The Molina Messenger. Spring/Summer Edition Molina s Commitment to the Individual Health Insurance Marketplace

Transcription

1 The Molina Messenger Spring/Summer Edition 2016 From the Desk of Ray Coto, Chief Operation Officer Molina s Commitment to the Individual Health Insurance Marketplace Molina has been an active participant in the state s individual health exchange since the later part of Molina had tremendous membership growth in 2015 across the South Florida Tri-County area, with the predominance of this growth in Miami-Dade County. The growth of Molina s Marketplace product can be attributed to many things including: expansion within key counties, low cost, quality networks, and community engagement activities. Molina s product offerings for 2016 have again been very well received and we have seen a significant increase in our Marketplace membership levels during the first quarter of this year. We are very excited to continue to provide affordable quality healthcare insurance solutions to the individual insurance marketplace. In this Edition Molina s Commitment to the Individual Health Insurance Marketplace... 1 AHCA Implements Express Enrollement... 2 Importance of Quality HEDIS... 3 Web Portal Functions- HEDIS Profile... 4 Molina NOW Pays for a Sick and Well Visit on Same Date of Service Prior Authorization Update Common Reasons for Returned Claims Coordination of Care Continuity and Coordination of Provider Comprehensive Laboratory Test Menu Pharmacy Services Prior Authorization Form Risk Adjustment - Coding Tips and Errors Hierarchical Condition Categories (HCC) Pearls of Wisdom EFT (Electornic Funds Transfer) - Direct Deposit Mobile Provider Online Directory is Now Live! Community Engagement Corner Did You Know? April is National Nutrition Month... 27

2 AHCA Implements Express Enrollment In January 2016, the Agency for Health Care Administration (AHCA) implemented Express Enrollment for Medicaid recipients who enroll in a Managed Medical Assistance (MMA) plan. Express Enrollment does not impact the Long Term Care (LTC) program. Prior to Express Enrollment, new Medicaid recipients were required to wait 30 to 60 days before they could enroll in a MMA plan and access program enhancements. Express Enrollment gives recipients the opportunity to make a health plan decision when they apply for Medicaid eligibility. It also enrolls Medicaid-eligible recipients who are mandated to participate in the MMA program into a health plan immediately after eligibility determination. Express Enrollment does not change eligibility requirements, MMA participation requirements or the services offered under MMA. How will Express Enrollment Affect You? Recipients enrolled via Express Enrollment may become eligible with Molina at any time throughout the month. Primary Care Physicians (PCP) may receive member assignments throughout the month as well. Providers should check eligibility and PCP assignment at the time of service delivery via Molina s Web Portal at www. or by contacting Customer Service at (866) Recipients may access network providers for care as soon as they are eligible, and may not have received their Molina identification card yet. Provider must verify eligibility at the time of service delivery via Molina s Web Portal at or the state s Web Portal at Molina s Web Portal is updated nightly. Recipients loaded into our systems may not be immediately available on our Web Portal. In these cases, providers should utilize the state s Web Portal at to verify eligibility and plan assignment. For additional information regarding Express Enrollment, visit AHCA s Express Enrollment web page at or contact Molina s Provider Services Department at (855) THE MOLINA MESSENGER - SPRING/SUMMER 2016

3 Importance of Quality and HEDIS The Healthcare Effectiveness Data and Information Set (HEDIS ) is a tool used by more than 90 percent of America s health plans to measure performance on important dimensions of care and service. Altogether, HEDIS consists of 75 measures across eight domains of care. Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an apples-to-apples basis. Molina Healthcare utilizes HEDIS as a measurement tool to provide a fair and accurate assessment of specific aspects of our performance. Selected HEDIS results are submitted directly to NCQA, consistent with the original intent of HEDIS to provide health care purchasers data with which to make informed decisions. The data is also used by NCQA to establish health plan performance benchmarks and is an integral part of the NCQA health plan accreditation process. Depending on the specific HEDIS measure, the reported rate may be based entirely on claims (administrative rate), or on a combination of claims and information extracted from medical records (hybrid rate). Providers are contacted during the first quarter of the year and requested to provide specific information documented in the medical records for a small fraction of their patients in order to assist with HEDIS data collection. All reported measures must follow rigorous specifications and are externally audited to assure continuity and comparability of results. The HEDIS measurement set currently includes a variety of health care aspects including immunizations, women s health screening, diabetes care, appropriate use of asthma medications, and prenatal and postpartum care. HEDIS results are used in a variety of ways. They are the measurement standard for many of Molina Healthcare s clinical quality improvement activities and health improvement programs. The standards are based on established clinical guidelines and protocols, providing a firm foundation to measure the success of these programs. These activities include Molina Healthcare s disease management programs, childhood and adolescent well child and immunization programs, and prenatal and postpartum care programs. As part of the QI Program, providers agree to allow Molina to use practitioner performance data, including provider-specific HEDIS rates for quality improvement activities, public reporting to members, and determining preferred network status. Why is HEDIS important to physicians? HEDIS measures track a health plan s and physician s ability to manage health outcomes. Generally, strong HEDIS performance reflects enhanced quality of care. With proactive population management, physicians can monitor care improving quality while reducing costs. Additionally, if you participate in the Pay for Performance-P4P program, improving your HEDIS performance increases your practice s earning potential. Performance measures are critical tools that help determine how well organized healthcare delivery systems perform patient care. Today performance measure reporting has shifted from reimbursement-driven data reporting toward quality of patient care. THE MOLINA MESSENGER - SPRING/SUMMER

4 Web Portal Functions- HEDIS Profile The Healthcare Effectiveness Data and Information Set (HEDIS ) Profile is an application used to measure performance on significant dimensions of care and service. The HEDIS Profile is updated in the final week of every month and reflects all processed data received in the prior month. You will be able to: View your HEDIS scores and compare performance against peers and national benchmarks. (You must have the Admin, All Access, or Clinical role-type to view the HEDIS Profile) Search/filter for members who need HEDIS services Submit HEDIS chart documentation online for completed service, so we can update our system. Retrieve/print a list of members who need HEDIS services completed. View Your HEDIS Scores If you are registered for multiple lines of business; click on the drop down arrow to toggle between your accounts. This will allow you to view information specific to that account. Once you are in the HEDIS Profile tool, the My Rates tab will display. Filter the list by clicking on the drop down menu options: Select a Provider (for Facility/Groups) Select a Group (for Individual Providers) Select a Service Location If a Group or Provider is grayed out, they do not have members assigned to display. Your Measures will appear alongside your current measurement year performance. The % of Patients who Received Services column will change color based on the national benchmarks. Medicare Star Ratings: (Shown on the Medicare Profile Only) Green = Your rate is at or above the 5 star rating Yellow = Your rate is at or above the 4 star rating Red = Your rate is below the 4 star ratings Medicare Star Ratings: (Shown on the Medicare Profile Only) Green = Your rate is at or above the 5 star rating Yellow = Your rate is at or above the 4 star rating Red = Your rate is below the 4 star ratings 4 THE MOLINA MESSENGER - SPRING/SUMMER 2016

5 Search for Members who Need HEDIS Services If you switch to the Members tab, it displays a list of members who either need a HEDIS service, or have completed one. If you are searching for members who need services, select Needed Services in the Service Status drop down menu. The Measure column indicates the HEDIS Measure that the member needs or has completed. To see a definition of the Measure, toggle back to the My Rates tab and hover over the question mark. All the fields, except for address and phone number, are searchable by entering a search term in the blank text boxes below the respective column headers. You can also search or filter by the Measure and PCP Name by selecting the drop-down menu of each column. Submit HEDIS Chart Documentation for Completed Services To view documents for a specific member, first select a member by checking the box in the first column. Then select View Documents at the bottom of the screen. A pop up will display with a list of documents submitted for this member. If a member has completed a service that is being shown as needed, you can submit relevant medical record documentation (e.g., progress note, immunization record, lab report, etc.) by choosing the member and selecting Upload Documents. The attachment tool will appear allowing you to upload multiple files. Any file format can be attached as long as the total size is under 2GB. Once the documentation has been uploaded, the HEDIS team will review the chart. If it meets HEDIS criteria, we will update our records within 60 days of receipt of documentation. Tip: If you are struggling to get the attachments under the 2GB limit, try changing the file format. Retrieve/Print List of Rates or Members Please make sure to turn off your pop-up blocker for these functions to work properly. At the bottom of both the My Rates and Members tab, there are options to Print or Export. To print a report, click on Print and a print-ready version of the report will display in a new window. If you select Export, you can choose between two formats - PDF or Excel. THE MOLINA MESSENGER - SPRING/SUMMER

6 MEDICAID HEDIS REFERENCE SHEET FOR PROVIDERS ALL ADULTS WOMEN ADULT HEDIS HEDIS Age Requirement and Documentation Billing Adult BMI Assessment Controlling High Blood Pressure Breast Cancer Screening Cervical Cancer Screening Chlamydia Screening years 21 years: Documented body mass index (BMI) during the measurement year or the year prior <21 years: Documented BMI percentile during the measurement year or the year prior years (hypertensive members) Members years of age whose BP was <140/90 mm Hg. Members years of age with a diagnosis of diabetes whose BP was <140/90 mm Hg. Members years of age without a diagnosis of diabetes whose BP was <150/90 mm Hg years One mammogram any time on or between October 1 two years prior to the measurement year and December 31 of the measurement year. Exclusion: Bilateral mastectomy years Women who were screened for cervical cancer using either of the following criteria: Women age who had cervical cytology performed every 3 years Women age who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years Exclusion: Hysterectomy with no residual cervix years women At least one Chlamydia test during the measurement year for sexually active women. ICD-9: V85.0-V85.5 *ICD-10: Z68.1, Z68.20-Z68.39, Z68.41-Z68.45, Z68.51, Z68.52, Z68.53, Z68.54 Codes to Identify Hypertension ICD-9: 401.0, 401.1, *ICD-10: I10 CPT: HCPCS: G0202, G0204, G0206 ICD-9PCS: 87.36, UB Rev: 0401, 0403 Codes to Identify Cervical Cytology CPT: , 88147, 88148, 88150, , , 88174, HCPCS: G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 UB Rev: 0923 Codes to Identify HPV Tests CPT: CPT: 87110, 87270, 87320, , THE MOLINA MESSENGER - SPRING/SUMMER 2016

7 PRENATAL CARE ADULT HEDIS HEDIS Age Requirement and Documentation Billing Timeliness of Prenatal Care Frequency of Prenatal Care All pregnant women All pregnant women Prenatal care visit in the first trimester or within 42 days of enrollment. Prenatal care visit, where the practitioner type is an OB/GYN or other prenatal care practitioner or PCP*, with one of these: Basic physical obstetrical exam (e.g., auscultation for fetal heart tone, or pelvic exam with obstetric observations, or measurement of fundus height); standard prenatal flow sheet may be used Obstetric panel Ultrasound of pregnant uterus Pregnancy-related diagnosis code (For visits to a PCP, a diagnosis of pregnancy must be present) TORCH antibody panel (Toxoplasma, Rubella, Cytomegalovirus, and Herpes simplex testing) Rubella & ABO, Rubella & Rh, or Rubella & ABO/Rh testdocumented LMP or EDD with either a completed obstetric history or risk assessment and counseling/education (for when the practitioner is a PCP) * For visits to a PCP, a diagnosis of pregnancy must be present along with any of the above. Completing at least 81% of expected prenatal care visits. The percentage is adjusted by the month of pregnancy at the time of enrollment and gestational age. A full 42 week gestational pregnancy is expected to have 16 prenatal care visits. Prenatal Care Visits CPT: , , , CPT II: 0500F, 0501F, 0502F UB Rev: 0514 HCPCS: H1000-H1004, T1015, G0463 Obstetric Panel CPT: Prenatal Ultrasound CPT: 76801, 76805, 76811, 76813, , ICD-9 PCS: *ICD-10 PCS: BY49ZZZ, BY4BZZZ, BY4CZZZ, BY4DZZZ, BY4FZZZ, BY4GZZZ ABO and Rh CPT (ABO): CPT (Rh): TORCH CPT (Toxoplasma): 86777, CPT (Rubella): CPT (Cytomegalovirus): CPT (Herpes Simplex): 86694, 86695, 86696Pregnancy Diagnosis: ICD-9: 640.x3, 641.x3, 642.x3, 643. x3, 644.x3, 645.x3, 646.x3, 647.x3, 648.x3, 649. x3, 651.x3, 652.x3, 653.x3, 654.x3, 655.x3, 656.x3, 657.x3, 658.x3, 659.x3, 678.x3, 679.x3, V22-V23, V28 *ICD-10: O9-O16, O20-O26, O28-O36, O40-O48, O60.0, O71, O88, O91, O92, O98, O99, O9A, Z03.7, Z33, Z34, Z36 Prenatal Care Visits CPT: , , , CPT II: 0500F, 0501F, 0502F UB Rev: 0514 HCPCS: H1000-H1004, T1015, G0463 Obstetric Panel CPT: Prenatal Ultrasound CPT: 76801, 76805, 76811, 76813, , ICD-9 PCS: *ICD-10 PCS: BY49ZZZ, BY4BZZZ, BY4CZZZ, BY4DZZZ, BY4FZZZ, BY4GZZZ ABO and Rh CPT (ABO): CPT (Rh): TORCH CPT (Toxoplasma): 86777, CPT (Rubella): CPT (Cytomegalovirus): CPT (Herpes Simplex): 86694, 86695, Pregnancy Diagnosis: ICD-9: 640.x3, 641.x3, 642.x3, 643.x3, 644.x3, 645.x3, 646.x3, 647.x3, 648.x3, 649.x3, 651.x3, 652.x3, 653.x3, 654.x3, 655.x3, 656.x3, 657.x3, 658.x3, 659.x3, 678.x3, 679.x3, V22-V23, V28 *ICD-10: O9-O16, O20-O26, O28-O36, O40-O48, O60.0, O71, O88, O91, O92, O98, O99, O9A, Z03.7, Z33, Z34, Z36 THE MOLINA MESSENGER - SPRING/SUMMER

8 POSTPARTUN CARE ADULT HEDIS HEDIS Age Requirement and Documentation Billing Postpartum Care Comprehensive Diabetes Care All women who delivered a baby years (diabetics) Postpartum visit for a pelvic exam or postpartum care with an OB/ GYN practitioner or midwife, family practitioner or other PCP on or between 21 and 56 days after delivery. A Pap test within days after delivery also counts. Documentation in the medical record must include a note with the date when the postpartum visit occurred and one of these: Pelvic exam, or Evaluation of weight, BP, breast and abdomen, or Notation of postpartum care, PP check, PP care, six-week check notation, or pre-printed Postpartum Care form in which information was documented during the visit. All diabetic tests listed below completed during the measurement year. Postpartum Visit CPT: 57170, 58300, 59430, CPT II: 0503F HCPCS: G0101 ICD-9-CM: V24.1, V24.2, V25.1, V72.3, V76.2 ICD-9-PCS: *ICD-10-CM: Z01.411, Z01.419, Z30.430, Z39.1, Z39.2 Cervical Cytology CPT: , 88147, 88148, 88150, , , 88174, HCPCS: G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 UB Rev: 0923 Codes to Identify Diabetes ICD-9: , 357.2, , , *ICD-10: E10, E11, E13, O24 DIABETES Diabetes HbA1c Test and Control years (diabetics) HbA1c test during the measurement year with the most recent test <8%. CPT: 83036, CPT II: 3044F (if HbA1c<7%), 3045F (if HbA1c 7.0%-9.0%), 3046F (if HbA1c>9%) Codes to Identify Nephropathy Screening (Urine Protein Tests) CPT: , 82042, 82043, 82044, CPT II: 3060F, 3061F, 3062F Diabetes Nephropathy Screening Test years (diabetics) Urine microalbumin during the measurement year. Requirement also met if there is evidence of nephropathy: Visit to nephrologist, ACE/ARB therapy, or positive macro albumin test during measurement year. Codes to Identify Nephropathy Treatment CPT II: 3066F, 4010F ICD-9: 250.4, , 580, , 753, 791 *ICD-10: E08.2-E11.2, E13.2, I12, I13, I15, N00-N08, N14, N17, N18, N19, N25, N26, Q60, Q61, R80 8 THE MOLINA MESSENGER - SPRING/SUMMER 2016

9 DIABETES ADULT HEDIS HEDIS Age Requirement and Documentation Billing Diabetes Retinal Eye Exam Appropriate Medications for Asthmatics Appropriate Tx for Children w/ URI years (diabetics) 5-64 years persistent asthmatics 3 months- 18 years Eye exam (retinal or dilated) performed by an optometrist or ophthalmologist in the measurement year, or a negative retinal exam in the year prior. Dispense at least one prescription for an asthma controller medication during the measurement year. If diagnosed with upper respiratory infection (URI), an antibiotic should not be dispensed. Codes to Identify Eye Exam (performed by optometrist or ophthalmologist) CPT: 67028, 67030, 67031, 67036, , 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, , 92230, 92235, 92240, 92250, 92260, , , HCPCS: S0620, S0621, S3000 Codes to Identify Diabetic Retinal Screening with Eye Care Professional (billed by any provider) CPT II: 2022F, 2024F, 2026F, 3072F HCPCS: S0625 (retinal telescreening) Codes to Identify Asthma ICD-9: , , , , *ICD-10: J45.20, J45.21, J45.22, J45.30, J45.31, J45.32, J45.40, J45,41, J45.42, J45,50, J45,51, J45.52, J45.901, J45.902, J45.909, J45.990, J45.991, J Asthma Controller Medications Antiasthmatic combinations: Dyphylline-guaifenesin, Guaifenesintheophylline Antibody inhibitor: Omalizumab Inhaled steroid combinations: Budesonide-formoterol, Fluticasonesalmeterol, Mometasone-formoterol Inhaled corticosteroids: Beclomethasone, Budesonide, Ciclesonide, Flunisolide, Fluticasone CFC free Leukotriene modifiers: Montelukast, Zafirlukast, Zileuton Mast cell stabilizers: Cromolyn Methylxanthines: Aminophylline, Dyphylline, Theophylline Codes to Identify URI ICD-9: 460, 465.0, 465.8, *ICD-10: J00, J06.0, J06.9 THE MOLINA MESSENGER - SPRING/SUMMER

10 ADULT HEDIS HEDIS Age Requirement and Documentation Billing Appropriate Testing for Children with Pharyngitis Adults with Acute Bronchitis 2-18 years If a child was diagnosed with pharyngitis and dispensed an antibiotic, a Group A strep test should have been performed within 3 days prior to the diagnosis date through the 3 days after the diagnosis date years Adults diagnosed with acute bronchitis should not be dispensed an antibiotic. Codes to Identify Pharyngitis ICD-9: 462, 463, *ICD-10: J02.0, J02.8, J02.9, J03.00, J03.01, J03.80, J03.81, J03.90, J03.91 Codes to Identify Group A strep tests CPT: 87070, 87071, 87081, 87430, , Codes to Identify Acute Bronchitis ICD-9: *ICD-10: J20.3-J THE MOLINA MESSENGER - SPRING/SUMMER 2016

11 Controlling High Blood Pressure Measure Description Patients years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (<140/90) during the measurement year. Patients years of age who had a diagnosis of hypertension (HTN) and diabetes and whose BP was adequately controlled (<140/90) during the measurement year. Patients years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (<150/90) during the measurement year. Documentation Must Include Date of hypertension before 30th of the measurement year (Diagnosis can be from progress note, problem list, consult note, hospital discharge summary) Last BP Reading (date and result) in the measurement year Common Chart Errors Rechecked elevated BPs during the same visit not documented Diagnosis date of hypertension is not clearly documented Coding Tips Assessing BP higher than 140/90. Recheck if necessary. White coat syndrome check again at the end of the visit. Clearly documenting diagnosis date of hypertension (time sensitive for compliance) THE MOLINA MESSENGER - SPRING/SUMMER

12 Lead Screening Measure Description Documentation Must Include Common Chart Errors Coding Tips The percentage of children 2 years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday. A note indicating the date the test was performed, and the result or finding Lead screening done in the office but not documented or lead assessment does not constitute a lead screening Make the most of every visit (even sick visits) and educate parents on the dangers of lead poisoning Adult BMI Assessment Measure Description The percentage of members years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year. Documentation Must Include Date, BMI value, Weight. *For members younger than 19 years old, BMI percentile counts Common Chart Errors *Height and weight are present, but no calculation of BMI. *EMR functionality to calculate BMI automatically not turned on to capture Coding Tips Include BMI assessment in every patient encounter. Easy measure that can be met at every visit. Use correct billing codes 12 THE MOLINA MESSENGER - SPRING/SUMMER 2016

13 Childhood Immunizations Measure Description Documentation Must Include Common Chart Errors Coding Tips Percentage of children 2 years old who received the following vaccines by their 2nd birthday: 4 DTaP 3 IPV 1 MMR 3 HiB 3 Hep B 1 VZV 4 pneumococcal conjugate (PCV) 1 Hep A 2-3 Rotavirus 2 flue vaccines Well Visits 0-15 Months The administration of all vaccinations listed below and dates of service: 4 DTaP 3 IPV 1 MMR 3 HiB 3 Hep B 1 VZV 4 pneumococcal conjugate (PCV) 1 Hep A 2-3 Rotavirus 2 flue vaccines Immunizations received after the 2nd birthday PCP charts do not contain immunization records if received elsewhere, i.e. Health Departments or immunizations that are given in the hospital at birth or previous providers Providers not using state immunization registry Use Florida Shots to record immunizations Educate parents on the misconceptions of vaccinations. (i.e. MMR causes Autism) Make sure that immunizations are within the appropriate time frame. (i.e before 2nd birthday not on or after) Measure Description Documentation Must Include Common Chart Errors Coding Tips Six or more well-child visits* 0 to 15 months. Health and Development History (e.g., growth chart, Tanner Stage, reaching, talking, pretend play, interaction with peers, motor s kills) Physical Exam (i.e., BP, height, weight, review of s ys tems, eye/skin/mouth, Tanner Stage, lab work, reflexes/gait) Children more likely to miss the 9 month vis it because there are no immunizations given Lack of or poor documentation of education and anticipatory guidance 6 visits are needed in order to be compliant with this meas ure *Document health & developmental his tory, physical exam AND health education/anticipatory guidance If patient comes for a sick visit, make it an well child visit. Perform any required immunizations, BMI percentile and lead testing if applicable. Bill appropriately and document clearly (e.g., injury/illnes s prevention, nutrition) Anticipatory Guidance (e.g., printed handout given at visit, advice about safety, exercise and nutrition, discipline, hygiene, sleeping) Children being seen for sick visits only and no documentation related to wellchild visits 6 visits not completed by 15 months of age Using a standard template when charting will facilitate documentation THE MOLINA MESSENGER - SPRING/SUMMER

14 Well Child Visits 3-6 Years Measure Description Documentation Must Include Common Chart Errors Coding Tips One or more well-child visits* with a PCP during the measurement year. Health and Development al History (e.g., Tanner Stage, developmental questionnaires, motor skills, interaction with peers, communication s kills, grades in school) Physical Exam (i.e., BP, height, weight, BMI percentile, Tanner Stage, review of systems, lab work, eye/s kin/mouth, reflexes/gait) Anticipatory Guidance (e.g., printed handout given at visit, advice about safety, exercise and nutrition, discipline, hygiene, sleeping, injury prevention, car seat use) Children less likely to be seen during this age range because there are no immunizations given Make every visit count. No immunizations in this age range so make the most of every opportunity. Sick visits into well visits. *Document health & developmental his tory, physical exam AND health education/anticipatory guidance Lack of or poor documentation of education and anticipatory guidance Document clearly and include anticipatory guidance (e.g., injury/illnes s prevention, nutrition) Children being seen for sick visits only and no documentation related to wellchild visits Preschedule well child visits 14 THE MOLINA MESSENGER - SPRING/SUMMER 2016

15 Adolescent Well Care Visit Measure Description Documentation Must Include Common Chart Errors Coding Tips One comprehensive wellcare visit* with a PCP or OB/GYN during the measurement year Health and Development (e.g., development assessment, school progress, interaction with peers, depression, physical activity, depression, menarche, interaction with others) Lack of or poor documentation of education and anticipatory guidance Turn all sick visits into a well child visit. If immunizations, BMI calculations, etc. are due then complete them at time of visit *Document health & developmental history, physical exam AND health education/ anticipatory guidance Physical Exam (e.g., BP height, weight, review of systems, eye/skin/ mouth, Tanner Stage, lab work, reflexes/gait) Children being seen for sick visits or sports physicals only and no documentation related to wellchild visits Bill all appropriate codes to ensure the visit counts Anticipatory Guidance (e.g. advice about safety, exercise and nutrition, discipline, hygiene, sleeping, sexuality, substance abuse, suicide ideations) take advantage of every visit opportunity THE MOLINA MESSENGER - SPRING/SUMMER

16 Molina NOW Pays for a Sick and Well Visit on Same Date of Service Your time is limited. Instead of scheduling sick visits and well care appointments separately, why not combine the services? Molina Healthcare covers preventive services rendered during visits other than well care visits for our members, regardless of the primary intent of the appointment. IMPORTANT PAYMENT GUIDELINES RELATED TO PREVENTIVE VISITS: Molina Healthcare will pay for preventive services even if it has not been 12 months since the last service. Molina Healthcare will pay for both a new/established patient E&M and a new/established patient preventive visit for the same member on the same date of service if the diagnosis codes billed support payment of both codes. Be sure to bill the correct diagnosis codes and bill the new/established patient E&M with modifier 25 to ensure accurate payment. SICK VISITS When you provide care to a sick patient who is due for a well visit, document all the components of a well visit. Documentation must support that both services were provided. Services included in a well visit are: Health and developmental history, both physical and mental Physical exam Health education and anticipatory guidance Body Mass Index (BMI) percentile, and counseling for nutrition and physical activity BILLING TIPS Well Child Visits 7 visits: Newborn (0 to 4 days), 1, 2-3, 4-5, 6-8, 9-11, and 12 to 14 months Use CPT-4 codes: , 99391, 99392, Use diagnosis codes: Z00.00, Z00.01, Z00.110, Z00.111, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0- Z02.6, Z02.71, Z02.79, Z02.81-Z02.83, Z02.89, Z02.9 Well Child Visits 15 to 17 months, 18 to 23 months, 24 months and annually thereafter Use CPT-4 codes: 99382, 99383, 99392, Use diagnosis codes: Z00.00, Z00.01, Z00.110, Z00.111, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0- Z02.6, Z02.71, Z02.79, Z02.81-Z02.83, Z02.89, Z02.9 Adolescent Well Care Annual visit for adolescents 12 to 21 years Use CPT-4 codes: 99384, 99385, 99394, Use diagnosis codes: Z00.00, Z00.01, Z00.110, Z00.111, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0-Z02.6, Z02.71, Z02.79, Z02.81-Z02.83, Z02.89, Z THE MOLINA MESSENGER - SPRING/SUMMER 2016

17 Adult Preventive Care Visits 21 to 65 years and older Use CPT-4 Codes: , , , 99385, 99395, Use diagnosis codes: Z00.00, Z00.01, Z00.5, Z00.70, Z00.71, Z00.8 Z02.0, Z02.2, Z02.4, Z02.6, Z02.82, Z02.89 Please visit the Florida Department of Medicaid (MCD) website for a complete listing of CPT codes at ProviderSupport_FeeSchedules/tabid/51/desktopdefa ult/+/default.aspx WEIGHT ASSESSMENT AND NUTRITION COUNSELING Document date of service, height, and weight and BMI percentile from the current year. Documentation must be from the same data source. BMI value is not acceptable for patients 15 and younger. Use evidence of the BMI percentile or BMI percentile plotted on an age-growth chart. A BMI value expressed as kg/m2 is acceptable for adolescents 16 to 17. Documentation of counseling for nutrition or referral for nutrition education must include: Anticipatory guidance for nutrition Discussion of current nutrition behaviors, like eating habits and dieting behaviors Checklist indicating nutrition was addressed Counseling or referral for nutrition education Member received educational materials on nutrition Documentation of counseling for physical activity or referral for physical activity must include: Anticipatory guidance for nutrition Discussion of current physical activity behaviors, like exercise routine, participation in sports activities and exam for sports participation Checklist indicating physical activity was addressed Counseling or referral for physical activity Member received educational materials on physical activity Documentation related solely to screen time is not sufficient for counseling for physical activity. Molina Healthcare has a library of health education materials on nutrition and exercise. Contact your Provider Services representative to request materials for your office. THE MOLINA MESSENGER - SPRING/SUMMER

18 Prior Authorization Update Molina recently removed the authorization requirement for many codes throughout These changes are part of our effort to standardize our authorization guidelines across all Molina health plans, and remove administrative barriers to healthcare for both our members and providers. On March 1, 2016, Molina Healthcare of Florida added several codes to our Prior Authorization Code Matrix (2016 Codification Document) for our Medicaid, Medicare and Marketplace lines of business. All of the service categories affected by the changes already require authorization under our current Prior Authorization Guidelines. However, the code changes are necessary to address new Currently Procedural Terminology (CPT ) and Healthcare Common Procedure Coding System (HCPCS) codes implemented in 2016 Molina Healthcare has recently reduced the number of services that require a Prior Authorization. The code additions can be found on Molina s website, at in the Forms section, Prior Authorization Code Matrix. To find the updated Codification List please follow the steps below: 1. Please visit our website at molinahealthcare.com, 2. Select I am a Health Care Professional, 3. Select the line of business located at the top of the web page, 4. Then choose the frequently used forms under the forms tab and, 5. The list of services that require prior Authorization can be found in the Prior Authorization/Pre-Service Review guide. This guide is updated regularly; we urge you to review the Prior Authorization Codification Matrix on our website, frequently, to determine how the relaxed authorization guidelines may affect you. 18 THE MOLINA MESSENGER - SPRING/SUMMER 2016

19 Common Reasons for Returned Claims Claims submitted with missing or invalid information will not be processed. A letter will be sent to the provider with instructions as to why Molina was unable to process claims. Returned claims are removed from the Molina claims processing system, and may not be accessible by our customer service representatives if providers call for assistance. Common reasons for returned claims include: Claim does not match current provider information on file Pay- to Name and address does not match the W9. Box 33 of the claim should match the W9 exactly Rendering provider is not affiliated with the billing provider NPI Billing NPI, rendering provider NPI, or service facility NPI does not match our provider file or is not listed in our file Invalid NPI format Incorrect Federal Tax Identification Number Member Information Mismatch-incorrect name, ID number, DOB, or sex How to correct: When returned claims are received you can contact Molina Healthcare Provider Services at MFLProviderServices@Molinahealthcare.com with a copy of your most recent W-9 and provider roster. At this time your information will be validated and our systems will be updated as appropriate. Alternatively, if a system updates is needed, please refile your claim with the corrected information. Coordination of Care Molina Healthcare s Utilization Management, Case Management and Disease Management work with Providers to assist with coordinating services and benefits for Members with complex needs and issues. It is the responsibility of contracted Providers to assess Members and with the participation of the Member and their representatives, create a treatment care plan. The treatment plan is to be documented in the medical record and is updated as conditions and needs change. PCP collaboration with specialists is encouraged to ensure appropriate coordination of care. Molina Healthcare staff assists Providers by identifying needs and issues that may not be verbalized by Providers, assisting to identify resources such as community programs, national support groups, appropriate Specialists and facilities, identifying best practice or new and innovative approaches to care. Care coordination by Molina Healthcare staff is done in partnership with Providers and Members to ensure efforts are efficient and non-duplicative. THE MOLINA MESSENGER - SPRING/SUMMER

20 Continuity and Coordination of Provider Communication Molina Healthcare stresses the importance of timely communication between Providers involved in a Member s care. This is especially critical between Specialists, including behavioral health Providers, and the Member s PCP. Information should be shared in such a manner as to facilitate communication of urgent needs or significant findings. Comprehensive Laboratory Test Menu Quest Diagnostics offers both high-quality routine laboratory testing such as total cholesterol, Pap testing and white blood cell counts--and advanced genetic, molecular and other specialty tests. Its portfolio includes more than 3,000 tests with specialized expertise in cancer, cardiovascular diseases, infectious diseases, neurology and more. Explore the Quest Diagnostics Test Center to learn more about available tests designed to meet the needs of a diverse patient population. Additionally, Quest Diagnostics has more than 700 scientific experts on staff to connect you with the information you need. Browse the directory of scientific staff. For providers who are not current Quest Diagnostics clients, it is easy to set up an account and get up and running. Call 1-(866) MYQUEST (1-(866) ), and select 1 and then 8 to set up a new account. Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics 20 THE MOLINA MESSENGER - SPRING/SUMMER 2016

21 Pharmacy Services Prior Authorization Form Please note the following change has been implemented regarding the Pharmacy Services prior authorization form: PARequest Form.pdf THE MOLINA MESSENGER - SPRING/SUMMER

22 Risk Adjustment - Coding Tips and Errors Patients should be seen at least once a year for a comprehensive medical exam and a claim must be submitted in order to provide the data to CMS for risk score calculation. Ensuring documentation and claims are accurate and submitted protects you and your practice from CMS audits! Progress Notes must include provider printed name, signature, and provider credentials. EMR must include signature with CMS approved authentication, provider credentials, and date stamp. What is required from physicians? Perform a comprehensive medical evaluation at least once a year. Encourage and facilitate member scheduling of comprehensive visits where chronic conditions can be adequately assessed Ensure that all of your patient s medical conditions are appropriately evaluated and documented in the medical record. Ensure that the diagnoses codes are accurate, coded to the proper level of specificity and match the medical record documentation. Follow medical record guidelines provided by CMS Timely submission of data to the health plan Why is accurate Diagnosis Code selection important? Improves communication and care coordination Increases recognition of comorbid conditions that are responsive to treatment Validates the care that was provided Improves quality of care Shows compliance with quality and safety guidelines Reduces compliance risk while capturing reimbursement and codes with integrity. Affects patient benefits and resources Coding Tips Abuse vs. Dependence The word Chronic Some Conditions site and stage or condition and organism Address forever codes yearly Open wounds vs Skin Ulcer Essential Tremor vs Parkinson s CAD vs Angina or Old MI Remember to use proper linkage terms such as due to secondary to and with Improper symbols or acronyms Prioritize order of chronic conditions on your claims All Chronic Conditions must be billed on a claim for score calculation 22 THE MOLINA MESSENGER - SPRING/SUMMER 2016

23 Hierarchical Condition Categories (HCC) Pearls of Wisdom Molina Healthcare knows that HCC coding can be confusing and time-consuming. The HCC Pearls are concise tips for easily and effectively identifying, coding and documenting the status of your patients, according to the rules of the Centers for Medicare and Medicaid Services (CMS). Reading and understanding HCC Pearls will take just a few minutes of your time and avoid coding errors. The HCC Pearls are sent every week for different medical conditions. Molina Healthcare Coding Tips Chronic Respiratory Failure Welcome to the Molina Healthcare Coding Institute. Molina Healthcare is committed to supporting your clinical practice. Pelase take a moment to review this HCC Pearl. What are the criteria for Chronic Respiratory Failure? Criteria for hypoxemic chronic repiratory failure = Medicare criteria for Home 0 2 PaC 2 55 mmhg, or 0 2 sat 88% PaC 2 59 mmhg, or 0 2 sat 89% Applies to reeadings awake or asleep, at rest or with exercise Criteria for hypercapnic chronic respiratory failure (if had ABG as part of work up)* PCO2 > 50 mmhg Generally only pulmoologistt, or pulmonologist s request. Documentation Examples: Examples of Chornic Respiratory Failure in COPC: PLUS 496 Initial Diagnosis 68 year old African American male with Chronic Respiratory Failure Assessment: 0 2 sat confirms Chronic Respiratory Failure Plan: Will obtain home 02 Established Diagnosis 71 year old Latino male with Chronic Respiratory Failure Assessment: Comfortable on home 0 2 Plan: Continue current care 65 year old Asian male with severe Chronic Respiratory Failure Assessment: Pulmonary work up show Chronic Pypercapnia Plan: Optimize Chornic Respiratory Failure therapy, inhalers manage with 0 2 for hypoxemic episodes THE MOLINA MESSENGER - SPRING/SUMMER

24 EFT (Electronic Funds Transfer) - Direct Deposit Alegeus has now changed its name to Change Healthcare/Providernet. Providers are encouraged to enroll in Electronic Funds Transfer (EFT) in order to receive payments quicker. To enroll, visit To Register for EFT, providers will need the following: A Molina check number Name of the Bank Institution Bank Routing and Account Number Provider NPI Provider TAX ID Provider Billing Address (pay-to address) Benefits of EFT/ERA: No cost to the provider Improves cash flow Reduces accounting expenses Maintains control over bank accounts and remittances Ability to match payments and remittance advices Manage multiple payers EFT vs. Paper Check Turnaround Times Payment Type EFT-Director Deposit Average TAG fromclaim paid dait 3-4 days Paper Checks 3-4 days to drop to mail plus mail time, average 11 days Contact your Provider Services Representative for assistance in confirming your last Molina check and billing address of record. 24 THE MOLINA MESSENGER - SPRING/SUMMER 2016

25 Mobile Provider Online Directory is Now Live! The mobile version of the Provider Online Directory (POD) is now live! Your patients can now access a new easy-to-use version of the POD on their mobile devices and tablets. This new design helps improve our users experience while they browse through Molina s provider directory. This mobile POD includes most of the existing content and functionality available on a desktop, but the design is specifically designed for a mobile device. The highlighted mobile features are: The ability to easily navigate and Find a Provider, Find a Hospital/Facility, and Find a Pharmacy The ability to search by their location The ability to click a phone number to call The ability to compare providers on an easy-to-use screen The ability to search for a provider or hospital/facility they are searching Important Molina Provider News PSYCHCARE IS NOW BEACON HEALTH! Effective March 1, 2016, Molina Healthcare s Behavioral Health vendor, Psychcare, has changed their name to Beacon Health Options. This change will not affect Molina Healthcare s Behavioral Health services to members or claims and prior authorization processing. You must continue to utilize providers that are part of the Psychcare/Beacon Health network. You can reach Beacon Health 24 hours a day, 7 days a week at: Beacon Health Options (855) THE MOLINA MESSENGER - SPRING/SUMMER

26 Community Engagement Corner Provider Outreach As providers continue to search for new and creative ways to get their patients in for regularly scheduled visits, your Molina Community Engagement team is here to help you! Our team has a wide range of activities that are geared to help get members in the office, entertain them while they wait for their visit, and improve their overall satisfaction throughout the visit. Additionally, our Community Engagement team works closely with our Provider Service Team and HEDIS Team to develop HEDIS related events. One of our most popular events is our baby shower. We generally hold these after the birth of the child so that the mother can come in for her postpartum check-up at the same time her newborn comes in for their Well Child Visit or immunizations. We offer a range of activities for various age groups based on the needs of the office. Some of these activities include the use of our Rocker Bike which turns fruits and vegetables into healthy smoothies, lessons on oral hygiene, and draw your doctor contest. So if you are looking for a way to get your patients into the office, please reach out to your Community Engagement Team, we welcome the opportunity to work with you! DID YOU KNOW? Molina offers Translation Services! Molina Healthcare can provide information in the members primary language. We can arrange for an interpreter to help you speak with our members in almost any language. We also provide onsite translation services in your office at no cost to the member or provider. If your office needs interpreter services or written materials in a language other than English, for a Molina member, please contact Molina s Member Services Department at (866) You can also call TDD/TTY: 711, if a member has a hearing or speech disability. 26 THE MOLINA MESSENGER - SPRING/SUMMER 2016

27 Tips to Help You Eat Right, on the Go! Here are some easy tips that will help you eat healthier without adding too much time to your day. Eating Right On the Go Whether it is a demanding job or a busy family life, eating healthy can prove to be a challenge when our lives get in the way. Many people turn to the quick, easy and cheap food options to help free up time in their day but in the long run that habit is working against you. Over time, poor eating habits can result in decreased energy levels, increased stress levels (think hangry) and even more serious health problems. To celebrate National Nutrition Month, we ve compiled some easy tips that will help you eat healthier without adding too much time to your day. Stay Away from Processed Food While they may seem appealing, processed foods can contain tons of chemicals and additives. Shop smart and go for the nutrient-rich whole foods your body will thank you. Pre-package Your Own Snacks Rather than spending tons of money on pre-packaged (and often unhealthy) snacks, make your own snack portions at home and keep them in separate Ziploc bags. Over the course of the day, reach for your homemade snacks to satisfy your hunger and keep your money in your wallet. Plan Your Weekly Menu Having a menu planned out allows you to stay ahead of the week and only buy ingredients that you ll need. Better yet, plan meals that utilize the same ingredients so that you can buy less, but still have a great variety in you meals! The Meal So Nice, You Ate it Twice Left overs are the easiest way to save yourself time preparing food while still maintaining a healthy diet. After your meal, seal the left overs up in an air tight container and enjoy an effortless meal later! THE MOLINA MESSENGER - SPRING/SUMMER

28 Provider Services 8300 NW 33rd Street Suite 400 Doral, FL Molina Patients with Questions About Their Health? Call Our Nurse Advice Line! English: (888) Spanish: (866) OPEN 24 HOURS! Your family s health is our priority! For the hearing impaired, please call TTY (English): (866) TTY (Spanish): (866) or FL0416