Molina Spring Workshops 2018 1 Enterprise Health Solutions

Molina Spring Workshops 2018 1 Enterprise Health Solutions

Molina Spring Workshops 2018 1 Enterprise Health Solutions (EHS) Processing Platform West Virginia Family Health Plan (WVFH) transitioned to the EHS claims processing platform on 1/1/18. The system transition will provide you with improved service and responsiveness by integrating resources and expertise into a single point. This upgrade, to an innovative and efficient system, will allow for timely, accurate payments and combined operations functionality. EHS updates are available on our website at If you have any questions about these changes, please 2 Navinet Enhancements

The following transaction Enhanced Provider Features are now available: transactions feature: Eligibility and Benefits Provider Directory Claims Status Inquiry NIA RadMD Authorizations

Allowance Inquiry Claims Cash Management EOB/Remittance Enhanced Investigations change from current process) Authorizations Provider

(no for J-codes ONLY Features * Availability may vary depending on your office type 3 Allowance Inquiry Allowance Inquiry allows you enter in the criteria to allow you to determine a Base Reimbursement* per Code/Modifier * Plan Design Coinsurance, Deductibles, & Limitations & Exclusions may affect actual rate paid 4

EOB and Remittance: Search This feature allows you to search by Billing Provider in 2 week increments. 6 months of history is kept in this section, too! Click in Billing Provider box to display the available selections. Next choose your beginning and ending date (no more than 14 days permitted @ a time) 5 EOB and Remittance: Search Results Search results not only allow you to view by Statement Date, Provider #, Check #, & Check Amount, but you can also Download the PDF to 6

save, print, or email. Appeal Request / Claim Dispute Step #1: Select New Request/Dispute Step #2: Choose your type of request 7 What will change for Providers? Member ID Cards Addresses (effective 1/1/2018) Medicaid General Correspondence: P.O. Box 890421, Camp Hill, PA 17089-0421 Medicaid Claims: P.O. Box 890406, Camp Hill, PA 17089-0406 Medicaid Checks: P.O. Box 890408, Camp Hill, PA 17089-0408 8 New Explanation of Payment

(EOP) Claim Denial Reason/Adjustment reason Patient Information including benefit and member type information Claim Information billed services Basic payment information pricing detail, member cost9 WVFH Key Contact Claim Information Timely filing criteria: 365 calendar days after Date of Service, 180 days from primary payment or denial of claim EPSDTs for data reporting we prefer 60 days from the date of service Timely filing for denied authorization appeals is 90 days Timely filing for denied claim appeals is 180 days Include current practitioner information, such as your NPI Number on electronic claims Include current member information, such as WVFH Member ID

number WVFH accepts electronic claims through Emdeon and Relay 10 Consumer Assessment of Healthcare Providers and Systems (CAHPS) CAHPS measures a Measures involving members experience providers: with their: Getting Needed Care

Providers Getting Care Quickly Health Plan Coordination of Care Shared Decision Making Health Promotion and Overall Health Care

Education Rating of Personal Doctor Rating of Specialist 11 Consumer Assessment of Healthcare Providers and Systems (CAHPS) What can providers do? Continue to provide excellent care Review WVFHs Accessibility Standards Work with your patient to make decisions about their health care Request that your patient keep you updated on care they receive from other providers Educate members on how to prevent illness and how they can be healthy

12 Consumer Assessment of Healthcare Providers and Systems (CAHPS) Other measures providers can impact Advising smokers & tobacco users to quit Discuss smoking cessation strategies with your patients Refer them to the Quitline Flu vaccination Recommend that your patients receive a vaccine every year Educate on the benefits of the flu vaccine Correct misconceptions about the vaccine 13 MEDICATIONS TO REQUIRE MEDICAL PRIOR AUTHORIZATION EFFECTIVE MARCH 5TH, 2018 The prior authorization* process will apply to all West Virginia Family Health members.

NaviNet is the most efficient means to request authorization for using autofill functionality. If you have trouble completing an authorization or have an issue with accessing NaviNet, contact your Provider Account Liaison. HCPCS codes requiring authorization on or After 3/5/18 J1300 J1561 J1745 J9355 J1322

J1566 J9042 J3490 J1459 J1568 J9228 J3590 J1556 J1569 J9271 J9999

J1557 J1572 J9299 J1561 J1599 J9305 *Outpatient services only. Authorization requests for the following medication classes / medications should be directed to the WV Rational Drug Therapy Program: Hemophilia, Spinraza, and Hepatitis C 14 WVFH Key Contact Claim Information WVFH Subcontractors Behavioral Health Beacon -1-855-371-8112

Vision Davis Vision 1-855-4158001 In network claims must file electronically Dental United Concordia Dental (UCD) /Scion 1-855-4349237 Member Services, Dental Referrals and Radiology NIA 1-800-424-4892 Authorization Diagnostic Imaging contact Nurse Line (24/7 availability) 1-844-850-9834 For more information regarding Medical, Vision, and Dental contacts and mailing addresses, visit us online at

15 Behavioral Health Beacon John Marks - Program Director 304-541-3385 [email protected] Sheila Kelly - Case Manager 304-963-6571 [email protected] Electronic BH Payer ID: 43324 Member Information, Claims, Authorizations 1-855371-8112

Contact Beacon to assist with registering for eServices access Visit Beacon online at 16 Provider Resources NaviNet Is The First Point of Lisa Shaffer - Senior Contact Provider Services 1-855-412-8001 phone 1-844-207-0334 - claim review request fax line Jason Landers President 1-304-424-7738 [email protected] Jean Kranz - Director,

Medicaid Operations 1-304-347-7682 [email protected] Provider Contract Analyst 724-831-7695 [email protected] m Kim Hammond - Manager Provider Relations 412-255-4819 [email protected] Website Provider Manual, Directory 17 (Audit Record), Bulletins, Policy Provider Account Liaisons Territories 18

WVFH Disease and Case Management Disease & Case Management - Providers and Member Referrals Welcome! Call WVFH at 1-855-412-8001 to reach our Case Management Department, Monday through Friday 8:30 am to 4:30 pm Case Managers work with members who have multiple chronic conditions, high coordination risk, frequent hospitalizations, high ED utilization, complex/special needs, high risk maternity needs, and/or transition management needs. Case managers focus on care coordination, collaboration, education, addressing care gaps, and patient self-management. Disease Management programs are aimed at improving the health outcomes for our members with COPD, Asthma, Cardiac Disease, and Diabetes. 19 WVFH Disease and Case Management Growing Up/EPSDT program is focused on identifying childrens health problems early and to keep checking to be sure those children stay healthy. Mom Matters program offers support to pregnant members including

ongoing care monitoring, evaluation, education and tailored interventions through pregnancy and up to one year post delivery. Wellness Coaches are available for targeted member inventions including a Nutritionist, Certified Diabetes Educator, and a Rehabilitative Coach. 20 WVFH Value Added Services and Wellness Rewards 2018 Wellness & Reward Incentives (Value Adds) for Member and Provider Maternity to Post Partum - Diabetics ages 18-75 who have Member $150 potential + completed the following three Provider Incentive $200 PRSI exams: HbA1C blood test,

DHHR notification by month 5 of pregnancy $50 member reward Well visit Adults and children - Member $25 annually Dental exam for 2-3 year old children $25 Member nephrology exam, and diabetic eye exam $50 Member Preventive dental care during pregnancy and 6 weeks postpartum Smoking Cessation Quit Line (1800-784-8669) for members who 21 are trying to quit smoking West Virginia Family Health Thanks You All For Coming! Questions?


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