A NEWSLETTER FOR MASSHEALTH PROVIDERS MassHealth Update Contents 1 New and Noteworthy 2 Provider-Specific Information 3 Tips for Avoiding Claim Denials 4 POSC Connection 5 Did You Know? 7 We Heard You… 8 And For Your Members New and Noteworthy MassHealth’s newly publicized policy, regulations, resources, and programs, including references for further exploring the topics, are among the notable items in this issue of Update. NewMMIS Training Materials Relocated on MassHealth Web Site NewMMIS has been operational for over a year, and the need for detailed implementation- related eLearning training materials has decreased significantly. As a result, to ensure the availability of key training materials that support day-to-day functions, most NewMMIS job aids have been updated and relocated from the NewMMIS Learning Management System (LMS) and added to the mass.gov Get Trained Web site (http://www.mass.gov/masshealth/newmmis/providertraining). This ensures that all job aids are in one centralized location. Please be sure to bookmark this new Web-site location. MassHealth’s Implementation Approach for the HIPAA X12 5010 Electronic Transactions The Centers for Medicare & Medicaid Services (CMS) has mandated that on January 1, 2012, the standards for electronic health care transactions must change from version 4010/4010A1 to version 5010. All electronic health care transactions currently submitted to, or returned from, MassHealth in the 4010/4010A1 version are impacted. This includes the following transactions: 270/271, 276/277, 837P, 837I, 835, 834, and 820. Additionally, the new 999 acknowledgement transaction (replacing 997) will be implemented along with the other 5010 changes. MassHealth will conduct testing with active submitters before the 5010 implementation date and will communicate further details on testing activities in the months ahead, including when companion guides will be available for review. 5010 testing is targeted to begin in the second quarter of 2011 with selected trading partners and then for all trading partners in the third and fourth quarters. If you have questions about the status of the 5010 implementation as it relates to your software vendor, clearinghouse, or billing intermediary, contact them directly to understand their plans and how those plans impact you. Please note that pharmacies and other providers using the Pharmacy Online Processing System (POPS) will receive separate MassHealth communications detailing the migration to the new National Council for Prescription Drug Programs (NCPDP) D.0 telecommunications standards and implementation schedule. MassHealth encourages these providers to contact their software vendor in anticipation of the changes. Some of the CMS-mandated 5010 changes will also impact how you use the Provider Online Service Center (POSC) and/or submit paper claims to MassHealth. You will receive notice of these changes once they have been fully processed. September/October 2010 page 1 Please look for future announcements and updates from MassHealth about the CMSmandated 5010 changes by monitoring our Web site at www.mass.gov/masshealth/newmmis. All Provider Bulletin 205 (September 2010) also provides more detail on the 5010 change. You can download a copy of the bulletin from the MassHealth Web site. Go to www.mass.gov/masshealthpubs, click on Provider Library, then on Provider Bulletins. If you have any questions about the version changes, you can contact the MassHealth EDI Department by fax at 617-988-8972, or e-mail your inquiry to edi@mahealth.net. Provider Participation and the Payment Error Rate Measurement (PERM) Project PERM is designed by the Centers for Medicare & Medicaid Services (CMS) to measure improper payments in the Medicaid program, as required by the Improper Payments Information Act of 2002 (IPIA; Public Law 107-300). PERM regulations at 42 CFR 431.950 through 431.1002 (published in the Federal Register on October 5, 2005) direct states to work with CMS in developing a national payment error rate to comply with the IPIA. Massachusetts is one of 17 states participating in the CMS FY2010 PERM project. As part of the FY2010 PERM project, CMS will review a random sample of MassHealth’s FY2010 provider claims to test for data-processing accuracy and medical necessity. Providers whose claims are selected will be contacted directly by a CMS contractor to provide copies of their medical records and supporting documentation for the sampled claim(s). Provider cooperation to furnish requested records is critical. Insufficient documentation or failure to respond to the requests in a timely manner will be classified as an error. All claims classified as errors will result in a claim adjustment against the provider’s claim and may also result in an onsite visit. For more information about the PERM project, including patient privacy concerns, provider responsibilities, and specifics on claim-classification errors, refer to All Provider Bulletin 203 (March 2010). You can download a copy of the bulletin from the Provider Library on the MassHealth Web site at www.mass.gov/masshealthpubs. The CMS PERM Web site also provides PERM-related information at www.cms.hhs.gov/PERM. If you have questions, you can fax your inquiry to 617-988-8974 (attention Massachusetts PERM Representative), contact MassHealth Customer Service at 1-800-841-2900, or send an e-mail to david.kerrigan@state.ma.us. Provider-Specific Information Provider-specific policy, and regulatory, informational, educational, and functional communications that are relevant to and affect your daily business processes with MassHealth. Frequently used acronyms CFR Code of Federal Regulations CMR Code of Massachusetts Regulations CMS Centers for Medicare & Medicaid Services DDS Department of Developmental Services DME Durable Medical Equipment DTA Department of Transitional Assistance EAEDC Emergency Assistance to the Elderly, Disabled and Children EDI Electronic Data Interchange EOHHS Executive Office of Health and Human Services EVS Eligibility Verification System FEIN Federal Employer Identification Number FOM Feature of the Month FY Fiscal Year HIPAA Health Insurance Portability and Accountability Act HIV Human Immuno-Deficiency Virus HOH Head of Household HOS Hospice HSP Healthy Start Program September/October 2010 page 2 MassHealth Healthy Start Program Announces Changes for Billing and Payment of Global Delivery Codes MassHealth and the Healthy Start Program (HSP) have announced changes that will simplify certain billing procedures. HSP provides prenatal and postpartum care for low-income pregnant women who are not eligible for any other MassHealth coverage type, except MassHealth Limited, and do not have other health insurance. Healthy Start benefits are administered by, and claims are paid through, an administrative vendor, UniCare, on behalf of MassHealth. Providers currently submit global delivery code claims to both UniCare (for prenatal and postpartum care) and MassHealth (for labor and delivery). Effective July, 1, 2010, to streamline the process, providers need to submit only one claim to MassHealth when billing global codes for labor and delivery. The eight global delivery service codes are 59400, 59410, 59510, 59515, 59610, 59614, 59618, and 59622. Any claims submitted to UniCare for these eight global delivery codes for dates of service on or after July 1, 2010, will be denied. The physician program regulations at 130 CMR 433.421 and 433.424 provide more information about the requirements for global delivery and fee-for-service billing. In addition, the June Feature of the Month on the MassHealth Web site spotlighted the changes to the HSP global billing policy. All Provider Bulletin 204: Revised Billing Instructions for Healthy Start Program (HSP) Providers (May 2010) also describes these changes in detail. You can access the bulletin and regulations from the Provider Library at www.mass.gov/ masshealthpubs. You can download a copy of the Feature of the Month from the Publications panel at www.mass.gov/masshealth. For more information about the Healthy Start Program and a description of covered services, visit the HSP Web site at www.hspmoms.com or call 1-888-488-9161. If you have questions about the change, MassHealth claims submission, or MassHealth payments, please contact MassHealth Customer Service at 1-800-841-2900. Tips for Avoiding Claim Denials A summary analyzing MassHealth’s top claim-denial reasons from monthly reports across claim or program type, Tips provides instructional briefs to help you to avoid repeat errors. To view the Top 10 Claim Denials report for your PID/SL, logon to the POSC at www. mass.gov/masshealth/providerservicecenter. Select the Manage Correspondence and Reporting link in the Provider Services panel, then click View Metrics/Reports. Claim Denial Reason: Service Not Covered for Limited BP Tip: One of the top documented customer service calls is providers requesting information about their claims and questioning denials. These calls are often related to member-eligibility inquiries. A reminder: Member Services cannot give out this information due to HIPAA restrictions. You can check member eligibility on the POSC (www.mass.gov/masshealth/ providerservicecenter) via the Eligibility Verification System (EVS) from the Manage Members link. IPIA Improper Payments Information Act IRS Internal Revenue Service LMS Learning Management System MAP My Account Page MH MassHealth MBHP Massachusetts Behavioral Health Partnership MCO Managed Care Organization MMIS Medicaid Management Information System NCPDP National Council for Prescription Drug Programs NewMMIS New Medicaid Management Information System PA Prior Authorization PCC Primary Care Clinician PERM Payment Error Rate Measurement PID/SL Provider ID Service Location POPS Pharmacy Online Processing System POSC Provider Online Service Center September/October 2010 page 3 Claim Denial Reason: Invalid ICD-9 Diagnosis or Procedure Code Tip: MassHealth has updated the claims-processing system to accept new 2011 ICD-9 diagnosis and procedure codes, effective 10/01/10. Providers may begin using the new diagnosis and procedure codes for claims with dates of service on or after 10/01/10. Any claim submitted with a date of service on or after 10/01/10 that does not contain valid diagnosis or procedure codes will be denied. POSC Connection Explore the functionality available through the POSC. MassHealth encourages providers to use the Internet and the capabilities offered at this portal whenever possible. POSC ID Numbers Please note that if someone has a POSC ID that is associated only with an inactive provider, it will be deactivated by EOHHS Security. In order to get it reactivated, the user must have the ID linked to an active provider by that provider's primary user. POSC Reports MassHealth encourages users to check the reports available in the POSC (www.mass.gov/ masshealth/providerservicecenter). Reports enable providers to better support operations and identify trends that could help to enhance business procedures. The metrics and reports function is available through the View Metrics/Reports link. This function gives users the opportunity to view and download detailed provider-specific history, statistics, and reports based upon their business transactions with MassHealth. The NewMMIS-generated reports are tailored to a provider’s individual practice and are available for six months. Some of the available reports include • Turnaround Report (claims-related: displays time frames from date of service to date of submission, and from date of submission to date of payment); • claims volume; • remittance advices (RAs); and • top-10 claims denials. The View Metrics and Reports POSC job aid provides a tutorial on accessing POSC reporting functions. Go to the NewMMIS Web page (www.mass.gov/masshealth/newmmis) and click on the Need Additional Information or Training link, then on the Get Trained link, then on the View Metrics Reports link under Metrics Reports. RA Remittance Advice SNAP Supplemental Nutrition Assistance Program (Formerly Food Stamps) SSN Social Security Number TAFDC Transitional Aid to Families with Dependent Children TL Transmittal Letter TPL Third-Party Liability U.S.C. United States Code VG Virtual Gateway September/October 2010 Page 4 Did You Know? General issues, information, and/or reminders that MassHealth would like to convey. New Change of Address Web Page A new Web page has been added to the MassHealth Web site. Change of Address – Provider Requirements provides instructions on how to update your addresses based on your MassHealth provider type. The Change of Address –Provider Requirements Web page may be reached from the MassHealth Web site at www.mass.gov/masshealth. Click on Information for MassHealth Providers, then on MassHealth Provider Enrollment and Credentialing. Providers must notify MassHealth within 14 days of any changes in information (as stated in 130 CMR 450.223(B)). You may download a copy of the Change of Address form by clicking on the link by that name. The Provider Change of Address Form has been updated and is also available from the MassHealth Provider Forms link in the Publications panel on the MassHealth Web site. Providers may update their information on the Provider Online Service Center (POSC) instead of using the MassHealth Provider Change of Address Form. For information on how to update your provider file, please refer to the job aid located at www.mass.gov/masshealth. Click on New Medicaid Management Information System (NewMMIS) and the POSC, then Need Additional Information or Training, then on Get Trained, and finally, on Update Provider Profile, under the heading Provider Profile Maintenance. Changes made on the POSC may still require the submission of a paper document. Prior Authorization (PA) If you have questions about how to properly perform many PA request functions, MassHealth has several job aids that can help you. The recently revised NewMMIS Job Aid - Create a Prior Authorization Request, in addition to several others, can instruct you about creating, completing, updating, voiding, and inquiring on your PAs. To view the job aids, go to the NewMMIS Web site (www.mass.gov/masshealth/newmmis) and click on the Need Addition Information or Training link, then on Get Trained. Use Your 12-Digit NewMMIS Member ID on Claim Submissions The legacy 10-digit member IDs are no longer acceptable when submitting claims to MassHealth. Claims submitted using the legacy member ID will be denied with error code 2006 and HIPAA Reason and Remark code 31. Medicare crossover claims submitted on paper or through electronic batch submissions will not be denied with this edit. Updated Tools The Durable Medical Equipment (DME), Oxygen, Pharmacy with DME Specialty, and the Orthotics and Prosthetics Payment Coverage Guidelines Tools have been updated. These references provide abbreviated descriptions for all service codes covered by MassHealth for the applicable programs and identify applicable modifiers, place-of-service codes, PA requirements, service limits, and pricing and markup information. September/October 2010 page 5 To view the Tools, visit www.mass.gov/masshealthpubs. Click on Provider Library and then on the MassHealth Payment and Coverage Guideline Tools link at the bottom of the page. Check Broadcast Messages Please remember to check POSC Broadcast Messages (www.mass.gov/masshealth/providerservicecenter). Click on Manage Correspondence and Reporting, then on View Broadcast Messages. You can also view these messages from the NewMMIS Web site at www.mass.gov/masshealth/newmmis. Click on Important: Please Read NewMMIS Notices – by Function or Please Read NewMMIS Notices – Chronological Archive. In addition, your remittance advices can be a valuable resource for MassHealth announcements. The messages are also available and archived on the MassHealth Web site for six months at www.mass.gov/masshealthpubs. Click on Provider Library then on Remittance Advice Message Text. Revised Managed Care Requirements Regulations that took effect on July 1, 2010, revise certain managed care requirements to • allow MassHealth Essential, Basic, and Standard members who have breast or cervical cancer and MassHealth Family Assistance members who are HIV-positive to enroll in a managed care organization (MCO) or in the Primary Care Clinician (PCC) Plan; • require MassHealth CommonHealth members to receive services through either an MCO or the PCC Plan; and • allow MassHealth members who are Native Americans or Alaska Natives who are enrolled in an MCO to choose to receive services through an Indian provider, pursuant to CMR 130 450.117 (I): "Individuals who are Native Americans (within the meaning of "Indians" as defined at 42 U.S.C. 1396u-2) or Alaska Natives and who participate in managed care under MassHealth may choose to receive covered services from an Indian healthcare provider. All participating MCOs must provide payment for such covered services in accordance with the provisions of 42 U.S.C. 1396u-2(h) and comply with all other provisions of 42 U.S.C. 1396u-2(h). For the purposes of 130 CMR 450.117(I), the term Indian health-care provider means an Indian Health Program or an Urban Indian Organization." For more information about these changes, refer to Transmittal Letter (TL) ALL-178 (June 2010). You can download a TL from the MassHealth Web site at www.mass.gov/masshealth/masshealthpubs. Click on the Provider Library, then on Transmittal Letters. Initial Denial Notice Policy for Acute Inpatient Hospitals Hospitals receiving Initial Notices of Denial of Payment from Permedion, the company that conducts MassHealth’s acute hospital utilization management, have the option to request reconsideration or to rebill MassHealth for the service as an outpatient service. If no reconsideration is requested, the Initial Notice of Denial constitutes the final decision; Permedion will not send out a Final Denial letter, as the denial issued constitutes the final action of the agency. For more information about this policy, please refer to MassHealth regulations for acute inpatient hospitals at 130 CMR 415.414 and 130 CMR 450.209(C). You can access the MassHealth Provider Regulations Web page from the MassHealth Regulations link on the MassHealth Web Site at www.mass.gov/masshealth. September/October 2010 page 6 Pharmacy Providers: Test Strips Used for Blood Glucose Monitoring for Diabetes Require PA On April 1, 2010, MassHealth launched a new initiative involving test strips used for blood- glucose monitoring for diabetes. PA is now required for prescriptions for glucose test strips that are not manufactured by Abbott Diabetes Care and for all prescriptions over the 100-strips-per- month quantity limit. MassHealth informed affected prescribers via a letter dated March 23, 2010. For more details or to view the letter, go to http://www.mass.gov/ Eeohhs2/docs/masshealth/pharmacy/prescriber-letter_test-strip.pdf. You may also contact Abbott with any questions about this initiative at 1-866-216-5747. We Heard You… The topics you have identified during the various professional association meetings and training sessions as areas where assistance is requested. Primary Users Should Be Used MassHealth Customer Service should not be your first point of contact for POSC-access questions. If you have password-related reset problems or need help to modify access or link a subordinate user to POSC functions, call your primary user who manages such subordinate user functions. Primary users who have questions about their access and responsibilities can refer to the Primary User Guide found on the NewMMIS Web site (www.mass.gov/ masshealth/newmmis/posc-user-guide). Provider Tutorial Based on the top call reasons, MassHealth responds with recommended Web tools, navigation tips, resources, and information—automated system functions that can help you improve efficiency—all available from the POSC and mass.gov/masshealth, your primary sources for information and issue resolution. 1. (Ways to Avoid the Most Common Mistakes that Cause MassHealth to Reject a W-9. See also: Tips for Completing the Massachusetts Substitute W-9 Form (www.mass.gov/masshealth).) Click on the MassHealth Provider Forms link in the Publications panel. The Tips are located under the All Providers heading. 2. Enter only provider-specific information on your W-9 (for example, do not include group information, such as group Tax ID). 3. Only the Massachusetts Substitute W-9 Form is acceptable; the federal W-9 form should not be submitted. 4. Cross-outs or white-out marks on your W-9 submissions are not acceptable. 5. The Name and Legal Address sections on the W-9 must match the provider legal name and address on your application. 6. Confirm that you have checked the appropriate box to indicate your entity status. For example, check Individual/Sole Proprietor (for any one provider) in the Check the Appropriate Box section. Many doctors inappropriately check off the Corporation box. September/October 2010 page 7 7. Complete all fields with the requested information. Substituting the word ??same” in fields with identical information will cause your form to be rejected. 8. The Legal Address and Remittance Address fields must be filled out separately and completely. However, if your remittance address is the same as your legal address on the form, the Remittance Address field may be left blank. Note: the Legal Address field must ALWAYS be completed. 9. Be sure to complete Part I appropriately. You may not enter both an SSN and a federal employer identification number (FEIN). Only individuals should use an SSN; all others must use a FEIN. FEINs must be accompanied by either a tax coupon or a copy of your Notice of New Employer Identification Number Assigned document from the Department of the Treasury/IRS. 10. Do not forget to sign (Authorized Signature) and date the form. Name and/or date stamps are not acceptable. And for Your Members MassHealth encourages you to share this member information with your MassHealth patients. MassHealth offers a host of online resources for your enrolled members. The Information for MassHealth Members link and the Member Eligibility Library are two helpful access points to steer your members to as starting-off points from the MassHealth Web site (www.mass.gov/masshealth). Dental and Vision MassHealth covers dental and vision services for eligible members who are enrolled with Health New England. Please note that DDS eligibility for adult services is based upon: (1) the individual living in Massachusetts; and (2) the individual having an intellectual disability. The condition must have begun before the age of 18. Dental eligibility and coverage questions should be directed to Dental Customer Service/DentaQuest at 1-800-207-5019. Commonwealth Choice Plan You can assure members that recent confusion over issues spotlighting the Commonwealth Choice Plan does not affect those having coverage under MassHealth or Commonwealth Care plans. Commonwealth Choice is a health insurance program for uninsured adult Massachusetts residents. The Commonwealth Health Insurance Connector Authority is in charge of the program. Those covered under the Commonwealth Choice Plan should be referred to 1-877-MA-ENROL and follow system prompts if they have questions. They can call Monday through Friday, between 8 A.M. and 5 P.M. The June Feature of the Month’s And For Your Members column featured an article showcasing the fact that many members can now access the Virtual Gateway’s My Account Page (www.mass.gov/vg/selfservice). To go to the “Heads of Households that get SNAP, cash- , or health-assistance benefits can now use the Virtual Gateway to see their case information online!” article, click on the Feature of the Month link in the Publications panel on the MassHealth Web site (www.mass.gov/masshealth). September/October 2010 page 8