West Virginia Trading Partner Account (TPA) Eligibility Verification User Guide Date of Publication: 01/19/2016 Document Version: 1.1
Privacy Rules The Health Insurance Portability and Accountability Act of 1996 (HIPAA Public Law 104-191) and the HIPAA Privacy Final Rule 1 and the American Recovery and Reinvestment Act (ARRA) of 2009 provides protection for personal health information. Protected Health Information (PHI) includes any health information and confidential information, whether verbal, written or electronic, created, received, or maintained by Molina Healthcare. It is health care data plus identifying information that allows the data to tie the medical information to a particular person. PHI relates to the past, present and future physical or mental health of any individual or member; the provision of health care to an individual; or the past, present or future payment for the provision of health care to an individual. All member information including but not limited to claims data, prior authorization information, and attachments such as medical records and consent forms are all PHI. 1 45 CFR Parts 160 and 164, Standards for Privacy of Individually Identifiable Health Information; Final Rule Proprietary and Confidential Molina Medicaid Solutions Page ii
Disclaimer This document and information contains proprietary information. WV MMIS Authorization is hereby provided to you to copy documents published by Molina Medicaid Solutions on the Health PAS-Online portal provided such copies are used for non-commercial purposes and solely for use within your organization. This authorization is specifically conditioned upon including all legends, copyright, proprietary, and other notices that appear herein on all copies you make of such documents whether they pertain to Molina or another party. No license is granted herein expressly, impliedly, by estoppel or otherwise under any patent or to use any trademark of any party. No other rights under any copyrights are granted herein, except as expressly stated above. The documents herein may refer to products and/or services that are neither available nor planned for availability in your particular locality. In referring to such products and/or services, Molina incurs no obligation to subsequently make them available in your locality. DOCUMENTS PUBLISHED HEREIN ARE FURNISHED TO YOU "AS IS." THERE ARE NO WARRANTIES, EXPRESS, OR IMPLIED, BY OPERATION OF LAW OR OTHERWISE. MOLINA DISCLAIMS THE IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE AND NON-INFRINGEMENT AS TO BOTH MOLINA AND NON-MOLINA DOCUMENTS FURNISHED HEREIN. Some states or territories do not allow the exclusion of implied warranties and the foregoing exclusions may not be applicable to you. Any communication provided by you to Molina relating to the documents furnished herein by Molina will be received only on a non-confidential basis. There shall be no obligation on the part of Molina with respect to use or disclosure of any information in such communication. Molina shall have the unrestricted right to copy, use, and distribute any information you communicate including, but not limited to any ideas, concepts, know-how, techniques, software, documentation, diagrams, schematics, or blueprints. Additionally, Molina may use all such information in any manner or for any purpose including, but not limited to developing products or providing services. The documents furnished herein by Molina are subject to change without notice. All brand names and product names are acknowledged to be the trademarks or registered trademarks of their respective owners. Proprietary and Confidential Molina Medicaid Solutions Page iii
Revision History Version Date Author Action/Summary of Changes Status 1.0 01/18/2016 Molina Updated to the approved version after BMS approval Approved 1.1 01/22/2016 Molina Updated hyperlinks with new portal location Approved Proprietary and Confidential Molina Medicaid Solutions Page iv
Table of Contents 1. Introduction... 1 2. Logging into your TPA Account... 1 3. Check Eligibility... 2 3.1 Eligibility Inquiry... 6 3.2 Eligibility Verification Response... 7 3.3 Enrollments... 9 3.4 Other Insurance... 10 3.5 Copay... 11 3.6 Primary Care Provider... 11 3.7 Lock-In... 11 3.8 Limitations... 12 3.9 Spend Down... 12 4. Print Receipt... 13 Appendix A. Acronyms and Abbreviations... 14 Table of Figures Figure 2-1: Provider Sign In... 1 Figure 2-2: Username and Password... 2 Figure 3-1: Accessing Eligibility Verification... 3 Figure 3-2: Member Search... 3 Figure 3-3: Eligibility Verification Screen... 4 Figure 3-4: Coverage Code Details... 5 Figure 3-5: Participant Information... 6 Figure 3-6: Eligibility Inquiry... 7 Figure 3-7: Eligibility Verification Response... 8 Figure 3-8: Enrollment Tab... 10 Figure 3-9: Other Insurance... 10 Figure 3-10: Copay Information... 11 Figure 3-11: PCP Assignment... 11 Figure 3-12: Lock-In... 11 Figure 3-13: Limitations Tab... 12 Figure 3-14: Spend Down... 12 Proprietary and Confidential Molina Medicaid Solutions Page v
Figure 4-1: Eligibility Response for Printing... 13 Proprietary and Confidential Molina Medicaid Solutions Page vi
1. Introduction The Trading Partner Agreement (TPA) Eligibility Verification User Guide provides detailed instructions on how authorized healthcare providers can utilize the Health PAS-OnLine portal to quickly and efficiently verify a member s eligibility status. Providers must verify a member s eligibility prior to providing services. Verification of eligibility does not assure reimbursement if any requirements for medical eligibility and prior authorization have not been met. 2. Logging into your TPA Account To log into your Trading Partner Agreement (TPA) account, select the Sign in link in the upper right hand corner of the Molina Web portal at http://www.wvmmis.com. Refer to Figure 2-1. Figure 2-1: Provider Sign In Proprietary and Confidential Molina Medicaid Solutions Page 1 of 15
1. Enter the appropriate Username and Password associated with the TPA Account. 2. Select the I have read and accept HIPAA PHI privacy policy radio button each time you sign on to your account. Refer to Figure 2-2. 3. Check Eligibility Figure 2-2: Username and Password It is a best practice to verify eligibility for all Medicaid participants just before a service is rendered by a provider. This ensures the provider that the participant is eligible on that date and for the services that will be rendered. 1. Access the Member Eligibility Verification feature by clicking the Verify Member Eligibility icon on the Form Entry tab. Refer to Figure 3-1. Proprietary and Confidential Molina Medicaid Solutions Page 2 of 15
Figure 3-1: Accessing Eligibility Verification 2. To Search for a Member, the inquiry to verify eligibility for a participant appears. a. Always make certain that the correct Billing Provider is selected. This is important for TPA accounts that manage multiple billing providers. b. Enter two of the following criteria: o Member Identification (ID) o Name (Last and First Name) o Date of Birth o Social Security Number For example, you can enter the Name (Last and First) and the Date of Birth, or Name (Last and First) and the Member ID. c. Click Submit. Refer to Figure 3-2 Figure 3-2: Member Search Proprietary and Confidential Molina Medicaid Solutions Page 3 of 15
After the search a criterion has been submitted, the Eligibility Verification screen appears. Refer to Figure 3-3. The Name, Date of Birth, Medicaid ID, and Gender automatically fills in the Member section. This information cannot be edited on this screen. Figure 3-3: Eligibility Verification Screen After the search criteria have been submitted, the Eligibility Inquiry section verifies whether a member was eligible for a Medicaid program on the date(s) of service submitted in the request. This information does not guarantee eligibility or payment for the service rendered. The feature for Procedure Code/Service Code/HIPAA Category Codes is available, however, even if a HIPAA Category Code shows eligible that does not mean that every service is eligible. The information does not guarantee payment for services rendered. The applicable codes are based on the member s condition at time of verification and can be found in The National Current Procedural Terminology (CPT) or The Healthcare Common Procedure Coding System (HCPCS) book(s). Proprietary and Confidential Molina Medicaid Solutions Page 4 of 15
According to the selected coverage code, the details of the coverage code are listed. If further clarification is needed, call Provider Services between 7:00 a.m. to 7:00 p.m. Eastern Standard Time (EST) at 1(888) 483-0793, and choose option two. Refer to Figure 3-4. Figure 3-4: Coverage Code Details Proprietary and Confidential Molina Medicaid Solutions Page 5 of 15
3. To see additional information about the participant, including demographics, click the participant s name. A window displaying the participant information opens. Refer to Figure 3-4 on previous page. To go back to the Eligibility Inquiry screen, click the Back to Eligibility Verification link. Refer to Figure 3-5. 3.1 Eligibility Inquiry Figure 3-5: Participant Information The Tracking Number is a verification number assigned by the Health PAS system to the transaction. It is used to provide proof (when requested) that the eligibility for the participant was verified. Refer to Figure 3-6 for the location of the Tracking Number, Dates of Service, Procedure/Service and Modifiers, and HIPAA Category Codes. The Dates of Service, both From and To, are required fields for this form. The dates can be entered manually using the format MM/DD/YYYY or use the calendar at the end of each field. From Date o Automatically fills with current date o Date can be changed, but not for more than one year in the past To Date o Automatically fills with current date Proprietary and Confidential Molina Medicaid Solutions Page 6 of 15
o Cannot enter a future date Inquiry Type o Date Span only o HIPAA Category Code o Procedure/Service and Modifiers 1. To search for specific Procedure/Service and Modifiers, enter a maximum of 99 codes with optional Modifiers. The Modifiers displayed are only those that are available for the selected Procedure/Service Code. 2. To enter a new row, simply tab through the fields, and click on the search (magnifying glass) button. Refer to Figure 3-6. Figure 3-6: Eligibility Inquiry Note: Click the Reset button at the bottom of the screen, at any time to reset all the values. 3. Before submitting your inquiry, review your entries for accuracy. Click the Submit button to enter the request. After the request is submitted, the response will display under the Eligibility Inquiry section. 3.2 Eligibility Verification Response The Eligibility Verification Response screen contains multiple pieces of information for eligibility. The following sections will always appear in the response. Refer to Figure 3-7. Enrollments Other Insurance Copay Primary Care Provider (PCP) Proprietary and Confidential Molina Medicaid Solutions Page 7 of 15
Lock-In Limitations Spend Down Figure 3-7: Eligibility Verification Response Proprietary and Confidential Molina Medicaid Solutions Page 8 of 15
3.3 Enrollments The Enrollments section displays the types of coverage for which the participant is eligible. Each plan listed for the participant also shows the Coverage Status (either Active or Partial), the Coverage Level (Primary or Secondary), the Plan Type, Effective Date, and Termination Date. Refer to Figure 3-8. When the enrollment is active for the entire inquiry period, the coverage status is displayed as active. Otherwise, the coverage status is displayed as partial, effective date, termination date, or both are populated. For an example, enrollment is active from 01/1/2014 to 12/31/2014. If provider inquires on coverage between 03/1/2014 and 10/31/2014, then coverage status will be displayed as active; effective and termination dates are both blank. If provider inquires on coverage between 01/01/2014 and 12/31/2014, then coverage status will be displayed as active; effective and termination dates are both blank. If provider inquires on coverage between 10/01/2013 and 10/31/2014, then coverage status will be displayed as partial; effective date is displayed as 01/01/2014 and termination date is blank. If provider inquires on coverage between 03/01/2014 and 02/01/2015, then coverage status is displayed as partial and effective date is blank; termination date is displayed as 12/31/2014. If provider inquires on coverage between 10/01/2013 and 02/01/2015, then coverage status will be displayed as partial; effective date is displayed as 01/01/2014 and termination date is displayed as 12/31/2014. Proprietary and Confidential Molina Medicaid Solutions Page 9 of 15
When different providers are displayed in the response, it is important to note both of the following: Which provider is the PCP for that participant? and The dates when the participant is assigned to that PCP. If necessary, redo the eligibility check with a different date range to confirm the correct provider for a given date of service. Refer to Figure 3-8. 3.4 Other Insurance Figure 3-8: Enrollment Tab Other Insurance shows the, Plan, Plan Type, Policy Type, Policy #, Group #, Status, Carrier Name, Coverage Status, Effective Date, and Termination Date. Refer to Figure 3-9. Figure 3-9: Other Insurance Proprietary and Confidential Molina Medicaid Solutions Page 10 of 15
3.5 Copay Some West Virginia (WV) Medicaid members are required to pay a copay as part of their Medicaid Alternative Benefit Plan (ABP). The Copay section is where a provider can identify the member s copay responsibility for services rendered within a specific date of service. Refer to Figure 3-10. 3.6 Primary Care Provider Figure 3-10: Copay Information The Primary Care Provider section displays the information for the participant s PCP including the Effective Date, PCP Name, Address, Office Number, Office Hours, Termination Date, Provider ID, and the Coverage Status. Refer to Figure 3-11. 3.7 Lock-In section Figure 3-11: PCP Assignment The Lock-In section displays any Lock-In information that was found for the participant. If there is no Lock-In information available, the system will return a No Lock-In information found for DOS range requested message. Refer to Figure 3-12. Figure 3-12: Lock-In Proprietary and Confidential Molina Medicaid Solutions Page 11 of 15
3.8 Limitations The Limitations section of the member eligibility/benefit plan detail displays only those services that are covered by his/her plan and have service limitations. This section will not display all of the unlimited services available to the member; it is not intended to be a summary of services available. For example in Figure 3-13, this member likely has hundreds of available unlimited services, but these three specific services can only be offered a limited number of times. The PA Req column informs you if a Prior Authorization (PA) is required in conjunction with a claim for this service. Note: The Used units may be decremented for this member by any claim from any provider, so these are not a representation of only those claims entered by the provider who is currently logged into the system. Refer to Figure 3-13. 3.9 Spend Down Figure 3-13: Limitations Tab The Spend Down feature is active whenever a member is eligible for this WV Medicaid benefit. If there is no spend down information available, the system will return a No Spend Down information found at this time message. Refer to Figure 3-14. Figure 3-14: Spend Down Proprietary and Confidential Molina Medicaid Solutions Page 12 of 15
4. Print Receipt The request from the Eligibility Verification Response screen can be printed in order to have a paper record of the request. Refer to Figure 4-1. 1. Click the Print button found at the bottom of the screen below the eligibility response information. Refer to Figure 4-1. A new window displays the entire Eligibility Response that can be printed. Figure 4-1: Eligibility Response for Printing Proprietary and Confidential Molina Medicaid Solutions Page 13 of 15
Appendix A. Acronyms and Abbreviations WV MMIS Acronym Definition ABP Alternative Benefit Plan ARRA American Recovery and Reinvestment Act (2009) CFR Code of Federal Regulations HIPAA Health Insurance Portability and Accountability Act (1996) ID MMIS PA PCP PHI TPA WV Identifier/Identification Medicaid Management Information System Prior Authorization Primary Care Provider Protected Health Information Trading Partner Agreement West Virginia Proprietary and Confidential Molina Medicaid Solutions Page 14 of 15
End of Documentation Proprietary and Confidential Molina Medicaid Solutions Page 15 of 15