PROVIDER
Newsletter
NEW JERSEY | 2015 | ISSUE I
IN THIS ISSUE
Coming Soon! New Provider
Services Technology ...Page 1
Child Health Checkup Tips ...Page 2
Access to Utilization
Management Staff ...Page 3
Provider Satisfaction Survey ...Page 3
New Claim Edits
for 2015 ...Page 4-5
Hysterectomy and
Sterilization Claims ...Page 6
Q1 2015 Provider
Formulary Update ...Page 6
Appointment Access and
Availability Audits ...Page 6
Availability of Review Criteria ...Page 7
Change in Review Process for Medicare Admissions Effective February 2, 2015 ...Page 7
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.
WellCare members are entitled to receive a comprehensive package of preventive health care. Here are some questions and answers to help you conduct, document and bill for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services:
QUESTION:
How often is a well-child visit allowed for enhanced EPSDT payment?
ANSWER:
EPSDT exams are part of well-child checkups. An enhanced EPSDT rate is payable at the following schedule:
• 14 days
• 1 month
• 2 months
• 4 months
• 6 months
• 9 months
• 12 months
• 15 months
• 18 months
• 2 years
• 3 years
• 4 years
• 5 years
• 6 years
• Up to 21 years annually QUESTION:
The American Academy of Pediatrics has updated its schedule of recommended screenings and health assessments for each well-child visit from infancy through adolescence. What changes were made that pediatricians should be aware of?
ANSWER:
Additions include:
• Information about a specific screening tool to assess adolescents’ alcohol and drug use
• Screening and screening tools for depression from ages 11 through 21
• Cholesterol screening between ages 9 and 11
• Risk assessment for hematocrit or hemoglobin at ages 15 and 30 months
• Screening for HIV between ages 16 and 18 Other changes include:
Adolescents should no longer be routinely screened for cervical dysplasia until age 21.
Newborns should be screened for critical congenital heart disease using pulse oximetry before leaving the hospital.
QUESTION:
What must I do to perform an EPSDT exam?
ANSWER:
• An initial or interval history
• Measurements
• Sensory screening
• Developmental assessment, including autism, with validating screening tool
• TB risk assessment
• Lead risk assessment
• Psychosocial and behavioral assessment
• Alcohol and drug use assessment for adolescents
• STI and cervical dysplasia screening, as appropriate
• Complete physical exam
• Counseling for nutrition and physical activity
• Age-appropriate surveillance
• Immunizations
• Procedures such as hemoglobin and lead levels, as appropriate
• Referral to a dentist
• Referrals to state or specialty services
• Care coordination assistance, if needed
• Age-appropriate anticipatory guidance
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QUESTION:
To ensure I get credit for doing an EPSDT exam, how should I document it in my patient’s record?
ANSWER:
Documentation in the medical record must include a note indicating a visit with a primary care physician, the date the EPSDT visit occurred and evidence of all of the required components listed above. Providers must use the 8015 or 8016 form to document completion of the service.
You may complete EPSDT services during a sick-child visit, but remember to use the EP Modifier when billing to receive the enhanced payment.
There are several forms available to assist you in ensuring you have documented correctly. You may find these forms in the Forms section of your WellCare Provider Manual. You may complete EPSDT services during a sick- child visit, but remember to use the EP Modifier 25 when billing to receive the enhanced payment.
Remember: Vaccination is one of the best ways to protect infants and children. Visit www.cdc.gov/vaccines/
pubs/Parents-Guide/default.htm for a guide to vaccines. Help educate parents on preventing the spread of disease and remind parents of the value of immunizing their child and staying on schedule.
Source: www.aap.org/en-us/about-the-aap/aap-press-room/Pages/AAP-Updates-Schedule-of-Screening-and-Assessments-for-Well- Child-Visits.aspx
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.
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/New-Jersey/Providers/Medicaid or www.wellcare.com/New- Jersey/Providers/Medicare.
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3
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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
CHARGES
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
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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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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 WellCare of New Jersey Preferred Drug List (PDL) has been updated. Visit www.wellcare.com/New-Jersey/
Providers/Medicaid/Pharmacy to view the current PDL and pharmacy updates.
You can also refer to the Provider Manual available at www.wellcare.com/New-Jersey/Providers/Medicaid to view more information regarding WellCare of New Jersey’s pharmacy Utilization Management (UM) policies/procedures.
MEDICARE:
The Medicare Formulary has been updated. Find the most up-to-date complete formulary at www.wellcare.com/
New-Jersey/Providers/Medicare/Pharmacy.
You can also refer to the Provider Manual available at www.wellcare.com/New-Jersey/Providers/Medicare to view more information regarding WellCare’s pharmacy UM policies/procedures.
Federally prescribed documentation regulations for sterilization procedures are extremely rigid.
A Consent for Sterilization form (7473 M ED) must be attached to every sterilization claim including tubal ligation, vasectomy or similar procedures which are intended to permanently prevent pregnancy. The individual who has given voluntary consent for a sterilization procedure must sign the form at least 30 days prior to the procedure, be at least 21 years old at the time the consent is obtained, and must not be a mentally incompetent person.
Hysterectomy claims are required to have a Hysterectomy Receipt of Information form (FD-189) attached.
Hysterectomy procedures must have a primary indication other than sterilization. The claim can be paid without a FD-189 signed by the patient prior to the procedure only if the physician certifies that the member was already sterile at the time of the hysterectomy, or that the procedure was due to a life-threatening emergency and prior acknowledgement was not possible.
These forms are available at www.wellcare.com/New-Jersey/Providers/Medicaid/Forms .
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/New-Jersey/
Providers/Medicaid or www.wellcare.com/New-Jersey/Providers/Medicare.
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/New-Jersey/Providers/Clinical- Guidelines.
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/
New-Jersey/Providers/Clinical-Guidelines. GENERAL CLINICAL PRACTICE GUIDELINES
• Alzheimer’s disease
• Asthma
• Cancer
• 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
• Sickle cell disease
PREVENTIVE HEALTH GUIDELINES
• Adult preventive health
• Postpartum guidelines
• Preconception and interpregnancy
• Pregnancy
• Pediatric preventive health
• Smoking cessation
BEHAVIORAL HEALTH CPGS
• ADHD
• Depressive disorders in adults
• Depressive disorders in children
• Schizophrenia
• Substance use disorders
• Suicidal behaviors
MEDICARE
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.
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PROVIDER RESOURCES
WE’RE JUST A PHONE CALL OR CLICK AWAY!
WellCare of New Jersey, Inc.
Medicare:
1-855-538-0454
www.wellcare.com/New- Jersey/Providers/Medicare Medicaid:
1-888-453-2534
www.wellcare.com/New- Jersey/Providers
WEB RESOURCES
Visit www.wellcare.com/New-Jersey/Providers/Medicaid or www.wellcare.com/New-Jersey/Providers/Medicare 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 Provider Relations representative. For additional information, please refer to your Quick Reference Guide at www.wellcare.com/New-Jersey/
Providers/Medicaid or www.wellcare.com/New-Jersey/Providers/
Medicare.
PROVIDER NEWS
Remember to check messages regularly to receive new and updated information. Visit the secure area of www.wellcare.com/New-Jersey/
Providers 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.
NJ028514_PRO_NEW_ENG Internal Approved 01192015
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