PROVIDER
Newsletter
FLORIDA | 2015 | ISSUE I
IN THIS ISSUE
Coming Soon! New Provider
Services Technology ...Page 1 EPSDT Requirements for
Florida MMA ...Page 2 ATA Contract Ends Effective
January 31, 2015 ...Page 3 Q1 2015 Provider
Formulary Update ...Page 4 Appointment Access and
Availability Audits ...Page 4 Change in Review Process For
Medicare Admissions Effective
February 2, 2015 ...Page 5 Availability of Review Criteria ...Page 5 Provider Satisfaction Survey ...Page 5 New Claim Edits for 2015 ...Page 6 Dental Services Are Vital for
Total Health ...Page 8 Clinical Practice Guideliness ...Page 8 Healthy Behaviors
Rewards Program ...Page 9 Access to Utilization
Management Staff ...Page 9 New Toll-Free Phone Number for
Medicare Providers ...Page 9 Provider Resources ...Page 10
COMING SOON! NEW PROVIDER SERVICES TECHNOLOGY
WellCare is excited to unveil some major technology improvements in early 2015. You will see a difference in the speed and quality of service that you get when you call us.
• Are you tired of spending additional time with Customer Service to identify yourself?
• Are you tired of internal transfers?
• Are you tired of spending time to validate member information?
• Would you prefer to complete some of these standard inquiries via self- service?
We listened to your feedback and soon you will be able to provide your information, as well as your member’s, within our Interactive Voice Response system. This will greatly reduce the time you spend on the phone when calling us.
In preparation for these changes, we want to provide some quick tips to help you navigate this new process. Have the following information available with each call:
1. WellCare provider ID number
2. NPI or Tax ID number for validation if you do not have your WellCare provider ID number
3. For claims inquiries – the member’s ID number, date of birth, date of service and dollar amount
4. For authorization and eligibility inquiries – the member’s ID number and date of birth
Some additional features will soon be available, including improved call menus and enhanced self-service capabilities. You will also be able to select between speaking your commands or using your touch tone keypad to enter selections.
All of these changes are being implemented to make it easier to do business with us. Thank you for your support and all that you do for our members.
EPSDT REQUIREMENTS FOR FLORIDA MMA
The Florida Agency for Health Care Administration (AHCA) requires providers to include the Child Health Check up modifier and referral code that identifies the health screening of a child on the CMS 1500 form and the 837P EDI.
portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/HANDBOOKS/Child_Health_Check-UpHB.pdf (starting page 36)
Billing Requirements:
A claim with a procedure code that falls within the procedure code range of 99381-99384 or 99391-99394 must also contain the appropriate referral condition code NU, AV, S2 or ST in Form Item Number 24H shaded for paper on the CMS 1500 form or the SV111 segment with a CRC qualifier for EDI.
A claim submitted with procedure codes 99385 or 99395 must meet the age requirement (ages 18-20), be billed with an EP modifier and contain the appropriate referral condition code NU, AV, S2 or ST.
The EPSDT referral indicator must be present for all codes that meet the FL State requirement of being a Child Health Check up code.
The EPSDT indicator referral condition codes AV, ST, S2 and NU, and Y/N family planning indicator
requirements, are documented in the National Uniform Claim Committee (NUCC) billing guide for CMS 1500 and the X12N/005010X222 Professional 837P EDI guides. Please refer to the guides for correct billing requirements.
PAPER AND EDI EXAMPLES:
Paper Example when EP is required: The code is on the AHCA EPSDT-Child Health Checkup list and there is no referral for the service.
D. PROCEDURES,SERVICIES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS | MODIFIER
E.
DIAGNOSIS POINTER
F.
$ CHARGES G.
DAYS OR UNITS H.
EPSDT Family Plan NU
99392 | EP A 150 | 00 1 N EDI EXAMPLE WHEN EP IS REQUIRED:
Family Indicator/EPSDT referral field is N and EPSDT referral condition code is NU as shown below.
CRC*ZZ*N*NU LX*1
SV1*HC: 99392:EP*150*UN*1*11**1~
PAPER EXAMPLE WHEN EP IS NOT REQUIRED:
Code is not on the AHCA EPSDT-Child Health Check-Up list and there is not a referral for the service.
D. PROCEDURES,SERVICIES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS | MODIFIER
E.
DIAGNOSIS POINTER
F.
$ CHARGES G.
DAYS OR UNITS H.
EPSDT Family Plan
99123 | A 150 | 00 1
Family Indicator/EPSDT referral field is blank and EPSDT referral condition code is not required.
(continued on next page)
EDI EXAMPLE WHEN EP IS NOT REQUIRED:
No CRC Segment code is shown since it is not a EPSDT required code. SV111 and SV112 are not shown because N is not a valid value for that element. See below.
LX*1
SV1*HC: 99123*50*UN*1*11**1~
PAPER EXAMPLE WHEN EP IS REQUIRED:
Code is on the AHCA EPSDT-Child Health Check-Up list and there is a referral for the service D. PROCEDURES, SERVICIES, OR SUPPLIES
(Explain Unusual Circumstances) CPT/HCPCS | MODIFIER
E.
DIAGNOSIS POINTER
F. $ CHARGES G.
DAYS OR UNITS H.
EPSDT Family Plan ST
99381 | A 50 | 00 1 Y
EDI EXAMPLE WHEN EP IS REQUIRED:
Family Indicator/EPSDT referral field is Y and EPSDT referral condition code is ST as shown below.
CRC*ZZ*Y*ST LX*1
SV1*HC: 99381*50*UN*1*11**1****Y*Y~
The EPSDT code may only be submitted one time per claim. Multiple line entries will cause a claim to be rejected.
ATA CONTRACT ENDS EFFECTIVE JANUARY 31, 2015
American Therapy Administrators, Inc. (ATA) is Staywell, Staywell Kids, and HealthEase Kids Health Plans’ vendor for physical, occupational and speech therapy. The Staywell, Staywell Kids and HealthEase Kids contract with ATA terminated effective January 31, 2015.
Providers who were part of ATA’s network for Staywell, Staywell Kids and HealthEase Kids have been offered or will be offered, direct fee-for-service agreements with WellCare.
For a period following the termination, WellCare will closely monitor ATA’s activities and interactions with the provider community and our members.
Members who were in an active plan of treatment on January 31 will continue to receive services for up to six months after the ATA termination. To obtain an authorization for dates of service after February 1, 2015, providers should contact Staywell, Staywell Kids, or HealthEase Kids. For services that will continue after the continuity of care period, Staywell, Staywell Kids or HealthEase Kids Health Plan should be contacted to initiate new authorizations via phone at 1-800-351-8777, fax at 1-800-935-5752, or the WellCare web portal at www.wellcare.com/Florida.
If you have any additional questions about this transition, please contact your PR rep or call one of the Provider Services phone numbers at the end of this newsletter. Should your patients have any questions, please ask them to contact WellCare Customer Service at the number on the back of their card.
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APPOINTMENT ACCESS AND AVAILABILITY AUDITS
WellCare is required by CMS and state regulations to administer appointment access and availability audits. The audits are conducted by a third party vendor, The Myers Group, and keep us compliant with NCQA and other accreditation entities. Auditors identify themselves when calling provider’ offices, and provide appointment examples for existing members.
If an audit of your office reveals areas for improvement, you will receive a notification letter and an outline of the appointment types and standards. You will be given an opportunity to respond, and will be re-audited in 90 days.
For more information on appointment access and availability audits, please contact your PR rep or call one of the Provider Services phone numbers at the end of this newsletter.
Q1 2015 PROVIDER FORMULARY UPDATE
MEDICAID:
The Staywell, Staywell Kids and HealthEase Kids Preferred Drug List (PDL) has been updated.
Visit ahca.myflorida.com/Medicaid/Prescribed_
Drug/pharm_thera/fmpdl.shtml to view the current Staywell PDL and pharmacy updates.
Visit www.wellcare.com/Florida/Providers/
Medicaid/Pharmacy for the Staywell, Staywell Kids and HealthEase Kids PDL and pharmacy updates.
You can also refer to the Provider Manual available at www.wellcare.com/Florida/
Providers/Medicaid to view more
information regarding WellCare’s pharmacy Utilization Management (UM) policies/
procedures.
MEDICARE:
There have been updates to the Medicare formulary. Find the most up-to-date complete formulary at www.wellcare.com/Florida/
Providers/Medicare/Pharmacy.
You can also refer to the Provider Manual available at www.wellcare.com/Florida/
Providers/Medicaid to view more
information regarding WellCare’s pharmacy UM policies/procedures.
PROVIDER SATISFACTION SURVEY
WellCare continues to focus efforts on the experiences of both our members and providers. In order to better understand and remain well informed about our valued provider network, we conducted a Provider Satisfaction Survey in 2013, and again in 2014. The survey concentrated on a variety of subjects, including call center/member services, provider relations, continuity/
coordination of care, provider network, utilization and quality management, finance issues, pharmacy and drug benefits, and overall satisfaction and loyalty.
Extensive reviews of our 2014 survey results are underway to ensure that our focus aligns with the needs of our providers. Current areas of focus include enhancing provider services at the local level, claim processing and issue resolution, enriching administrative tools/capabilities, and continued emphasis on quality.
WellCare is continuously engaged with several cross- functional teams working on these initiatives, and others that are aimed at better serving our providers.
We anticipate incremental gains on several initiatives in 2015 and continued improvement beyond. These efforts will be further communicated as the year progresses.
Shortly, WellCare will again conduct a Provider Satisfaction Survey. This follow-up survey will be used to measure progress from last year’s effort to better evaluate how we can become more effective and productive business partners.
Your participation is encouraged – and appreciated – as together we strive to improve the lives of our members’
overall quality of care.
AVAILABILITY OF REVIEW CRITERIA
The determination of medical necessity review criteria and guidelines are available to providers upon request.
You may request a copy of the criteria used for specific determination of medical necessity by calling Provider Services at the number listed on your Quick Reference Guide at www.wellcare.com/Florida/
Providers/Medicaid.
Also, please remember that all Clinical Coverage Guidelines, detailing medical necessity criteria for certain medical procedures, devices and tests, are available on our website at www.wellcare.com/Florida/Providers/
Clinical-Guidelines/CCGs.
CHANGE IN REVIEW PROCESS FOR MEDICARE ADMISSIONS EFFECTIVE FEBRUARY 2, 2015
To reduce the administrative burden on behavioral health providers, WellCare is eliminating the requirement for concurrent reviews for members in an inpatient psychiatric unit. An initial review at the time of admission is still required. When medical necessity criteria are met for the inpatient level of care, you will receive an authorization of days for treatment of the member. If additional days beyond the initial authorization are required, you should continue to treat the member and submit the medical record at the time of discharge for medical review. This process change is only for Medicare members.
MEDICARE
5
NEW CLAIM EDITS FOR 2015
In order to comply with the Centers for Medicare & Medicaid Services (CMS) billing guidelines, WellCare is
implementing new Medicare Strategic National Implementation Process (SNIP) edits for 837I and 837P claims in 2015.
837I SNIP EDIT DETAILS:
WellCare will edit for HIPPS codes, attending provider NPI, and correct anesthesia units of measurement and modifiers in compliance with CMS mandates.
Health Insurance Prospective Payment System (HIPPS) Code Requirements:
Effective July 1, 2014, all claims from Skilled Nursing Facilities (SNFs) and Home Health Agencies (HHAs) must appropriately bill with a valid HIPPS code for Type of Bill 018x, 021x, or 032x (x represents the Type of Bill Frequency).
• SNFs Bill Types and HHAs Bill Types must bill the HIPPS code derived from the “Initial Assessment”
• The first line must be the PPS Revenue Code (0022 or 0023), and corresponding HIPPS code
• Submit subsequent lines in the appropriate order as detailed in the Uniform Billing guide
Additional information on the new CMS mandate can be reviewed at: www.csscoperations.com/internet/cssc3.
nsf/files/Encounter%20Data%20-%20HIPPS%20Codes.pdf/$FIle/Encounter%20Data%20-%20HIPPS%20Codes.pdf EDI example:
Loop 2400 SERVICE LINE NUMBER:
LX*1~
SV2*0022*HP:CC160*.00*UN*5~
Paper example:
42 REV.
CD 43
DESCRIPTION 44 HCPCS/RATE/
HIPPS CODE 45 SERV
DATE 46 SERV
UNITS 47 TOTAL
CHAREGS
0022 SNF PPS CC160 1/1/2015 1 100.00
Attending Provider for UB-04/837I Claims Requirements:
The CMS Medicare Claims Processing Manual documents the Attending Provider reporting requirements in Chapter 25 FL 76 – Attending Provider Name and Identifiers (including NPI). Attending provider’s name and NPI are required when a claim/encounter contains any services other than nonscheduled transportation services.
The attending provider is the individual who has overall responsibility for the patient’s medical care and treatment reported in this claim/encounter.
EDI example:
Loop 2310A Attending Provider Name and NPI (XX qualifier):
NM1*71*1*JONES*JOHN****XX*1234567891~
Attending Provider Taxonomy (AT qualifier):
PRV*AT*PXC*208D00000X~
Paper example:
76 ATTENDING NPI 1234567891 QUAL
LAST JONES FIRST JOHN
(continued on next page)
837P SNIP Edit Details:
Professional Claims Unit of Measure Requirements:
The CMS 837P Companion Guide documents requirements for the Unit of Basis for Measurement when an anesthesia modifier is billed the Unit of Measure is to be an “MJ”. All other claims are to report “UN” as the Unit of Measure.
EDI example:
Loop 2400 Service Line Units:
SV1*HC:99211:25*12.25*UN*1*11**1:2:3**Y~
Loop 2400 Service Line Minutes:
SV1*HC:00142:QK:P1*827*MJ*61***1~
837P Companion Guide
www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/CompanionGuides.html Paper example:
24.A DATES(S) OF SERVICE FROM TO MM|DD|YY MM|DD|YY
B.
PLACE OF SERVICE
C. EMG D. PROCEDURES SERVICES OR SUPPLIES
(Explain Unusual Circumstances) CPT/HCPCS MODIFIER
E. DIAGNOSIS POINTER
F. $ CHARGES G.
DAYS OR UNITS
01 |01|2014 01|01|2014 11 00142 | QK | | | A 100 |00 61 Anesthesia Modifier Requirements:
The CMS Medicare Claims Processing Manual Chapter 12 section 50 documents the appropriate anesthesia modifier to denote whether the service was personally performed, medically directed, or medically supervised.
Specific anesthesia modifiers include: AA, AD, QK, QX, QY and QZ EDI example:
Loop 2400 – Service Line:
SV1*HC:00142:QK:P1*827*MJ*61***1~
Medicare Claims Processing Manual Chapter 12 Section 50 pages 121 and 122: www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
Paper example:
24.A DATES(S) OF SERVICE FROM TO MM|DD|YY MM|DD|YY
B.
PLACE OF SERVICE
C. EMG D. PROCEDURES SERVICES OR SUPPLIES
(Explain Unusual Circumstances) CPT/HCPCS MODIFIER
E. DIAGNOSIS POINTER
F. $ CHARGES G.
DAYS OR UNITS
01 |01|2014 01|01|2014 11 00142 | QK | | | A 100 |00 61
Source: Medicare Claims Processing Manual Chapter 25, page 23.
www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c25.pdf (continued from previous page)
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CLINICAL PRACTICE GUIDELINES
Clinical Practice Guidelines (CPGs) are best practice recommendations based on available clinical outcomes and scientific evidence. WellCare CPGs reference evidence-based standards to ensure that the guidelines contain the highest level of research and scientific content. CPGs are also used to guide efforts to improve the quality of care in our membership. The CPGs listed below are available on our Provider Resources website at
www.wellcare.com/Florida/Providers/Clinical-Guidelines/CPGs. GENERAL CLINICAL PRACTICE GUIDELINES
• Asthma
• Cholesterol management
• Chronic heart failure
• Chronic kidney disease
• COPD
• Coronary artery disease
• Diabetes in adults
• Diabetes in children
• HIV antiretroviral treatment in adults
• HIV screening
• Hypertension
• Imaging for low back pain
• Lead exposure
• Obesity in adults
• Obesity in children
• Osteoporosis
• Pharyngitis
• Rheumatoid Arthritis PREVENTIVE HEALTH GUIDELINES
• Adult preventive health
• Postpartum guidelines
• Preconception and
interpregnancy • Pregnancy
• Pediatric preventive health BEHAVIORAL HEALTH CPGS
• ADHD
• Depressive disorders in adults
• Depressive disorders in children
• Schizophrenia
• Substance use disorders
• Suicidal behaviors
FL028400_PRO_NEW_ENG ©WellCare 2014 FL_12_14
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DENTAL SERVICES ARE VITAL FOR TOTAL HEALTH
WellCare encourages providers to reinforce the importance of dental services to our members.
An oral health screening is an important part of a patient’s physical exam, but it does not replace a dental examination performed by a dentist. Dental visits should start by the child’s first birthday or within six months of the first tooth’s emergence.
To keep teeth healthy, WellCare provides for preventive dental care for Medicaid members on an annual basis.
This includes teeth cleaning every six months, dental exams and annual X-rays with $0 co-pays. For Medicare members, many of the plans cover preventive services such as exams, X-rays and cleanings with $0 co-pays for covered services.
Please refer your WellCare members to a dental provider and encourage them to complete their annual dental check-up.
Source: American Academy of Pediatrics
www.healthychildren.org/English/healthy-living/oral-health/Pages/Brushing-Up-on-Oral-Health-Never-Too-Early-to-Start.aspx
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ACCESS TO UTILIZATION MANAGEMENT STAFF
The Utilization Management (UM) section of your Provider Manual contains detailed information related to the UM program. Your patient, our member, can request translation services and materials in a different format including other languages, large print and audio tapes. There is no charge for this service.
If you have questions about the UM program, please call Provider Services at the number listed on your Quick Reference Guide located at www.wellcare.com/Florida/Providers/Medicaid or www.wellcare.com/Florida/Providers/Medicare.
HEALTHY BEHAVIORS REWARDS PROGRAM
Staywell believes healthy behaviors lead to effective medical care for all enrollees. Enrollees are encouraged to manage their health needs, start and /or enhance habits that positively impact their health status, and take advantage of available preventive screenings.
ENROLLEE DISCOUNT CARD
Enrollees receive a discount card per household which can be used to purchase select healthy items.
HEALTHY PREGNANCY REWARDS
Enrollees who complete six prenatal visits can receive a $30 incentive plus their choice of a free stroller or portable playpen delivered to their homes.
HEALTHY REWARDS CARD
Enrollees receive a reloadable debit card for completing specific preventive health, wellness and engagement milestones.*
Please contact your PR rep or call Provider Services at 1-866-334-7927 for any questions about this information.
*Cumulative value of debit card not to exceed
$50 per calendar year.
NEW TOLL-FREE PHONE NUMBER FOR MEDICARE PROVIDERS
Effective January 1, 2015, Medicare providers can reach WellCare Provider Services directly with a new toll-free number. The new phone number, 1-855-538- 0454, will be listed in the Quick Reference Guide as well as the “Contact Us” section of our website.
The benefits of this new phone number are:
• Reduced scripting and menu options
• Time saved reaching a particular area
• Dedicated line will reduce transfers
• Improved provider experience
We value our provider partners and look forward to hearing from you on the new provider line in 2015.
MEDICARE
9
PROVIDER RESOURCES
WE’RE JUST A PHONE CALL OR CLICK AWAY!MEDICARE:
1-855-538-0454
Or visit www.wellcare.com/ Florida/Providers/Medicare
MEDICAID:
HealthEase Kids 1-800-278-8178
Staywell 1-866-334-7927
Staywell Kids 1-866-698-5437
Or visit
www.wellcare.com/Florida/
Providers/Medicaid WEB RESOURCES
Visit www.wellcare.com/Florida/Providers/Medicaid or www.wellcare.com/Florida/Providers/Medicare to access our Preventive, Behavioral and Clinical Practice Guidelines, Clinical
Coverage Guidelines, Pharmacy Guidelines, key forms and other helpful resources. You may also request hard copies of any of the above documents by contacting your Provider Relations representative. For additional information, please refer to your Quick Reference Guide at www.wellcare.com/Florida/Providers/Medicaid or
www.wellcare.com/Florida/Providers/Medicare.
PROVIDER NEWS
Remember to check messages regularly to receive new and updated information. Visit the secure area of www.wellcare.com/Florida to find copies of the latest correspondence. Access the secure portal using the
“Provider Secure Login” area in the Provider drop down menu on the top of the page. You will see Messages from WellCare located in the right-hand column.
FL028400_PRO_NEW_ENG
©WellCare 2015 FL_12_14 Internal Approved 01282015
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