WV Bureau for Medical Services, WV Children s Health Insurance Program, & Molina Medicaid Solutions

Transcription

1 WV Bureau for Medical Services, WV Children s Health Insurance Program, & Molina Medicaid Solutions 1

2 The Provider Enrollment/Revalidation Project is the web based enrollment application designed by the State of West Virginia to comply with ACA and Federal Regulations. This initial Provider Revalidation began June 3, All participating providers must be screened upon initial submission, including applications for a new practice location and any applications received in response to a request for revalidation. The required screening measures vary according to the provider s categorical risk level and provider type. With the implementation of this project in West Virginia we are: Assuring our State Medicaid agency complies with the process for screening providers Assuring providers will be screened in accordance with federal and state regulations Assuring the State Medicaid agency has a method for verifying providers are licensed and such licenses have not expired or have current limitations Assuring providers will be revalidated regardless of provider type at least every 5 years Assuring the required federal database checks are performed on all providers and any person with ownership and/or controlling interests Assuring the State Medicaid agency is requiring the National Provider Identifier (NPI) of Ordering/Referring or other professionals to be specified on any claim for payment 2

3 WV Provider Revalidation ,000 23,356 20,000 19,397 15,000 15,242 10,000 5,000 6,038 4,865 4,155 - Total WV Provider Population Total Number of Pay to Providers Current Total of Submitted Applications WV Pay- to Provider Revalidations Completed WV Servicing Providers Revalidated Completed Total WV Providers Revalidated and Completed

4 Phases by Provider Type Revalidation Completed in 10 Phases Work In Process Status Phase apps completed/521 apps started 90.97% Phase apps completed/1,175 apps started 84.08% Phase apps completed/299 apps started 86.28% Phase 4 65 apps completed/81 apps started 80.24% Phase 5 55 apps completed/72 apps started 76.38% Phase apps completed/491 apps started 89.81% Phase apps completed/212 apps started 91.50% Phase 8 1,348 apps completed/1,559 apps started 86.46% Phase apps completed/286 apps started 76.57% Phase apps completed/169 apps started 66.86% Total Revalidations Completion 4,155 apps completed/4,865 apps started 85.40% Target Completion Date June 1,

5 Target dates to meet federal deadline of September 25, 2016: May 2, 2016 All providers who have not submitted a complete revalidation application or who are not currently in communication with and working with Molina to complete their revalidation application will be placed on pay hold June 1, 2016 All providers placed on pay hold in May who have not completed the revalidation process will have their West Virginia Medicaid participation terminated July 1, 2016 All complete revalidation applications in-house will be completed by Molina August 1, 2016 Providers with incomplete revalidation applications will be placed on pay hold September 1, 2016 Molina will begin terminating participation of all Medicaid providers who have not completed revalidation Revalidation Cycle 2 begins June

6 Molina has completed the major project of transitioning WVCHIP claim processing to Molina Medicaid Solutions. Some on-going processes are listed below. WVCHIP Provider Communication Ongoing efforts to identify and communicate with providers who service WVCHIP members. This information is used to provide an enrollment application and information to assist in the enrollment process. Enrollment Procedures All WVCHIP only providers must enroll with Molina. If you are a current WV Medicaid provider with a completed revalidation, an abbreviated application will be required to provide WVCHIP specific information. Current Medicaid/WVCHIP providers which are currently revalidated will not be required to revalidate/re-enroll again. Continued focus on identifying claims processing procedures and communicating effectively with the provider and member population. More information can be found on the Molina Web Portal. 6

7 Implementation of the Unenrolled Prescriber Edit for the pharmacy program and unenrolled ORP provider for the medical program. Discussion points: Continued communication with the member population indicatin that Starting June 1, 2016 West Virginia Medicaid will only pay for drugs ordered by West Virginia Medicaid enrolled health care providers. If your health care provider is not enrolled in Medicaid, you will have to pay for your drugs. Continued communication with the provider community indicating that Starting June 1, 2016 West Virginia Medicaid will only pay for services ordered, referred, or prescribed by West Virginia Medicaid enrolled health care providers. If the provider is not enrolled in Medicaid, the service will be denied. Some examples of services which will deny without an enrolled ORP when this rule is implemented are: Equipment/DME Laboratory Services Radiological Services 5/27/2016 7

8 WV Operational Statistics Claims Processing ,342,737 Claims processed in ,894 Claims processed monthly Change Control 301 Change Requests entered 2015 WV Site training 801 sessions conducted Provider Enrollment 1,464 New Providers enrolled 23,367 Provider changes (Maintenance) completed 967 Average provider revalidations completed monthly Call Center 26,080 received calls per month 98% average call quality Member Count 2015 Year Ending - 559,625 5/27/2016 8

9 Molina Medicaid Solutions web site & EDI Web Portal provides significant functionality for the WV Medicaid provider community. 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 More enhancements and functionality continuing to be implemented. 9

10 Molina Medicaid Solutions Fiscal Agent for the WV Medicaid and CHIP programs. Web portal - EDI Helpdesk - (888) or (304) Provider Services (888) or (304) Member Services - (888) or (304) Provider Enrollment wvproviderenrollment@molinahealthcare.com or (888) Pharmacy Helpdesk - (888) or (304) WVCHIP (800) Provider Field Representatives:WVProviderFieldRepresentative@Molinahealthcare.com * Debbie Rhodes * Freda Creighton * Gloria Hays * James Wallace * Christina Martin *Member Services ( ; ) Medicaid Pharmacy Help Desk ( ) 10