WV Bureau for Medical Services & Molina Medicaid Solutions

Transcription

1 WV Bureau for Medical Services & Molina Medicaid Solutions 1

2 Referred to as One to Many provider records This means one NPI to multiple Medicaid provider ID numbers. Spring to Fall Workshops 600 down to 271. Separate NPI number can be obtained by NPPES CMS expects BMS/Molina to use NPI numbers on all transactions. Benefits Eliminates the use of taxonomy Reduces delay of claims processing Facilitates electronic enrollment 2

3 Molina Medicaid Solutions web site & EDI Web Portal now provides significant enhancements and functionality. Improved Functionality Real Time Capabilities Fully automated Trading Partner registration and administration. WVMMIS trading partner accounts support multiple users in compliance with HIPAA security regulations. Multiple billing providers can be linked to one account. Real-time claims Direct Data Entry (DDE) will include the following: Edit & correct on non-finalized claims Real-time claim adjustments, reversal and reversal/replacement of claims Upload of Electronic claim attachments and documentation Real time Direct Data Entry of: Claims Submission Eligibility Verification Claim Status Referral Status Prior Authorization Status Payment Status Improved Patient/Member Roster Set-up and Editing 3

4 Current Revalidation Statistics: To date we have invited providers to revalidate their enrollment for 9 of our 10 scheduled phases with the last phase scheduled to begin early November. Revalidation and new enrollments via web-based portal: 63% Provider Participation 54% of Provider Participation have submitted. Over half of the submitted are missing required documentation. Turn around time increases for revalidations submitted to Molina by paper because we must key it in the web portal. Since the start of Provider Revalidation, Molina has processed over 700 new enrollments for WV Medicaid. This number includes Pay-To Providers with new affiliations. Must enroll Ordering/Referring/Prescribing (ORP) providers ORPs = providers that order/refer/prescribe but do not submit claims. (Example: hospital residents, providers at free clinics) Application fees for certain providers Can be waived if paid to Medicare, other state Medicaid or CHIP Hardship exception can be requested; must be approved by CMS BMS must revalidate all providers every 5 years with the exception of high risk provider types every 3 years. 4

5 Letters and s generated to providers per phase Initial Re-enrollment/Revalidation Notice sent to physical address for providers included in phase One to two weeks later, Case Number letter for access to portal is sent to the providers in phase 30 days from date of Case Number letter, providers who have not completed revalidation will receive a 30 day reminder letter and, if they have entered the portal, a reminder 45 days from date of Case Number letter, providers who have not completed revalidation will receive 45 day reminder letter and, if they have entered the portal, a reminder Total of two separate 30-day extensions are available at end of 60 days and 90 days from date of Case Number letter BMS/Molina uses info in Medicare s Provider Enrollment System (PECOS) to validate some provider information Technical assistance available from Molina Resources on Molina website under provider enrollment link Webinars to assist in revalidation process Provider Reps may schedule a WebEx or on-site visit to provider s office to offer guidance for the revalidation process. 5

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10 Timely Filing Policy (See Timely Filing Guidelines at and in the Provider Manual chapter 800 located on BMS website) To meet timely filing requirements for WV Medicaid, claims must be received within one year from the date of service. The year is counted from the date of receipt to the from date on a CMS 1500, Dental or UB04. Claims that are over one year old must have been billed and received within the one year filing limit. (See exceptions for Medicare primary claims, TPL primary claims, MCO primary claims, and backdated medical card under guidelines) The original claim must have had the following valid information: Valid provider number Valid member number Valid date of service Valid type of bill Claims that are over one year old must be submitted with a copy of the remittance advice showing where the claim was received prior to turning a year old. Claims with dates of service over two years old are NOT eligible for reimbursement. This policy is applicable to reversal/replacement claims. If a reversal/replacement claim is submitted with a date of service that is over one year old, the replacement claim must be billed on paper with a copy of the original remittance advice to: Provider Relations, PO Box 2002, Charleston, WV You are NOT allowed to add additional services to the replacement claim. If additional services are billed on the replacement claim that were not billed on the original claim and the dates of service are over one year old, the claim will be denied for timely filing Following these reminders can reduce the number of denied claims: Claims with dates of service over the filing limit must be submitted on paper with proof of timely filing to: PO Box 2002, Charleston WV Reversal/Replacement and claims with dates of service over the filing limit should also be sent to: PO Box 2002, Charleston WV It is not necessary to submit all remittance advices related to a claim. Only one remittance advice that documents proof of filing is required. (refer to Timely Filing Guidelines at 10

11 Provider surveys on a quarterly basis to address hot topics with webinars. 11

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20 WV Bureau for Medical Services Website at Molina Fiscal Agent Provider Services & EDI Helpdesk (888) or (304) Member Services Helpdesk (888) or (304) Pharmacy Helpdesk (888) Medicaid Member Services ( ; ) Medicaid Provider Services ( ; ) Medicaid Pharmacy Help Desk ( ) 20