been billed, the provider must accept the Medicaid payment as payment in full; therefore, if any primary payer pays the provider after Medicaid has paid, the provider must first refund Medicaid and then if there is any excess over the Medicaid payment, that amount must be refunded to the patient. For more information review Chapters 600 and 700, 620, 620.1, and for Chapter 600 and 745, in Chapter 700 and Appendix G Subrogation as well as Appendix E Third Party Liability

20 Timely Filing Policy To meet timely filing requirements for WV Medicaid, claims must be received within one year from the date of service The year is counted from the from date on a CMS 1500, ADA 2006 or UB04 to the receipt date of the claim. Claims that are over one year old must have been billed and received within the one year filing limit. The original claim must have had the following valid information listed on it: Valid provider number Valid member number Valid date of service Valid type of bill (UB-04, CMS 1500, ADA 2006 or Universal Billing Form for Pharmacy) Claims that are over one year old must be submitted to Provider Relations with a copy of the a remittance advice showing where the claim was received prior to turning a year old Service dates (claims) over two years old are NOT ELIGIBLE for reimbursement. This policy is applicable to reversal/replacement claims If a reversal/replacement claim is submitted with a date of service that is over one year old, the replacement claim must be billed on paper with a copy of the original remittance advice You are NOT allowed to add additional services to the replacement claim If additional services are billed on the replacement claim that were not billed on the original claim and the dates of service are over one year old, the claim will be denied for timely filing Medicare Primary Claims Timely Filing The normal WV Medicaid timely filing requirement for Medicare primary claims is one year from the EOMB date Claims Processing The back log of all paper Medicare primary claims has been processed Beginning 07/08/2005, the web portal is available to direct data enter Medicare and TPL primary claims TPL Primary Claims Timely Filing The normal WV Medicaid timely filing requirement for TPL primary claims is one year from the date of service Backdated Medicaid Cards When a Member has a backdated Medicaid card the Member must provide a copy of the card/letter of eligibility (LOE) to the Provider. Providers have one year from the date the eligibility was backdated in order to get the claim in. The claim must be sent on paper with a copy of the card/loe to our Provider Relations address at P O Box 2002 Charleston WV in order for us to verify the card was truly backdated. Once verified, timely filing will be waived and the claim will be submitted for processing. Special Exceptions for HMO Unisys will accept HMO Medicaid remits as proof of timely filing. The HMO must be one of the Medicaid HMOs acting on behalf of Medicaid, not an HMO that has a private insurance policy for the member. The claim could be denied for timely filing from the HMO as they sometimes have a 3 month billing period, but if the date of denial is not over a year from the date of service it can be used as proof of timely filing. 824 s as Proof of Timely Unisys will accept a Unisys 824 rejection as proof of timely filing. The 824 must contain valid values for the following: Provider Name and Number, Member Name or Number (either or), Date of Service, Claim Type, and the Date it was rejected. The general timely filing rules apply as specified above and special cases will be reviewed by BMS. WV Medicaid Timely Filing Policy

21 Summary of Medicaid Cost Report Requirement Revisions Effective November 1, 2006 (For informational purposes only; please refer to the West Virginia Medicaid Chapter Provider Participation Requirements Manuals at for complete rules and regulations regarding cost report submission requirements.) The following provides a summary of the West Virginia Medicaid program cost report submission requirements: o Section Medicaid Cost Report Submissions and Filing Deadlines o Cost reports must be filed with OAMR by applicable due date (see chart in for due dates and applicable cost report forms). Regardless of whether providers file electronically with their Medicare intermediary, a hard (paper) copy of the cost report with required supporting schedules is required to be filed with OAMR. The filing address is: WVDHHR-Office of Accountability & Management Reporting ATTN: Division of Audit & Rate Setting 1900 Kanawha Blvd., East State Capitol Complex Building 3, Room 550 Charleston, WV o Cost reports must include an original signature on the certification page and include a transmittal letter or memorandum that states that the cost report is intended to satisfy the West Virginia Title XIX Medicaid reporting requirements o For CMS Filers-cost report filing should include a settlement summary calculation including the following elements that shows the settlement amount due to or from the WV Medicaid program: Provider Name: Provider Number(s): Calculation of WV Medicaid Settlement: Rate per Visit $XXX.XX WV Medicaid Visits during the reporting period X,XXX Total cost for Covered WV Medicaid Visits XXX,XXX Less: Total payments received (XXX,XXX) Balance due to (or from) WV Medicaid $ XX,XXX o Section Cost Report Extensions o Extensions of up to 30 days must be requested in writing prior to the cost report filing deadline; extension request must include cause o OAMR will provide a written response approving or rejecting the extension request along with extended due date o OAMR will honor extensions granted by Medicare; provider must notify OAMR in writing (prior to the cost report filing deadline) of the extension and provide a copy to OAMR

22 Summary of Medicaid Cost Report Requirement Revisions Effective November 1, 2006 (For informational purposes only; please refer to the West Virginia Medicaid Chapter Provider Participation Requirements Manuals at for complete rules and regulations regarding cost report submission requirements.) o Section Cost Report Exemptions o Providers with no WV Medicaid utilization or low WV Medicaid utilization may request an exemption in writing from OAMR o Exemption request must be submitted prior to cost report filing deadline o Section details low utilization criteria (provision of services to less than five WV Medicaid recipients during provider s fiscal year) o Cost report may be required even if provider meets low utilization criteria o Section Cost Report Late Filing Penalties o OAMR will notify providers in writing when cost reports are not received by the cost report filing deadline o Upon the thirtieth day after the cost report filing deadline has passed, the provider becomes subject to suspension of future interim payments until such time as an acceptable cost report submission is made o Continued failure to submit an acceptable cost report may result in termination from the WV Medicaid program (in accordance with section 310.7)

23 DIAGNOSIS CODES WHICH CAN BE BILLED TO MEDICAID AS PRIMARY PRENATAL CODES PEDIATRIC CODES V22.0 THRU V22.1 V01.0 THRU V07.9 V23.0 THRU V23.9 V20.0 THRU V21.9 V24.0 THRU V24.2 V70.0 V27.0 THRU V27.9 V72.0 THRU 72.3 V28.0 THRU V28.9 V73.0 THRU V THRU V77.0 THRU V V79.1 THRU V THRU V80.0 THRU V THRU V82.3 THRU V THRU 677 These codes have been mandated by CMS as pay and chase claims. The provider can bill Medicaid as primary for these diagnosis codes and Medicaid will pursue payment with the primary insurance.

24 NDC SUBMISSION FOR PHYSICIAN/OUTPATIENT FACILITY ADMINISTERED DRUGS The Deficit Reduction Act of 2005 (DRA) requires that Medicaid agencies collect rebates from drug manufacturers for physician/outpatient facility administered drugs. (A drug rebate is a payment that a manufacturer who has agreed to participate in Medicaid pays the State after an invoice has been submitted to them by the State.) Per the Centers for Medicare and Medicaid Services (CMS Federal agency that oversees Medicaid), Medicaid agencies MUST collect NDC information on claims for physician/outpatient facility administered drugs in order to receive Federal matching funds. Rebates must be invoiced to manufacturers based on the drugs National Drug Codes (NDC) The NDC code is found on the drug container and consists of 11 digits (XXXXX- XXXX-XX). Some packages will display less than 11 digits, but leading 0 s can be assumed. For example: XXXX-XXXX-XX = 0XXXX-XXXX-XX XXXXX-XXX-XX = XXXXX-0XXX-XX XXXXX-XXXX-X = XXXXX-XXXX-0X o XXXXX (identifies the manufacturer) XXXX (identifies the drug product) XX (identifies the package size) Units for NDCs must also be submitted. The four valid units of measure for NDC codes are: International unit (F2) Gram (GR) Milliliter (ML) Unit of Each (UN) o Units for NDC codes may be different than units for HCPCS codes o You may bill partial NDC units with decimals (i.e., 0.6ml) General rules for NDC s: If vial contains powder, bill the number of EACH vials used If a vial contains liquid, bill the number of MILLILITERS (mls) or decimal of ML used If a factor product (i.e., antihemophilia factor), bill the number of international units used If oral tablets or capsules, bill the number of EACH tablet or capsule used Examples:

25 Ceftriaxone 1GM injection Bill J0696 (per 250mg) X 4 units AND NDC (for example) (ceftriazone 1gm vial) X 1 unit tobramycin 80mg injection Bill J3260 X 1 unit AND NDC (for example) (tobramycin 40mg/ml, 2ml vial) X 2 units enoxaparin sodium, 60mg injection Bill J1650 (per 10mg) X 6 units AND (for example) (enoxaparin 60mg/.6ml syringe) X.6 units Other rules also apply o The Provider MUST bill the NDC that is USED not just one that is on a reference file. It is considered fraudulent billing, is illegal to submit claims for drugs that are not administered or dispensed, and is subject to audit. o The manufacturer must be participating in the Federal Drug Rebate Program for Medicaid agencies to receive federal funds for prescription drugs. Drugs that are not rebate eligible are not covered. o Drugs that are classified as Less Than Effective (DESI) by the FDA are not eligible for federal funds and are not covered. o Vaccines do not meet the definition of drugs and NDCs for these products are not required. Beginning July 1, 2007, WV Medicaid will begin accepting NDC codes on CMS forms and UB-04 forms both paper and electronically submitted claims. o Edits will be set to WARN initially o The claims with these edit warnings will be shown on the providers Remittance Advice o Edits will WARN for: NDC not on the form NDC does not match HCPCS code NDC is not rebate eligible Units for NDC not on the form Beginning October 1, 2007, claims will DENY if the NDC codes and their respective units are not submitted appropriately. NOTE claims will still be priced and adjudicated based on the HCPCS codes not the NDC codes. NOTE Medicare cross-over claims will be priced and adjudicated based on Medicare guidelines. Even though Medicare may not require the submission of NDC codes, it will be beneficial to the State if NDC codes are included, as the State is allowed to collect rebates for these drugs.

26 The BMS website is the best place to look for information regarding this significant change Look for: o Frequently Asked Questions (FAQs) o The list of drugs which are covered, have special limitations/requirements and/or require an NDC o The HCPCS NDC Crosswalk NDCs will be noted whether they are rebate eligible o Provider billing instructions Providers may call for assistance with NDC codes to the Unisys Provider Services at PLEASE PASS THIS INFORMATION TO OTHER INTERESTED PARTIES AND SUBMIT YOUR QUESTIONS TO: medpharm@wvdhhr.org

27 Unisys Contact List Name Phone Fax /Address Unisys Provider Relations Unisys Members Unisys EDI PO Box 2002 Charleston, WV PO Box 2002 Charleston, WV PO Box 625 Charleston, WV Unisys Pharmacy Help Desk Unisys Provider Enrollment Unisys Claim Address PO Box 3765 Charleston, WV PO Box Charleston, WV PO Box 3765-Pharmacy PO Box UB92 PO Box 3767-HCFA 1500 PO Box 3768-ADA Dental PO Box Provider Relations PO Box Hysterctomy, Sterlization and Pregnancy Termination Forms Charleston, WV Rational Drug Therapy Help Line WVMI- Outpatient or or WVMI- INPT WVMI- All other Carelink Customer Service Virginia St E Suite 400 Charleston, WV Carelink Member Advocate- Dennis May Carelink Medicaid Manager- Todd White

28 Name Phone Fax /Address Unicare Director Regional Field Office and Advocate- Mitch Collins Unicare Customer Service The Health Plan of the Upper Ohio Valley-Customer Service The Health Plan Member Advocate & Manager Government Programs Jennifer Johnson BMS Main Number Quarrier St. Charleston, WV

29 Presented by, Shannon Riley West Virginia Department of Health and Human Resources Bureau for Medical Services

30 DEMOGRAPHICS West Virginia Beneficiaries By Expenditures WEST VIRGINIA MEDICAID BENEFICIARIES AND EXPENDITURES BY ENROLLMENT GROUP 100% 90% 80% 70% 8.33% 24.39% 21.00% Elderly (31,144) Blind & Disabled (91,190) Adults (60,233) Children (191,316) 60% 50% 16.11% 44.16% 40% 30% 20% 10% 0% 51.17% Beneficiaries 7.48% 27.36% Expenditures Note: Beneficiaries are enrollees who received a Medicaid service. Blind & Disabled includes adults, children, and elderly who qualify based on a disability.

31 DEMOGRAPHICS Population Forces Driving Changes 85% of Medicaid members have or are at-risk for a chronic condition 70% of Medicaid members are overweight or obese 70% of Medicaid members are sedentary

32 Implementation Mountain Health Choices began with establishment of a medical home for each Medicaid member. has started small in order to build on successes. is responsive to providers and members when changes are necessary. is focused on the AFDC-related population in the first phase and will encompass 63% of the Medicaid population when rolled out statewide.

33 Phase I-Rollout I by County System triggers for member inclusion: Re-determination date ( Rate code (AFDC-related population) Geographical location Implemented in 3 counties and counting.

34 Process Mountain Health Choices Member Information Packet (mailed to all eligible members 60 days in advance of re-determination date) New Program Notice and Benefit Changes Steps for Enhanced Plan Enrollment Member Responsibility Agreement Health Improvement Plan Benefit Package Descriptions

35 Mountain Health Choices Member Information IMPORTANT NOTICE ABOUT CHANGES TO YOUR MEDICAID BENEFITS Your Medicaid Plan is now called MOUNTAIN HEALTH CHOICES

36 Process-Program Program Announcement Informs members of a choice of Benefit Plans Basic or Enhanced Instructs members to call their Medical Home to schedule a check-up, discuss the Member Responsibility Agreement and develop a Health Improvement Plan with their health care provider in order to receive the Enhanced Benefit Plan

37 Basic Benefit Package Basic Benefit Package-Covers all mandatory services and some optional services, but with limits including: 4 Prescriptions per month 5 NEMT round trips per year No chiropractic or podiatry services

38 Enhanced Benefit Package Covers all basic benefits plus new ones.. Weight Management Programs (including diet and exercise opportunities) Nutritional Counseling Diabetes Education Smoking Cessation Cardiac Rehabilitation Services More non-emergency medical transportation and

39 Enhanced Benefit Package No limits on the number of prescriptions Contact lenses for children Chiropractic Visits Podiatry Visits Cardiac Rehabilitation and in the future. Access to a Healthy Rewards Account (under development)

40 Member Agreement I will go to my medical home when I am sick. I will take my children to their medical home when they are sick. I will go to my medical home for check-ups. I will take my children to their medical home for check-ups. I will take the medicines my health care provider prescribes for me. I will show up on time when I have my appointments.

41 Member Agreement I will bring my children to their appointments on time. I will call the medical home to let them know if I cannot keep my appointments or those for my children. I will let my medical home know when there has been a change in my address or phone number for myself or my children.

42 Health Improvement Plans Adults and Adolescents/Children Members and providers agree upon goals: preventive screenings immunizations laboratory tests number of well visits for the year health education classes

43 Outcomes and Measurements Compliance with medications Missed appointments Compliance with screenings Compliance with health improvement programs (All measured with claims data)

44 Facts and Figures Over 100 Member Responsibility Agreements returned It s s been very slow going, but picks up each day as the 90 day deadline grows closer..

45 Lessons Learned Members want to make healthier choices. Providers are enthusiastic about rewards for discussing the Member Agreements and Health Improvement Plans. Provider and member education is key to success.

46 West Virginia Mountain Health Choices Creates a partnership of Medicaid, its members and the medical homes Is patient-centered with pro-active personalized care Uses teams providing Continuity of Care (not episodic)

47 West Virginia Mountain Health Choices Seeks to address long term program growth by promoting prevention and wellness Provides shared accountability Encourages integration of technology into medical homes

48 Contact Shannon Riley West Virginia Department of Health and Human Resources Bureau for Medical Services (304)