Our toll-free phone number to reach provider and member services

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1 PROVIDERNEWS Second Quarter TABLE OF CONTENTS 1 Transitions to New Claims Processing Effective July Provider Quick Reference 4 Friendly Reminder: Verify Member Eligibility. 4 New Alpha- Numeric: Newborn IDs 4 Help Medicaid Members Exercise Their Right to Choose 4 Claims Information Insert 5. HEDIS and ADHD 5 Plan First Members Receive New ID Cards. 6 Webinar and Provider Manual 6 Formulary Changes Important Changes Effective July 1, 2016 Effective July 1, 2016, will transition to a new claims processing and call center back office partner: DST Health Solutions. We chose DST because of their high quality, efficient systems and services for many Medicaid providers and members. We have prepared well in advance to ensure a smooth and seamless transition. Please review the following or our recent mailed notice for more information on what this means for you as an provider. WEBINAR ABOUT NEW OPERATIONAL CHANGES AT What Stays the Same What Changes Effective July 1, 2016 s commitment to serving our providers and members. Our toll-free phone number to reach provider and member services Fax number for Pre-Authorization Requests The local INTotal team that is here to support you and answer your questions Provider Portal hosted by Navinet for Member Eligibility (7/1) and Claims Status Inquiry (8/1). Our mailing address. For claim submission for dates of service on or after July 1, 2016, mail paper claims to: Claims Payer IDs for EDI claim submission. For dates of service on or after July 1, 2016, submit claims electronically using these payer IDs: Change Healthcare (formerly Emdeon): Emdeon One (formerly Capario): Gateway (Trizetto): INT01 Availity: Panel Reports will be mailed to PCPs. When submitting claims for lab services, please include CLIA number in Box 23 or EDI 2300 Ref Loop. Enhancements Additional features, such as claims submission, will be available via the Navinet provider portal in early fall. Clearer remark codes on your Explanation of Payment to make it easier to understand how your claim paid. New Nurse Advice Line Carenet (will be available 24/7) We look forward to continuing to serve you and our members. For your convenience, we have updated our Provider Quick Reference on Page 2 and 3. In addition, on Page 4, we included a copy of our claims information insert that was recently mailed to every provider.

2 Important Phone Numbers: Member Services: (Opt 1) Provider Services - Claims Status, Eligibility, and General Inquiries: (Opt 2) Pharmacy Authorizations/Services (Caremark): (Opt 3) Medical Authorizations Management: (Opt 4) evicore (formerly MedSolutions) CAT, CT, MRA, MRI and PET Authorizations: Non-Emergent Transportation Services (Logisticare): (Opt 6) Provider Relations - Provider Issues, Network Participation, Credentialing, contact PR Rep: Care Management: includes complex case management, disease management, maternity case management and behavioral health coordination: (Press 0 to speak with a Health Services Representative) Nurse Helpline 24 hrs/365 days: (Opt 1, Select 1) TTY English: , TTY Spanish: Language Line/Interpreter Services: (Opt 2, Select 3) Open Access: Covered services do not require a referral from a PCP when provided by in-network providers. Please refer to our online Find-A-Doc tool to locate in-network providers. All non-emergent services rendered by non-participating providers require pre-authorization. Please see information on the pre-authorization process. EFFECTIVE JULY 1, 2016 Pre-Authorization Notifications at a Glance: You may obtain pre-authorization forms online at or by calling Please refer to our online pre-authorization look-up tool under Provider Resources and Documents to ensure authorization compliance Incomplete and/or insufficient information will cause a delay in processing requests. Please call (Opt 4) or refer to our website for detailed information and guidelines for pre-authorization requests Urgent pre-authorization requests are processed within 72 hours of request Routine/non-urgent requests are processed within 14 calendar days of request All non-emergent services rendered by non-participating providers require pre-authorization All inpatient admissions require pre-authorization. Note: All inpatient stays for emergent, urgent and maternity/delivery services require notification within 24 hours or the next business day after admission evicore (formerly MedSolutions) CAT, CT, MRA, MRI and PET Authorizations: Smiles for Children Dental Authorizations/Services: Superior Vision (formerly Block Vision) Vision Authorizations/Services: Pre-authorization approval of services does not guarantee payment, since claims payment is subject to member and provider eligibility requirements, contractual benefits coverage and exclusions. Claims Submission: Electronic Data Interchange (EDI) Payer IDs: Change Healthcare (formerly Emdeon): , Opt 1 Emdeon One (formerly Capario): , Opt 1 Gateway (TriZetto): INT Availity: Paper Claims: Please submit paper claims on original forms (Current CMS 1500 or CMS 1450) printed with dropout red ink and typed in large, dark font, not handwritten. Online Claims Submission: Submit CMS 1500 (02-12) claims via our Provider Portal (Effective Fall 2016) Itemized bills, Medical Records, Coordination of Benefit information and other supporting documentation should be included and mailed to the address below. Please mail paper claims to: Attn: Provider Claims Timely filing guidelines will apply 2

3 Corrected Claims/Claims Reconsiderations: Corrected Claims/Claims Reconsiderations must be filed within 180 days (or within contractual timely filing) of the date on your Explanation of Payment (EOP). Please return the completed form and any supporting documentation to. Corrected Claims/Claims Reconsideration forms may be found at Please use value 7 in field 22 on the claim form to indicate the claim is a corrected claim. Please allow 30 days to process this request. Please use a separate request form for each Corrected Claim/Claim Reconsideration request. Please mail Corrected Claims/Claims Reconsiderations to: Attn: Provider Claims Medical Appeals: Medical appeals may be initiated by members, or providers on the member s behalf, and must be submitted within 30 calendar days from the date of the notice of the adverse decision. A provider submitting on behalf of a member can write a letter or use the Medical Appeals form which can be found on our website. Please mail Medical Appeals to: Attn: Appeals Dept Fairview Park Drive, Suite 900 Falls Church, VA Payment Appeals: Claims payment appeals must be filed within 90 days of the date on your Explanation of Payment (EOP). The Provider Payment Appeal Submission form can be found on our website. Submit a written request with an explanation of what is in question and why, including supporting documentation such as an EOP, a copy of the claim and/or contract page. Please mail Payment Appeals to: Attn: Appeals Dept. Online Provider Portal: Please register online at to access our Provider Portal which enables you to: Verify member eligibility Check claim status Submit CMS 1500 claims (Effective Fall 2016) Please visit our website to access complete, detailed information about all of our features and services: Provider Manual/ Resources & Documents Quick Tools Authorization Process & Guidelines Clinical Practice Guidelines Formulary Provider Newsletter (Quarterly) Provider Orientation Additional Resources Follow Us on Social Media: 3

4 Friendly Reminder: Verify Member Eligibility When individuals become a Medicaid member, they receive a blue and white plastic medical assistance card (Virginia Medicaid card) that has their name and ID number on the card. members are required to show their Virginia Medicaid Card to the provider. In addition to the Virginia Medicaid card, members are required to show their member ID card. Please ensure you verify eligibility prior to each visit. Help Medicaid Members Exercise Their Right to Choose! Open Enrollment in the far southwestern region of Virginia is May 1 through June 30 and in Northern Virginia from July 1 through Aug. 30. This is the time when Medicaid enrollees can exercise their right to choose a health plan. New Alpha-Numeric Newborn IDs Effective July 1, 2016, you will be required to submit claims with the new alpha-numeric temporary newborn Medicaid ID. Please note, this ID will be required for any newborn claim submission on or after July 1, regardless of date of service. Additional Claims Information (continued from Page 1) Please see below for claims submission requirements pre- and post-july 1, Do you or your staff have questions about the Medicaid enrollment process? We can help explain the following: How to switch MCOs Where patients can apply for Medicaid The number to call to apply or switch MCOs over the telephone We can provide you with paper Medicaid applications and locations to submit them as well as information about how to apply online. We can even come to your office and answer patient questions. Call us at We re here to help! 4

5 HEDIS and Attention-deficit/hyperactivity disorder (ADHD) Our Medical Advisory Board (MAC) actively engages in clinical and non-clinical quality improvement efforts. Recently, Dr. Sunil Gupta, an pediatrician located in Leesburg, Va., led the review of ADHD medication compliance and follow up based on our current clinical guidelines. data was also compared to HEDIS standards related to ADHD and the findings are summarized below: Review of the medical literature indicates the following trends related to ADHD: Prevalence is between 5-8% 2-3 times more common in boys Lifelong condition No association between race, ethnicity or socioeconomic status Increased risk factors include prematurity, intrauterine growth restriction (IUGR), low birthweight Burden of care mostly on primary care providers due to lack of mental health providers 2 out of 3 patients have co-existing condition oppositional defiant disorder (ODD) (35%), anxiety disorder (25%), mood disorders (18%) A review of 2014 medical and pharmacy claims was conducted and similar trends were identified. For HEDIS, there are two established standards for 6-12 year olds: Initiation Phase: Within 30 days following the Index Prescription Start Date (IPSD), a patient should have one follow-up visit with a provider. Continuation & Management (C&M) Phase: Patient remains on medication for at least 210 days and has 2 additional follow-up visits (in addition to the follow-up visit during the Initiation Phase) within 270 days after the Initiation Phase. Our goal is to exceed DMAS compliance rates. In order to do so, we ask providers to please follow the established guidelines to ensure patient compliance. When treating a member for ADHD: Be sure to schedule a follow-up visit within 30 days of IPSD Schedule at least 2 follow-up visits during the next 9 months to monitor compliance We appreciate your attention to these guidelines. If you have any questions or would like to refer a member for case management, please call Provider Services at , option 2. References: 1. American Academy of Pediatrics. Committee on Quality Improvement and Subcommittee on Attention-Deficit/Hyperactivity disorder. Pediatrics. 2000; 105: Wilms Floet AM, Schneider C, Grossman L. Attention-Deficit/ Hyperactivity Disorder. Pediatrics in Review. 2010; 31: Stein MT, Perrin JM. Diagnosis and Treatment of ADHD in School-age Children in Primary. Pediatrics in Review. 2003; 24: Wender EH. Managing Stimulant Medication for Attentiondeficit/Hyperactivity Disorder. Pediatrics in Review. 2001; 22: Plan First Members Receive New ID Cards The Department of Medical Assistance Services (DMAS) issued a new Plan First ID card for Plan First members. The Plan First program pays for birth control and family planning services for women and men. It is a limited benefit program and not considered full coverage Medicaid. The new Plan First card is green and white with the Plan First logo and will indicate limited benefits. Plan First members may visit for more information. Please note: Plan First cards are green and white 5

6 NON PROFIT U.S. POSTAGE PAID PERMIT #2469 MERRIFIELD, VA Webinar and Updated Provider Manual Available Online Provider Webinar: Please view our webinar summarizing operational changes effective July 1, located on our website at provider.intotalhealth.org Provider Manual: Our Provider Manual reflects the changes specified on Page 1 and 4 and is available on our website at: provider.intotalhealth.org. Please click the link Provider Resources & Documents and choose Manuals & Provider Education. If you need a printed copy, please contact your Provider Relations Representative. Formulary Changes Effective July 1 We update our formulary quarterly and post changes on our website: intotalhealth.org. To request pre-authorization of any of the drugs on our formulary that require it, fax us a completed Pharmacy Pre-Authorization Form that s located located at 6