PROVIDER NEWSLETTER
SOUTH CAROLINA | 2016 | Issue IV
NOTICE OF NEW INBOUND EDIT FOR
SOUTH CAROLINA PROFESSIONAL MEDICAID CLAIMS AND ENCOUNTERS
On Sept. 1, 2016, WellCare deployed a new edit to South Carolina Professional Medicaid Claims that rejects CMS1500/837P submissions if the billing provider and/or rendering provider taxonomy code is incorrect or omitted.
Claim Reject Error Description: [No taxonomy information to accompany the submitted NPI for either the Rendering or Bill-To Provider.]
For Providers participating in the South Carolina State Medicaid program, the submitter should send the taxonomy the provider is registered with for the NPI(s) billed in the submission. The State of South Carolina utilizes the taxonomy code to derive Provider Type for professional claim submissions.
A list of the State of S.C. accepted taxonomy codes can be found at the following link: https://www.scdhhs.gov/provider
For questions relating to additional guidance on the appropriate state-approved taxonomy code, please contact a Provider Representative at 1-888-588-9842.
For inquiries related to placement of taxonomy, please contact our EDI team at [email protected]. We appreciate your attention and preparation for making these changes.
IN THIS ISSUE
Notice of New Inbound Edit for South Carolina Professional Medicaid Claims and Encounters ...1 WellCare Members Now Have Access to Regional HealthPlus in South Carolina...2 We Need Your Help Closing the Gap for BMI...2 Clinical Appeals versus Claims
Payment Disputes ...3 Q4 2016 Provider Formulary Update ...3 How to Improve Patient Satisfaction and CAHPS® Scores, Part 3 of 3 ... 4 Expanded Benefits for Wellcare of
South Carolina Members... 5 Coding Corner ... 6 2016-2017 Influenza Season ...7 Updating Provider Directory
Information ...7 Smoking Cessation in Pregnancy... 8
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working with you and others to help our members live better, healthier lives.
WELLCARE MEMBERS NOW HAVE ACCESS TO REGIONAL HEALTHPLUS IN SOUTH CAROLINA
Regional HealthPlus joined WellCare of South Carolina’s provider network for Medicaid effective June 1, 2016.
WellCare of South Carolina Medicaid members now have access to Regional HealthPlus’ full spectrum of services through three member hospitals: Spartanburg Medical Center, Pelham Medical Center and Union Medical Center, and more than 500 physicians and allied health professionals. In addition, Regional HealthPlus includes three ambulatory surgery centers and a number of ancillary providers.
Heralded in U.S. News and World Report as the “best hospital in South Carolina,”
Spartanburg Medical Center also earned high- performing status in nine areas: cardiology and heart surgery; diabetes and endocrinology;
gastroenterology and gastrointestinal
surgery; geriatrics; nephrology; neurology and neurosurgery; orthopedics; pulmonology; and urology.
“Our members’ health is our first priority, and we must ensure that they get the right care at the right time in the most appropriate setting,” said Kathy Warner, plan president, WellCare of South Carolina. “Regional HealthPlus is a strong addition to our network of providers. We look forward to working with them to help our members live better, healthier lives.”
For more information about Regional HealthPlus, call 1-864-560-6561 or visit
www.regionalhealthplus.com.
WE NEED YOUR HELP CLOSING THE GAP FOR BMI
The pediatric body mass index (BMI) is one of the HEDIS measures that will require our focus this year.
We appreciate the care that you provide to our members whether they are sick or well.
Our members usually receive a height and weight check with each office visit. However, if there is no BMI percentile with the proper code, the Care Gap remains open. We are aware that you are providing the service, and we want you to get credit for it. Close the gap by coding the BMI percentile for each office visit the member receives.
Pediatric BMI (Ages 3-17) ICD-10 Code
Less than 5th percentile for age Z68.51 5th percentile to less than
85th percentile for age Z68.52 85th percentile to less than
95th percentile for age Z68.53 Greater than or equal to
95th percentile for age Z68.54 Please remember Medical record documentation for Pediatric BMI must be reported as an exact
percentile or plotted on an age-growth chart for iHOP submissions. (CPT codes and ranges are not acceptable.)
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 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 and 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.
CLAIM PAYMENT POLICY DISPUTES
The Claims Payment Policy disputes are strictly related to payment policy issue such as EOP denial reason codes beginning with IHXXX, ICXXX, PDXXX, or SCXXX. Provider 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.
Q4 2016 PROVIDER FORMULARY UPDATE
The WellCare of South Carolina Preferred Drug List (PDL) has been updated. Visit www.wellcare.com/
South-Carolina/Providers/Medicaid/
Pharmacy to view the current PDL and pharmacy updates.
You can also refer to the Provider Manual available at www.wellcare.com/
South-Carolina/Providers/Medicaid to view more information regarding WellCare of South Carolina’s pharmacy Utilization Management 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 patients’ perceptions of the key aspects of their care.
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 PCPs, and they rate you favorably.
• Thank you for helping members feel good about their PCPs.
Overall, WellCare members say it is not always easy to get needed care.
• Please be sure your patients can get routine and urgent appointments when needed.
Here are some tips that can improve the member experience and your CAHPS scores:
• Make sure your members know:
– Your office hours
– How and where to get care and treatments after hours – Who the on-call staff is and how to contact them – WellCare 24-hour Nurse Advice Line
• When appropriate, be prepared to offer the following value-added assistance to WellCare members:
– CommUnity Assistance Line: Helps to connect members with services in the community 1-866-775-2192.
– Case Management at 1-866-635-7045 and Disease Management at 1-877-393-3090.
• 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.
• Follow up after tests/screenings by calling/contacting your patients with results as soon as possible.
• Maintain contact information for community service alternatives in your area such as:
– Local crisis centers, including 24/7 suicide and domestic violence lines
– Local youth and family service center/Department of Children & Family Services – Local homeless services
– Student counseling – Smoking cessation services – Medication assistance programs
Thank you for all you do to help our members reach and maintain good health.
EXPANDED BENEFITS FOR WELLCARE OF SOUTH CAROLINA MEMBERS
WellCare is excited to offer the following expanded benefits and special programs to our members (your patients):
HEALTHY REWARDS PROGRAM
The Healthy Rewards Program rewards members for taking steps that help them live a healthy life. When they complete a healthy behavior, we send them a $20 CVS Select® gift card. When they complete another healthy behavior, we’ll load another $20 onto their gift card. It’s that simple.
Members can use their gift card to buy healthy items such as vitamins, pain relief medicine, baby items and other over-the-counter items. Ineligible items include alcohol, cosmetics and candy. The chart below displays the full list of healthy behaviors members can complete to earn additional rewards.
Healthy Rewards Reward Type Reward
Type Reward Criteria
Children’s Healthy Behaviors Well-Child Visit:
0–15 months Reloadable CVS Select Card $20 Members 0–15 months: Complete a well-child visit per periodicity schedule (reward for each visit, up to six visits).
Annual Child Health
Checkup: 3–6 years Reloadable CVS Select Card $20 Members 3–6 years: Complete an annual child health checkup visit (EPSDT).
Annual Adolescent
Checkup: 7–21 years Reloadable CVS Select Card $20 Members 7–21 years: Complete an annual adolescent checkup visit.
Healthy Pregnancy Rewards Prenatal and
Postpartum Checkups Baby stroller or portable playpen N/A Pregnant members: Complete six prenatal visits and one postpartum visit.
Adult Healthy Rewards Annual Adult
Checkup Reloadable CVS Select Card $20 Members 18–39 years: Complete a checkup every one to three years. Members ages 40–64: Complete a
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 Claim Editing Update 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 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 According to WellCare’s policy, which is WellCare Health Plans CE141 Denied:
Unacceptable Principal based on National Coding Standard as will deny claims if the Inpatient Diagnosis designated by the 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, they are unacceptable as a principal diagnosis.
principal diagnosis on a claim has a designation as an unacceptable principal diagnosis.
Dispute rights will be provided.
Unacceptable Principal Diagnosis
Facility Inpatient According to WellCare’s policy, which is WellCare Health Plans CE142 Denied:
Unacceptable Other based on National Coding Standard as will deny claims if the Inpatient Diagnosis designated by the 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, they are unacceptable as a principal diagnosis.
In a few cases, some unacceptable codes will be acceptable as principal diagnosis if a secondary diagnosis is coded.
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.
Unacceptable Principal Diagnosis, requires Secondary Diagnosis
VITAMIN D TESTING
DESCRIPTION OF SERVICE:
According to CMS, providers should perform Vitamin D testing only 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.
2016-2017 INFLUENZA SEASON
By now, your practice should be prepared for the 2016–2017 influenza season. It is important to develop an influenza vaccine purchasing plan that allows you to meet the needs of your patients. Influenza seasons are unpredictable and can begin earlier or last longer than expected, so plan ahead in order to protect your patients and employees. You should regularly review your influenza vaccine purchasing options and reassess the needs of your organization. For assistance, please call one of the Provider Services phone numbers at the end of this newsletter.
FOR THE IMMUNIZATION-RESISTANT
Misinformation about vaccine safety has existed since the dawn of vaccines, and its dissemination is permitted by the freedom to express opinions, no matter how incorrect.
Nurses, physician assistants and other office staff play a key role in establishing and maintaining a practice-wide commitment to communicating effectively about vaccines and maintaining high vaccination rates – from providing educational materials, to being available to answer questions, to ensuring that families that may opt for extra visits for vaccines schedule and keep vaccine appointments.
Confused parents may delay or refuse immunizations for their children because of misperceptions of disease risk and vaccine safety. A successful discussion about vaccines involves a two-way conversation, with both parties sharing information and asking questions. These communication principles can help you connect with patients and their caretakers by encouraging open, honest and productive dialogue.
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. This can be done by contacting your Provider Relations representative, or by following the information below.
New Phone Number, Office Address or Change in Panel Status – Send a letter on your letterhead with updated information. Please include contact information if we need to follow up with you.
Please send the letter by any of these methods:
• Email: [email protected]
• Fax: 1-866-354-8711
• Mail: WellCare of South Carolina Attention: Provider Relations 200 Center Point Circle, Suite 180 Columbia, SC 29210�
The information above in bold is only for providers to give us updates. Any other correspondence sent through these channels will not be reviewed nor processed. Thank you for helping us maintain up-to-date directory information for your practice.
SMOKING CESSATION IN PREGNANCY
According to a 2014 study by the Kids Count Data Center (a project of the Annie E. Casey Foundation), 11% of women in South Carolina reported smoking throughout pregnancy, leading to higher risk of pregnancy complications, preterm delivery and stillbirth. Smoking cessation counseling by clinicians has been shown to be effective in improving tobacco quit rates.
SMOKING DOCUMENTATION TIPS:
• Smoking history
• Education/counseling regarding smoking cessation
• Referral to a smoking cessation program such as the SC Tobacco Quit Line at 1-800-QUIT-NOW (1-800-784-8669)
• Document if and when (the date) your patient has stopped smoking prior to delivery.
Sources:
Kids Count Data Center, http://datacenter.kidscount.org/data/tables/13-births-to-mothers-who-smoked-during-pregnancy#detailed The health consequences of smoking: a report of the Surgeon General. CDC, 2004, www.ncbi.nlm.nih.gov/books/NBK44697/
Grotsky, J., Gothard, M., Khalil, L., et. al., “Smoking Cessation and prevention in women of reproductive age: Resources and partnerships for physicians. Wisconsin Medical Journal, 2004. 103:31-33.
PROVIDER RESOURCES
WEB RESOURCES
Visit www.wellcare.com/South-Carolina/Providers 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/South-Carolina/Providers/Medicaid.
PROVIDER NEWS
Remember to check messages regularly to receive new and updated information. Visit the secure area of
www.wellcare.com/South-Carolina/Providers/Medicaid 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/South-Carolina/Providers/
Clinical-Guidelines/CPGs.
WE’RE JUST A PHONE CALL OR CLICK AWAY!
WellCare of South Carolina www.wellcare.com/South-Carolina 1-888-588-9842
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