Affordable Care Act Provider Enrollment and Ordering, Prescribing and Referring Providers

Transcription

1 Affordable Care Act Provider Enrollment and Ordering, Prescribing and Referring Providers HP Provider Relations

2 Agenda Session Objectives Affordable Care Act (ACA) Main Objectives Risk Levels Revalidation and Recertification New Provider Enrollment Requirement 2

3 Objectives Understand the goals of the Affordable Care Act Know the applied risk levels Understand the processes and differences of provider revalidation and recertification Know the requirements of Ordering, Prescribing and Referring providers 3

4 Define What is the Affordable Care Act?

5 Affordable Care Act (ACA) Centers for Medicare & Medicaid Services (CMS) Rule 6028-FC of the ACA provides procedures under which screening activities are performed for providers enrolling in Medicare and state Medicaid programs On January 1, 2012, the Indiana Health Coverage Programs (IHCP) adopted and enacted new provider enrollment and screening requirements mandated by the ACA All providers, including waiver (atypical) providers, have now been assigned to a definitive risk level, which impacts their enrollment process Providers are now required to revalidate, or reenroll, their entities in the IHCP at periodic intervals A new segment of providers is now required to enroll in the IHCP 5

6 Know Risk Level Identification

7 Risk Levels All provider types and specialties are assigned to one of the following risk levels: Limited Moderate High Waiver providers are assigned risk levels at the subspecialty level Providers are subject to screening tasks based on their assigned risk level The risk level categorization is established by CMS, based on an assessment of potential for fraud, waste, and abuse for each provider type/specialty. The risk level assignment may be modified at any time at the discretion of the State. In these instances, the provider will be notified by the State, and the new risk level will apply to processing enrollment-related transactions. 7

8 Risk Levels The Provider Type Application Fee and Risk Assignment Matrix (for Non- Waiver and Waiver providers) provides a full list of provider types and their assigned risk level Note: Please review your revalidation notification to know your current risk level assignment and requirements 8

9 Provider Screening Screening tasks Prior to completing enrollment processing, providers are subject to screening tasks based on their risk category: Limited risk category: Validation of disclosed individuals and practitioners with the Office of the Inspector General (OIG) Excluded Individuals database, the Excluded Parties List System (EPLS) and the Social Security Death Master List Practitioner license verification Proof of Medicare enrollment via Medicare Provider Enrollment Chain and Ownership System (PECOS) Validation of practitioner National Provider Identifier (NPI) with the National Plan and Provider Enumeration System (NPPES) 9

10 Provider Screening Screening tasks Moderate risk category: An unannounced, unscheduled site visit Validation of disclosed individuals and practitioners with the eligibility databases Practitioner license verification Proof of Medicare enrollment via PECOS Validation of practitioner National Provider Identifier (NPI) 10

11 Provider Screening Screening tasks High risk category: A fingerprint-based background check for provider owners with a 5% or more ownership interest An unannounced, unscheduled site visit Validation of disclosed individuals and practitioners with the eligibility databases Practitioner license verification Proof of Medicare enrollment via PECOS Validation of practitioner National Provider Identifier (NPI) 11

12 Understand Revalidation and Recertification

13 Revalidation (Provider Reenrollment) Providers essentially will be reenrolling, following the same processes that occurred at initial application Revalidation currently impacts all providers and suppliers that were enrolled in the IHCP prior to January 1, 2012 Most providers enrolled in the IHCP after January 1, 2012, will be required to revalidate beginning calendar year 2017 All states are required to revalidate enrolled providers at intervals not to exceed every five years Durable and home medical equipment providers and pharmacy providers that have DME/HME specialties will revalidate at intervals not to exceed every three years These provider types will begin revalidating calendar year 2015 Revalidating providers are subject to all required screening activities, just like at initial enrollment, according to their provider type 13

14 Revalidation Time Line In March 2012, the IHCP began revalidating pre-2012 enrolled providers in phases based on provider type Revalidation for these providers is scheduled for completion December 31, 2014 Providers will receive an initial notification 90 days prior to their respective deadline to revalidate If the IHCP has not received a response within 30 days of the initial notification, a 2 nd notice will be issued to inform the provider they now have 60 days until their revalidation deadline date Notifications for revalidation will be sent to the Mail To address listed on the provider s profile Providers are encouraged to verify their Mail To address by accessing the Provider Profile feature of Web interchange 14

15 Revalidation Deadline Providers that fail to answer notifications prior to their respective deadlines will be disenrolled from IHCP participation There will be no grace period; providers will be end-dated using their revalidation deadline date Claims billed with dates of service on or after the revalidation deadline date may be denied Managed care members assigned to a primary medical provider (PMP) will be automatically reassigned to another eligible PMP Disenrolled providers that submit revalidation materials and meet all federal and state guidelines to reenroll will be re-admitted into the IHCP 15

16 Revalidation Deadline Back-dating enrollments for disenrolled providers may not be possible once the revalidation deadline has end-dated the enrollment. If the in-house date of the revalidation paperwork is before the enrollment end-date, but it is not worked in time to prevent the closure, the enrollment should be reopened without a gap in enrollment once the paperwork is successfully processed. 16

17 Revalidation Deadline If the in-house date of the revalidation paperwork is after the enrollment has end-dated, the enrollment should be reinstated once the paperwork is successfully processed. Enrollments must be reviewed to determine whether there should be a gap in the enrollment segment. Each request will be determined on a case-by-case basis. If the paperwork is worked as a revalidation an application fee will not be required. 17

18 Revalidation Notification using Web interchange Web interchange users will be able to view the providers Service Location name, address, and revalidation deadline for those that are due for revalidation Users must have View access within Provider Profile to see the list of names Provider names will be listed under the View Upcoming Providers for Revalidation link under the Provider Profile feature Providers names will be removed from the list when the revalidation deadline passes 18 Continuing Evolution of the ACA

19 Revalidation Notification at Web interchange Select this link to view a list of providers due for revalidation 19 Continuing Evolution of the ACA

20 Revalidation Notification Listing 20

21 Revalidation Recap Required by 42 CFR Required for all currently enrolled providers at intervals of three or five years Involves completing a new enrollment application Requires performance of all risk-appropriate screening activities Does not require payment of any fees Providers are encouraged to not attempt revalidation prior to notification The timely return of revalidation paperwork is highly encouraged 21

22 Recertification Requires completion of the IHCP Provider Recertification Form Required by the state of Indiana Required for currently enrolled out-of-state providers and certain specialties Hospital Upon renewal of license or Joint Commission (JC) certification Ambulance Upon issuance of a renewed Emergency Medical Service (EMS) certificate or EMS Air Ambulance certificate Transportation Upon issuance of a renewed Motor Carrier Services (MCS) certificate/operating authority or Livery license and insurance policy Does not require completion of a new enrollment application Does not require completion of screening activities Does not require payment of any fees 22

23 Learn Ordering, Prescribing, and Referring (OPR) Providers

24 Ordering, Prescribing and Referring (OPR) Providers Defined Ordering, prescribing and referring providers are identified as: Practitioners who may treat a Medicaid-enrolled member who needs additional services or supplies that are eligible under the Medicaid program Practitioners who elect not to be enrolled as Medicaid providers An OPR provider may be an IHCP-enrolled provider Practitioners who will not submit claims to the IHCP for reimbursement of rendered services The servicing or billing provider (IHCP-enrolled) is the entity that will be submitting claims for payment for rendered services 24

25 OPR Providers 42 CFR (b) requires that all practitioners that are eligible to order, prescribe or refer services or supplies for a Medicaid recipient be enrolled in the IHCP Enrollment of OPR providers began June 2012 OPR practitioners are classified as non-billable Medicaid providers Billing providers report the OPR s NPI on claims submitted for payment In most cases, the OPR NPI reported on claims should be for a specified individual provider, not a group or organizational entity Some group or organizational entities, such as school corporations or districts, may have their NPI reported on claims 25

26 OPR Providers Institutional and medical claims submitted with dates of service on or after October 1, 2012, will be denied if the correct OPR information is not listed on the claim, or if the provider is not enrolled with the IHCP Claims for pharmacy services and supplies will continue to post and pay through date of service December 31, Claims submitted for date of service of January 1, 2013 and after will deny if the OPR provider information is not reported on the claim, or if the OPR provider is not enrolled in the IHCP 26

27 OPR Provider Information Begins at indianamedicaid.com 27

28 Ordering, Prescribing and Referring (OPR) Provider Search 28

29 Ordering, Prescribing and Referring (OPR) Provider Search / Directory 29

30 Ordering, Prescribing and Referring (OPR) Provider Search National Provider Identifier here Date of Service span entry here 30

31 Ordering, Prescribing and Referring (OPR) Provider Enrollment 31

32 Begin Your OPR Enrollment in IHCP 32

33 OPR Provider Enrollment 33

34 OPR Enrollment OPR providers will utilize a shorter, abbreviated enrollment form for membership in the IHCP Below is a sampling of the first of the five-page application for OPR enrollment: 34

35 Find Help Resources Available

36 Helpful Tools Avenues of resolution Provider Enrollment page at indianamedicaid.com IHCP Provider Manual, Chapter 4 (web, CD, or paper) Provider Bulletin BT Provider Enrollment Telephone Line Locate area consultant map on: indianamedicaid.com (provider home page> Contact Us> Provider Relations Field Consultants) or Web interchange > Help > Contact Us 36

37 Q&A