IN THIS ISSUE
PROVIDER NEWSLETTER
Florida | 2016 | Issue IV
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Q4 2016 Provider Formulary Update ..Page 1 How to Improve Patient Satisfaction and CAHPS® Scores, Part 3 of 3 ...Page 2 Coding Corner ... Page 3 Coding Corner Continued ...Page 4 Preliminary CAHPS Scores ...Page 4 Providers Can Submit Medicare
Enrollment Requirements
with PECOS ...Page 5 WellCare’s Elizabeth Miller
Appointed to State Telehealth
Advisory Council ...Page 5 Healthy Rewards Program ...Page 6 Wellcare Requests CPT II Codes ...Page 6 Updating Provider
Directory Information ...Page 7 Clinical Appeals Versus
Claims Disputes ...Page 7 Provider Survey Results ...Page 8 Provider Resources...Page 8 We’re Just a Phone Call or
Click Away ...Page 8
Q4 2016 PROVIDER FORMULARY UPDATE
MEDICAID:
The Staywell 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 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 and 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/Medicare to view more information regarding WellCare’s pharmacy UM policies and procedures.
HOW TO IMPROVE PATIENT SATISFACTION AND CAHPS
®SCORES, PART 3 OF 3
As a WellCare provider, you will be rated on the CAHPS survey by our WellCare members who are your patients.
You can improve patient perception of key aspects of their care.
THE CAHPS SURVEY MEASURES THE PATIENT’S HEALTH CARE EXPERIENCE.
The 2016 Medicaid Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey results are in.
The goal of the CAHPS survey is to obtain information from the person receiving care regarding satisfaction levels with providers, the health plan and the quality of the health care the member receives.
Overall, WellCare members are happy with their primary care providers (PCPs) and they rate you favorably.
• Thank you for helping members to feel good about their PCPs.
Overall, WellCare members say that it’s not always easy to get needed care.
• Please be sure your members can get routine and urgent appointments when needed.
HERE ARE SOME TIPS THAT CAN IMPROVE THE MEMBER EXPERIENCE AND YOUR CAHPS SCORES:
1) Make sure your members know:
a. Your office hours
b. How and where to get care and treatments after hours c. Who the on-call staff is and how to contact them d. How to contact WellCare’s 24-hour Nurse Advice Line
2) When appropriate, be prepared to offer the following value-added assistance to WellCare members:
a. CommUnity Assistance Line: Helps to connect members with services in the community, 1-866-775-2192 b. Care Management at 1-866-635-7045 and Disease Management at 1-877-393-3090
3) Call or contact your patients to remind them when it’s time for services, such as annual wellness exams, recommended cancer screenings, immunizations and follow-up care for ongoing conditions.
4) Follow up after tests/screenings by calling/contacting your patients with results as soon as possible.
5) Maintain contact information for community service alternatives in your area such as:
a. Local crisis centers, including 24/7 suicide and domestic violence lines
b. Local youth and family service center/Department of Children & Family Services c. Local homeless services
d. Student counseling
e. Smoking cessation services f. Medication assistance programs
Thank you for all you do to help our members reach and maintain good health.
MEDICAID
CODING CORNER
NOTIFICATION OF CLAIM EDITING UPDATE
The information outlines updates to claim editing. Please refer to the WellCare provider portal for the specific edit start date.
CLAIM EDITING UPDATE DESCRIPTION OF SERVICE UPDATES EFFECTIVE DENY REASON CODE
Inpatient Manifestation Code as Principal Diagnosis
According to WellCare’s policy, which is based on National Coding Standard as designated by the U.S. Department of Health and Human Services, manifestation codes cannot be used as the principal diagnosis. Manifestation is a condition that is an extension of the primary illness in question.
When a particular condition
(manifestation) is due to another underlying causal condition, the underlying condition (etiology) code is sequenced first, followed by the code for the manifestation.
WellCare Health Plans will deny claims when a diagnosis code that is designated as a manifestation code is used as a principal diagnosis on a claim.
Dispute rights will be provided.
CE139 Denied: Inpatient Manifestation Code as Principal DX
Facility Inpatient Unacceptable Principal Diagnosis
According to WellCare’s policy, which is
based on National Coding Standard as designated by the U.S.
Department of Health and Human Services, an Unacceptable Principal Diagnosis describes a circumstance that influences an individual’s health status but is not a current illness or injury; therefore, it is unacceptable as a principal diagnosis.
WellCare Health Plans will deny claims if the principal diagnosis on a claim has a designation as an unacceptable principal diagnosis.
Dispute rights will be provided.
CE141 Denied: Inpatient Unacceptable Principal Diagnosis
PRELIMINARY 2016 CAHPS SCORES
Preliminary Consumer Assessment of Healthcare Providers & Systems (CAHPS) scores indicate that a high percentage of WellCare of Florida’s Medicare and Medicaid recipients are satisfied with their care.
As you know, the survey administered by the Centers for Medicare & Medicaid Services (CMS) also asked our members to rate their doctors as well as the ability to get care quickly and get needed care. Preliminary results indicate the trend for the members’ ability to get needed care and get care quickly is declining, while doctor satisfaction remains flat.
We are focusing on improving these scores this coming year, and we would love to hear your thoughts and ideas. We are committed to working with our providers to provide quality care for our members and identifying ways to continually improve. Please email Pat Fowler, WellCare’s senior director of quality improvement, at [email protected].
Facility Inpatient Unacceptable Other Diagnosis
According to WellCare’s policy, which is
based on National Coding Standard as designated by the U.S.
Department of Health and Human Services, an Unacceptable Principal Diagnosis describes a circumstance that influences an individual’s health status but is not a current illness or injury; therefore, it is unacceptable as a principal diagnosis.
In a few cases, some unacceptable codes will be acceptable as principal diagnoses if a secondary diagnosis is coded.
WellCare Health Plans will deny claims if the principal diagnosis on a claim has a designation as an unacceptable principal diagnosis, unless a required secondary diagnosis is included on the claim.
Dispute rights will be provided.
CE142 Denied: Inpatient Unacceptable Principal Diagnosis, requires Secondary Diagnosis
VITAMIN D TESTING
DESCRIPTION OF SERVICE:
According to CMS, providers performing Vitamin D testing should only do so when the diagnosis supports medical necessity.
Additionally, Vitamin D testing (82306) should not be performed more than four times per year. While Vitamin D 1, 25 testing (82652) should not be performed more than once per year.
UPDATES EFFECTIVE 09/01/2016:
Per WellCare Claims Edit Guideline, if a covered indication for Vitamin D testing is not present on the claim line, the Vitamin D test (82306 or 82652) will be denied.
Additionally, WellCare will deny Vitamin D testing (82306) if billed more than four times per year and Vitamin D 1, 25 testing (82652) if billed more than once per year.
PROVIDERS CAN SUBMIT MEDICARE ENROLLMENT REQUIREMENTS WITH PECOS
On June 1, 2015, CMS implemented the provider Medicare Enrollment requirement identified in rule 4159-F to combat Part D fraud and abuse. Under this rule, a Part D sponsor/PBM must deny a pharmacy claim for a Part D drug if an active and valid prescriber NPI is not contained on the claim and the prescriber is not enrolled in or opted-out of Medicare. The enforcement date of the Part D enrollment requirement is Feb. 1, 2017.
Affected prescribers include eligible professionals (such as dentists, physicians, residents, psychiatrists, nurse practitioners and physician assistants). Having an NPI number and a DEA number alone does not meet this requirement. Prescribers can access the Provider Enrollment, Chain, and Ownership System (PECOS) to securely and electronically submit and manage Medicare enrollment information at pecos.cms.hhs.gov/pecos/login.do or they can enroll by completing the paper 855I or 855O application. Prescribers who already have an NPI and NPPES credentials (user ID and password) can use the same credentials to enroll in PECOS. A listing of providers who are enrolled or opted out can be accessed at Data.cms.gov and will be generated every two weeks.
Medicare payment cannot be made directly or indirectly for services furnished by an opt-out physician except for emergency and urgent care services. Therefore, no payment may be made under Medicare or under a Medicare Advantage Plan for services furnished by an opt-out physician.
When a pharmacy claim is received, Part D sponsors/PBMs will determine the NPI, enrollment, and opt-out status of a prescriber by checking the PECOS prescriber file at point-of-sale.
If you prescribe drugs to Medicare beneficiaries, you need to be enrolled. Otherwise, beneficiaries will be denied their prescriptions for drugs you prescribe.
Source:
Centers for Medicare & Medicaid Services. (2016, March 16). Retrieved August 01, 2016, from www.cms.gov/site-search/search-results.
html?q=CMS-4159 Implementation planning
WELLCARE’S ELIZABETH MILLER APPOINTED TO STATE TELEHEALTH ADVISORY COUNCIL
WellCare of Florida Chief Operating Officer Elizabeth Miller has been appointed to the state’s newly created Telehealth Advisory Council. The council is tasked with examining the types of telehealth services that are available in the state and developing recommendations for how to increase access to telehealth services for all Floridians.
Miller’s selection is an honor and recognizes her expertise and WellCare’s position as a pioneer in the telehealth arena.
The advisory council was created as part of House Bill 7087, which is designed to set the stage for widespread insurance coverage of telehealth services in the state. The group will meet throughout the year and present findings to the governor, senate president and house speaker by October 2017.
HEALTHY REWARDS PROGRAM
The Healthy Rewards Program rewards members for taking small steps to help them live healthy lives. When they complete primary care provider (PCP) visits, prenatal visits and certain health checkups, members earn rewards that are placed on reloadable Visa® cards. Members can use these cards at a variety of locations to purchase items including milk, bread, diapers and over-the-counter (OTC) items. The more services members complete, the more they earn.
Providers can encourage their patients to take part in this program by signing and including their provider ID on applicable activity reports.
For more information on the Healthy Rewards Program, please contact your Provider Relations representative or call one of the Provider Services phone numbers at the end of this newsletter.
MEDICAID
WELLCARE REQUESTS CPT II CODES
WellCare works diligently to ensure its members are receiving the most comprehensive care possible. Please be sure you are not inadvertently omitting or removing CPT II codes from your claims or encounters submitted to RelayHealth. WellCare wants to emphasize to all providers, billers and clearinghouses the importance of these services and the subsequent inclusion of the data on their claims and encounter submissions.
WHAT ARE CPT II CODES?
CPT II Codes are quality data codes that translate clinical actions so they can be captured in the administrative process. These codes relay that a measure requirement was met or not met. In addition, these are “tracking”
codes that facilitate data collection for the purpose of performance measurement.
WHY ARE THESE CODES NEEDED?
• These codes are used to track quality measures and monitor patient care.
• CPT II codes improve quality of care but are not “billable.”
• CPT II codes reduce the administrative encumbrance of HEDIS® chart reviews.
• Capturing CPT II codes helps drive HEDIS performance.
WILL I BE REIMBURSED FOR THE SUBMISSION OF A CPT II CODE?
At this time, WellCare does not provide reimbursement for the submission of any CPT II code. However, the reimbursement of CPT II codes may be embedded within some WellCare quality initiatives.
HOW DO I SUBMIT CPT II CODES?
CPT II codes are billed in the procedure code field just as CPT Category I codes are billed.
CPT Category II codes are arranged according to the following categories and are comprised of four digits followed by the letter “F.”
• Composite Measures 0001F - 0015F
• Patient Management 0500F - 0575F
• Patient History 1000F - 1220F
• Physical Examination 2000F - 2050F
• Diagnostic/Screening Processes/Results 3006F - 3573F
• Therapeutic, Preventive, or Other Interventions 4000F - 4306F
• Follow-up or Other Outcomes 5005F - 5100F
• Patient Safety 6005F - 6045F
• Structural Measures 7010F - 7025F
MEDICARE
UPDATING PROVIDER DIRECTORY INFORMATION
We rely on our provider network to advise us of demographic changes so we can keep our information current.
To ensure our members and Provider Relations staff have up-to-date provider information, please give us advance notice of changes you make to your office phone number, office address or panel status (open/closed). Thirty-day advance notice is recommended.
NEW PHONE NUMBER, OFFICE ADDRESS OR CHANGE IN PANEL STATUS:
Send a letter on your letterhead with the updated information.
Please include contact information if we need to follow up on the update with you.
Please update your information or send the letter by any of these methods:
• Call: 1-407-551-3200, Option 2
• Email: [email protected]
• Fax: 1-813-865-6764
This contact information is only for the updates mentioned above in bold. Any other correspondence sent through these channels will not be reviewed or processed.
CLINICAL APPEALS VERSUS CLAIMS PAYMENT DISPUTES
WellCare is dedicated to making the appeals and claims payment dispute processes as smooth as possible for our valued providers. In order to support this effort, we’d like to offer some insight into what is involved in these seemingly similar processes.
CLINICAL APPEALS
An appeal is an authorization-related claim issue. Providers can file an appeal due to claim denial for lack of prior authorization, services exceeded the authorization, insufficient documentation, or late notification. An authorization-related appeal must demonstrate medical necessity and identify any additional clinical information to WellCare that was not previously provided or used in the initial decision. The appeal must be filed in writing or fax, to the Appeals Department within the provider dispute timely filing date of the EOB.
PAYMENT DISPUTES
The claim payment dispute process is designed to address a claim when a provider disagrees with the claim decision regarding the denial for issues related to untimely, incidental procedures, unlisted procedure codes, non-covered codes, reimbursement, etc. A provider may file a dispute by mailing, faxing or emailing a letter with supporting documentation, such as medical records, adhering to WellCare’s dispute timely filing guidelines from the initial payment or denial.
CLAIMS PAYMENT POLICY DISPUTES
The Claims Payment Policy disputes are strictly related to payment policy issues such as EOP denial reason codes beginning with IHXXX, ICXXX, PDXXX or SCXXX. Providers must submit a written appeal along with medical records supporting the denial reason, adhering to WellCare’s dispute timely filing guidelines from the initial denial.
WE’RE JUST A PHONE CALL OR CLICK AWAY!
Medicare:
1-855-538-0454 Staywell
1-866-334-7927 Staywell Kids
1-866-698-5437 www.wellcare.com/Florida
78353
PROVIDER RESOURCES
WEB RESOURCES
Visit www.wellcare.com/Florida 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/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 column on the right.
ADDITIONAL CRITERIA AVAILABLE
Please remember that all Clinical Coverage Guidelines detailing medical necessity criteria for several medical procedures, devices and tests are available on our website at www.wellcare.com/Florida/Providers/Clinical- Guidelines.
PROVIDER SURVEY RESULTS
Every year, WellCare of Florida, in partnership with SPH Analytics, surveys our provider network to see how we’re doing. This year 1,000 providers were surveyed. We appreciate the feedback.
Our results:
• 82.8 percent of Medicaid providers were satisfied with our health plan and said they would recommend Staywell Health Plan to other providers – the highest rating among our competitors.
• 86.6 percent of Medicare Advantage providers were satisfied with our health plan and said they would recommend WellCare to other providers – the highest rating among our competitors.
We asked about several performance areas, such as how their provider relations representatives were doing, our ability to provide member eligibility and claim information quickly, and the formulary.
We are continually striving to improve all aspects of our provider relationships and will be reviewing these results in detail to determine how we can get even better. Thank you for helping us care for our members!
