If you have additional questions, you may contact the Office of the DHHR.

 

The WVSMA is doing additional training for ICD-10 on Tuesday, September 29th, with 2 specialty training sessions planned for Internal Medicine/Family Practice and Pediatrics. Click here to register for one of the sessions. 

 

Below are some recent important updates from Palmetto GBA.

 

CMS Conducts Final Successful Medicare FFS ICD-10 End-to-End Testing Week in July

 

From July 20 through 24, 2015, Medicare Fee-For-Service (FFS) health care providers, clearinghouses, and billing agencies participated in a third successful ICD-10 end-to-end testing week with all Medicare Administrative Contractors (MACs) and the Durable Medical Equipment (DME) MAC Common Electronic Data Interchange (CEDI) contractor. CMS was able to accommodate most volunteers, representing a broad cross-section of provider, claim, and submitter types.

 

 

Overall, participants in the July end-to-end testing week were able to successfully submit ICD-10 test claims and have them processed through Medicare billing systems. The acceptance rate for July was similar to the rates in January and April, but with an increase in the number of testers and test claims submitted. Most of the claim rejections that occurred were due to errors unrelated to ICD-9 or ICD-10.

 

Through its robust system release testing, CMS has ensured that the Medicare FFS claims processing systems changes for ICD-10 implementation have been thoroughly tested and validated. CMS also has conducted an unprecedented additional level of testing to help providers prepare for ICD-10.  This was the final end-to-end testing week, but providers are encouraged to participate in acknowledgement testing, which can be completed at any time prior to the implementation date.

  Be Prepared!

 

Medicare claims with a date of service on or after October 1, 2015, will be rejected

i f they do not contain a valid ICD-10 code. The Medicare claims processing systems do not have the capability to accept ICD-9 codes for dates of service after September 30, 2015; or accept claims that contain both ICD-9 and ICD-10 codes. 

 

 

  CMS Discovers PQRS Errors

(info from the American Medical Association)

 

The Centers for Medicare & Medicaid Services (CMS) recently announced that various errors were discovered in the 2014 Physician Quality Reporting System (PQRS) data submitted by vendors on behalf of physicians and group practices that reported via electronic health records (EHR) and qualified clinical data registries (QCDR). Physicians who participated and reported in 2014 PQRS through claims and clinical registries are not affected.

 

Because of the errors, the EHR and QCDR data is inconsistent and cannot be used to calculate quality performance for the 2016 value modifier, nor can PQRS performance information be included on Physician Compare. For PQRS and the meaningful use EHR incentive programs, there is no impact because physicians are judged on whether they successfully reported rather than on their actual performance-simply receiving the data will allow CMS to deem a physician or group practice as successful for purposes of avoiding a payment adjustment in 2016 or for receiving a 2014 incentive. There will be no need for physicians or group practices to submit a PQRS informal review request.

 

For the value modifier, which involves calculating actual quality scores in addition to determining whether quality measures were reported, CMS has acknowledged the vendor data errors may create problems. Specifically, CMS will not be able to accurately calculate the PQRS portion of the Quality Composite Score. Instead, the score will be based solely on the claims-based outcomes measures and Consumer Assessment of Healthcare Providers and Systems Survey, if applicable.

 

The AMA will provide additional information as it is available.

Important News Regarding Medicaid Authorizations!

(information from APS Healthcare and BMS)

In order to better serve our Medicaid members and to provide more efficient service to you as a Medicaid provider, please be aware:

Effective Thursday, OCTOBER 1, 2015, APS Healthcare will begin performing ALL Utilization Management functions associated with both Medical and Long Term Care Prior Authorizations, including Clinical Operations, which had previously been performed by a subcontractor.

Please take the time to review the attached forms and begin utilizing them effective IMMEDIATELY. Please note that fax numbers have changed and any request or correspondence faxed to WVMI on or after October 1, 2015 will not be processed.

Click here for the new phone and fax numbers.  

Managed Care Changes for State Fiscal Year 2016

(information from WV Medicaid)

 

As of July 1, 2015, Medicaid members who are currently enrolled with a managed care organization (MCO) began receiving behavioral health services through their MCO. Representatives from the West Virginia Department of Health and Human Resources (DHHR), the Bureau for Medical Services (BMS), the MCOs and behavioral health providers have been meeting for several months to ensure a smooth transition for Medicaid members.

 

The MCOs will allow members to continue seeing out-of-network providers for up to 90 days and will honor all pre-established prior authorizations. This will give members time to change to a provider which is enrolled with their current MCO. MAXIMUS, the new managed care enrollment broker, can assist members who wish to transfer to a new MCO which has the member's existing provider in-network.

 

Behavioral health providers serving Medicaid members in a MCO must start billing the MCO for all services provided on July 1 and thereafter. If a Medicaid member is not in a MCO, providers will continue to bill Medicaid through Molina Medicaid Solutions. If a provider has a question of whether a Medicaid member is in a MCO and/or what MCO they are a member of, they can:

 

 

Billing questions should be directed to the individual MCO.

 

BMS will also transition the Medicaid expansion population, approximately 164,000 individuals, into managed care under the SFY 2016 contract. Expansion members began receiving enrollment packets from MAXIMUS during the week of July 13. Members will have 30-45 days to decide which MCO they want to join. If they do not select a MCO by late August, a MCO will be chosen for them based on equitable distribution of the population to the plans. All questions regarding this process should be directed to MAXIMUS, the Managed Care Enrollment Broker, at 1-800-449-8466.

 

 

BMS Announces their Fall Medicaid Provider Workshops

 

Below are the dates and locations for the fall Medicaid trainings.  Additional information will be coming soon.

 

Monday, October 19: Beckley-Tamarack

Tuesday, October 20: Huntington-Big Sandy Arena

Wednesday, October 21 : South Charleston-Holiday  Inn and Suites

Monday, October 26: Martinsburg-Holiday Inn

Tuesday, October 27: Wheeling-Olgebay Resort

Wednesday, October 28: Morgantown-Lakeview  Resort

Thursday, October 29 : Flatwoods-Days Inn

 

 Important Reminder: Provider Revalidation Deadlines

 

WV Medicaid's revalidation of all providers enrolled prior to June 2013 must be completed by the end of 2015. Important deadlines for all providers are listed below:

July 2015 - Providers in Revalidation Phases 1 through 10 who have submitted an incomplete application

 

Beginning in July 2015, a list of providers who have submitted an incomplete application will be posted on the BMS website. The list will be refreshed every 2 weeks through September 30, 2015.

 

July 2015 - Providers in Revalidation Phases 5 through 10 who have not submitted an application

 

In July 2015, a list of all providers in Phases 5 through 10 who have not submitted an application will be posted on the BMS website for two weeks, then the providers will be placed on pay hold for 60 days. Once the 60 day period ends, the providers in Phases 5 through 10 who have not submitted an application to Molina will have their WV Medicaid participation terminated.

 

October 1, 2015 - All providers in Revalidation Phases 1 through 11

 

Providers in Phases 1 through 11 who have not submitted a complete application to Molina by October 1, 2015, will be placed on pay hold. Providers will have until December 1, 2015, to submit a complete application.

 

December 1, 2015 - All providers in Revalidation Phases 1 through 11

 

Molina will begin terminating the participation of all providers in Phases 1 through 11 who have not submitted a complete application. These terminations will be carried out through the month of December and completed by December 30, 2015.

If you have any questions or concerns regarding your enrollment or revalidation status, please contact the Molina Provider Enrollment Department at 304-348-3360 or 1-888-483-0793.

 

 

WVCHIP Moves to Department of Health and Human Resources

 

As reported in an earlier Wesgram,  as a result of legislation passed during the 2015 Legislative session, the administrative oversight of the West Virginia Children's Health Insurance Program (WVCHIP) was moved from the Department of Administration to the Department of Health and Human Resources (DHHR) on July 1, 2015.

 

 

Providers are strongly encouraged to begin the enrollment process as soon as possible. Failure to enroll by or before January 2016 may cause delay in payment or disruption of services for WVCHIP members. More information regarding this transition is available at www.chip.wv.gov and www.wvmmis.com.

 

 

Physician Assistants (PAs) Now Required to Enroll With Medicaid

 

Historically, Physician Assistants (PAs) have been considered "hidden" providers in West Virginia's Medicaid program because they are able to bill under a physician.

 

The Affordable Care Act of 2010 established a requirement that all providers of service for Medicaid members must be enrolled. In addition, claim edits are required to ensure that all ordering, referring and prescribing providers are enrolled before payment can be made. The enrollment of PAs in West Virginia Medicaid along with the federally required provider screening and enrollment process is expected to result in the proper identification of PAs for provider affiliation, claims payment and publication in provider directories. It also makes the process of finding care options easier for members, especially in underserved areas.

 

Providers who employ PAs who have not been enrolled must fulfill the BMS deadline of December 31, 2015, for payment of PA services. Those who do not enroll PAs by the deadline could face costly consequences such as denial of payment from West Virginia Medicaid.

 

For questions regarding enrollment for PAs, please contact Molina Medicaid Solutions at 888-483-0793 or 304-348-3365.

Highmark Update

At the recent provider training, Highmark announced that the West Virginia Family Health (Medicaid) is approaching fifty thousand (50K) members.  As of July 1, 2015, Behavioral Health benefits for this population are now being provided by Beacon Health.

Another important change for WV Family Health is that, as of September 1, 2015, the referral requirement has been eliminated. 

For Highmark Medicare Advantage patients, Highmark provides an added incentive for physicians. The Annual Wellness Visit (AWV) may be done once per calendar year, rather than once every 365 days as regular Medicare allows.