PROVIDER
Newsletter
NEW YORK | 2015 | ISSUE I
IN THIS ISSUE
Coming Soon! New Provider
Services Technology ...Page 1
Appointment Access and
Availability Audits ...Page 2
Provider Satisfaction Survey ...Page 2
Availability of Review Criteria ...Page 3
Access to Utilization
Management Staff ...Page 3
New Claim Edits for 2015 ...Page 4-5
New Toll-Free Phone Number
for Medicare Providers ...Page 6
Q1 2015 Provider Formulary Update ...Page 6
Change in Review Process for Medicare Admissions Effective February 2, 2015 ....Page 6
Clinical Practice Guidelines ...Page 7
Provider Resources ...Page 8
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.
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.
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 providers’ 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.
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/provider/quickreferenceguides.
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/provider/
quickreferenceguides.
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/provider/ccgs.
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 measurements 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:
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:
42 REV.CD 43 DESCRIPTION 44 HCPCS/RATE/HIPPS CODE 45 SERV DATE 46 SERV UNITS 47 TOTAL CHARGES
0022 SNF PPS CC160 1/1/2015 1 100.00
76 ATTENDING NPI 1234567891 QUAL
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:
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 DATE(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
24.A DATE(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)
Q1 2015 PROVIDER FORMULARY UPDATE
MEDICAID:
Updates have been made to the WellCare of New York Preferred Drug List (PDL). Please visit newyork.wellcare.
com/provider/pharmacy to view the current PDL and pharmacy updates.
You can also refer to the Provider Manual available at newyork.wellcare.com/WCAssets/newyork/assets/ny_
medicaid_provider_manual_05_2013.pdf to view more information regarding WellCare of New York’s pharmacy Utilization Management (UM) policies/procedures.
MEDICARE:
Updates have been made to the Medicare Formulary. The most up-to-date complete formulary can be found at www.wellcare.com/medicare/medication_guide.
You can also refer to the Provider Manual available at www.wellcare.com/WCAssets/corporate/assets/na_
care_providermanual_eng_01_2015.pdf to view more information regarding WellCare’s pharmacy UM policies/
procedures.
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
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
MEDICARE
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/
provider/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
NY028413_PRO_NEW_ENG
©WellCare 2015 NY_12_14 Internal Approved 01142015
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WE’RE JUST A PHONE CALL OR CLICK AWAY!
WellCare of New York, Inc.
Medicare:
1-855-538-0454 www.wellcare.com
PROVIDER RESOURCES
WEB RESOURCES
Visit www.wellcare.com (Medicare) or newyork.wellcare.com (Medicaid) to access our Preventive 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 PR rep. For additional information, please refer to your Quick Reference Guide at www.wellcare.com/
provider/quickreferenceguides.
PROVIDER NEWS
Remember to check messages regularly to receive new and updated information. Visit the secure area of www.wellcare.com (Medicare) or newyork.wellcare.com (Medicaid) to find copies of the latest
correspondence. Access the secure portal using the “Member/Provider Secure Sign-In” area on the right. You will see Messages from WellCare located in the right-hand column.
