MassHealth Update Inside this Issue A Newsletter for MassHealth Providers New MassHealth Benefit: Tobacco Cessation . . . . . 2 Your Everything Resource: The MassHealth Provider Library. . . . . . . . 2 Automated Solutions . . . . . . . . . . . . . . . . 3 Don’t Delay, Transition Today. . . . . . . . . . . . . 3 MassHealth Reminders. . . . . . . . . . . . . . . . 4 Health-Care Reform Legislation and MassHealth Due to health-care-reform legislation signed in April by Governor Romney, there will be some changes to the MassHealth program. The following policies in MassHealth eligibility and benefits are effective July 1, 2006. MassHealth eligibility for children will increase, allowing MassHealth coverage of children in families earning up to 300% of the FPL. Approximately 10,000 children will be transitioned from the Children’s Medical Security Plan (CMSP) to more comprehensive coverage through the MassHealth Family Assistance benefit. The legislation expands MassHealth coverage of certain benefits. Affected Benefits include dental and vision-care services, chiropractor services, orthotics, prosthetics, 24-hour post medical detoxification substance-abuse services, and acute inpatient administratively necessary days. Additionally, MassHealth will be introducing a two-year pilot program for tobacco-cessation treatment that allows members to receive group/individual cessation counseling and pharmacotherapy. Please refer to the “Tobacco Cessation” article in this issue of Update for more information on this new MassHealth benefit. MassHealth also looks forward to approval from the Centers for Medicare & Medicaid services to increase the enrollment caps for Family Assistance adults with HIV, CommonHealth, and Essential coverage. The Essential cap would increase to 60,000 members, allowing MassHealth to enroll the approximately 12,000 individuals on the waiting list (see MassHealth regulations at 130 CMR 519.013 for Essential coverage type requirements). An important change that some MassHealth providers can expect to see is an increase in reimbursement rates under a pay-for-performance model. The state will allocate $90 million each year for the 2007, 2008, and 2009 fiscal years to hospitals and physicians in the form of Medicaid rate increases. In 2008 and 2009, the rate increases to hospitals will be tied to performance goals related to quality, efficiency, the reduction of racial and ethnic disparities, and improved patient outcomes. The passage of such a historic health-care reform law has wide-ranging implications. Though the implementation will undoubtedly require the dedication and coordinated efforts among Massachusetts state agencies, employers, insurers, and providers, MassHealth is excited by our important role in this project and appreciates the efforts of providers as we all work toward implementing the law. A provider bulletin will be issued in June with more details on the upcoming changes to the MassHealth program. Do not forget to visit www.mass.gov/masshealth for the latest MassHealth communications. New policies will take effect July 1, 2006. New on mass.gov/masshealth: The Changes Keep Coming As promised, we are keeping our focus on finding innovative automated solutions to simplify all your MassHealth interactions. In addition to great online services already available, such as Web-based claims submission and member-eligibility verification, there are now three more enhancements to give you more flexibility and control in your MassHealth business transactions. Provider Account Management New self-service options will be introduced in June 2006 on our Web site once you have an established online provider account. These tools give you more control and opportunity to get the information you need when you need it. Whether it is own loading a form or provider publication, or submitting a Prescription for Transportation (PT-1) request, www.mass.gov/masshealth is the place to go, 24 hours a day, seven days a week. To establish a provider account and gain access to the Publications Ordering and PT-1 online tools, you will need a username and password to log in to our secure Web site. Signup for Your Account To create your own online provider account, you will need to submit a (continued on page 4) JUNE 2006 / VOLUME 6 / ISSUE 3 / Page 1 New MassHealth Benefit: Tobacco Cessation Almost 36% of MassHealth members are smokers. That’s almost double the 19.4% smoking rate of the general state population, according to the Massachusetts Department of Public Health. Taking these circumstances and serious health implications into consideration, MassHealth has created a new program to help assist members who wish to quit smoking. Beginning July 1, 2006, MassHealth will cover individual and group tobacco cessation counseling and pharmacotherapy through the MassHealth tobacco cessation benefit. Those members eligible to receive physician services, community-health-center services, acute-outpatient-hospital services, and pharmacy services are covered for tobacco-cessation services, based on their MassHealth coverage type as stated in the MassHealth Administrative and Billing Regulations at 130 CMR 450.105. Members covered by MassHealth Limited are only covered for emergency services and therefore are not eligible for tobacco-cessation services. Since stopping tobacco use may require multiple attempts, the program is designed to allow members and providers as much flexibility as possible. Members may use up to 16 counseling sessions in any combination of group or individual face-to-face sessions per year, including two intake/assessment sessions. Prior authorization is required for counseling sessions beyond this limit. The pharmacotherapy component of this benefit allows a 90-day supply of medication for nicotine-replacement therapy (NRT), such as nicotine gum, lozenges, and patches, per cessation attempt. Nicotine inhalers and nasal sprays require prior authorization. A maximum of two 90-day treatment regimens per year are covered. Additional NRT requires prior authorization. The pharmacotherapy component of this benefit also covers other medically necessary drugs for tobacco cessation, such as bupropion (the generic form of Zyban). Please see the MassHealth Drug List for further details about the pharmacotherapy benefit for tobacco cessation. The MassHealth Drug List can be found at www.mass.gov/druglist. It can also be accessed from the MassHealth Pharmacy Program Web page at www.mass.gov/masshealth/pharmacy. Physicians, as well as certain mid-level providers (for example, registered nurses, physician assistants, nurse practitioners, and nurse midwives), are authorized to provide tobacco-cessation counseling. Other health-care providers with specific training in the provision of tobacco cessation counseling may also qualify to provide counseling. Physicians who supervise those providers must ensure that they are trained by a degree-granting institute of higher education and have completed at least eight hours of course instruction. All nonphysicians must provide services under the supervision of a physician. If you have any questions about this program, contact MassHealth Customer Service at 1-800-841-2900. Additional provider communications introducing this program will be issued in the coming weeks. Your Everything Resource: The MassHealth Provider Library Need to check a billing code? Want to verify a MassHealth policy? Go to the online MassHealth Provider Library and download the PDF versions of the provider billing instructions that were made available in May 2006. In addition to being a one-stop reference for all provider bulletins, transmittal letters, remittance advice messages texts, Update newsletters, provider regulations, and MassHealth Companion Guides, the Provider Library now has updated sections of the provider manuals available for download. Simply go to our Web site at www.mass.gov/masshealth and select MassHealth Regulations and Other Publications, then Provider Library, to check out the latest additions. Billing Instructions You may have already heard that MassHealth is currently in the process of updating and reorganizing the layout of the provider billing instructions. This first set of revised instructions was communicated to providers in Transmittal Letter ALL-139, issued in April 2006. The reorganized administrative and billing instructions are located in Subchapter 5 of your provider annual and include: Part 1: Eligibility; Part 2: Prior Authorization; Part 4: Required Forms and Documentation; Part 6: Error Codes and Explanations; Part 7: Claim Status and Claim Correction; and Part 8: Other Insurance. These sections have been updated to reflect current terminology and procedures that have been announced in past bulletins and other written MassHealth issuances. Additional revisions to the administrative and billing instructions will be published and posted in the Provider Library in upcoming weeks. Stay tuned! The Provider Library is located under the MassHealth Regulations and Other Publications link on www.mass.gov/masshealth. JUNE 2006 / VOLUME 6 / ISSUE 3 / Page 2 Automated Solutions: The Recipient Eligibility Verification System and the Web Maximize your time and avoid the phone queue. Make WebREVS your member-eligibility and claim-status resource. Did you know that WebREVS: -can be accessed from any PC with an internet connection 24 hours a day, seven days a week; -is free; -contains the most current and complete eligibility information; -significantly reduces time spent verifying member eligibility and checking claim status; -allows inquires for large batches; meets HIPAA standards for both eligibility and claim status transactions; and -allows responses to be printed and retained for your files? The benefits are clear: Using WebREVS can improve your daily operations. Did you know that almost 50% of provider calls to MassHealth Customer Service are related to member-eligibility and claim status issues? That’s a lot of calls that could have been addressed just by logging into WebREVS. Don’t bother with the phone queue when you can get fast, accurate answers using this online resource. Member Eligibility Every month, providers see their claims denied for reasons related to the lack of, or faulty, member-eligibility verification. To avoid these errors, providers should use WebREVS to verify member eligibility before furnishing services. When using WebREVS to check eligibility, remember to view all of the information displayed, including coverage types, that may require you to follow specific instructions. Checking Claim Status The claim-status feature gives you up-to the minute information about the status of an adjudicated MassHealth claim. You can search adjudication history for the previous 18 months. Use the transaction control number (TCN), patient account number (PAN), or the member’s identification number (RID) to make your inquiry. Make WebREVS your first resource for checking member eligibility and claims status and experience the time-and cost saving benefits! Maximize your time and avoid the phone queue with WebREVS! Dental Providers: Don’t Delay, Transition Today! It’s about time to say goodbye to proprietary paper claim form no. 11 and say hello to the ADA claim form. Take advantage of the remaining time before June 30, 2006, to transition to the ADA claim form. Make your transition as seamless as possible to prevent disruptions in your billing processes. If you submit your claims for dental services on paper, try using the ADA claim form version 2002 or 2004 now. Don’t forget: MassHealth claim form no. 11 will not be accepted after June 30, 2006. Starting July 1, MassHealth will accept only the ADA claim form versions 2002 and 2004, regardless of the date on which services were provided. This transition affects only paper claims submitted to MassHealth. If you currently submit your claims using the electronic HIPAA-compliant 837D transaction, you can continue to use your current billing procedures. We strongly suggesting the 837D transaction for your MassHealth claims instead of paper as it is the easiest and most efficient method of claims submission. MassHealth also offers providers free electronic claims-submission software (PCSS). For more information, If you must submit paper claims, why should you transition to the ADA form today? Three simple reasons: 1. Avoid claim form no. 11 rejections in July. Submitting claims on MassHealth claim form no. 11 after July 1, 2006 will cause the claims to be rejected and returned to your office. To avoid this rejection process, begin submitting claims on the ADA claim form versions 2002 or 2004 now. 2. Avoid unnecessary denials for incorrectly completed ADA forms. Since some entries are tailored to MassHealth, it is important for you to be familiar with how to complete the ADA form according to these specifications. Failure to do so will result in a claim denial. Consult Dental Bulletin 34 (March 2006) for more information. 3. Beat the rush—get the help you need and bypass the July phone queue. If you have questions, others probably do, too, which could mean a heavy call volume if you call MassHealth Customer Service in July for assistance. Stay a step ahead and save yourself time and frustration by understanding how to use the ADA form for MassHealth before it is mandatory. Since April 18, 2006, MassHealth has accepted dental claims submitted on the ADA claim form. Dental Bulletin 34 explains this transition, gives helpful tips to make the transition easier for you, and includes item-by-item instructions on completing the form for MassHealth. Mark the date: MassHealth claim form no. 11 will not be accepted after June 30, 2006. JUNE 2006 / VOLUME 6 / ISSUE 3 / Page 3 New on mass.gov/masshealth (continued from page 1) Provider Account Management Request Form. This can be accessed from the MassHealth Provider Forms link on our Web site. Simply complete and submit this form electronically. Once your request has been processed, you will receive your account user-name and password in two separate e-mails. Creating a provider account allows you to use our new online self-service tools. Each of these automated solutions will help simplify your business processes. Publication Ordering Need a MassHealth provider form or manual but not quite sure where to go? No problem. With the online publications-ordering tool, enter search criteria to find the MassHealth publication you want when you want it. Most publications can be downloaded and printed directly from the Web site, or if you prefer paper or need multiple copies, the publication can be sent through mail delivery. Previously, these types of publication requests were submitted in writing to our Publications department. Once the request was received and fulfilled, the publication was mailed to the requested address—a lengthy and time-consuming process. Now you can bypass all the paperwork and transit time by accessing or ordering them directly from www.mass.gov/masshealth. Stay tuned to our Web site for more provider communications on how and when you can use this tool. Coming Soon Prescription for Transportation Form (PT-1) In the upcoming weeks, a new option will allow authorized users to complete and submit a PT-1 electronically from our Web site. Online form availability eliminates time and energy spent requesting and waiting to receive the form from MassHealth through the traditional paper method. With the option to complete and submit the form electronically via www.mass.gov/masshealth, you can use the online PT-1 24 hours a day, seven days a week at your convenience. In addition, filling out the form electronically with built-in checks ensures that all the required fields have an entry before it is submitted. This is a huge advantage over the traditional paper method, as it prevents incomplete forms received by MassHealth from being mailed back to the provider, lengthening the processing time. Another benefit of using the online PT-1 is that you need to enter information about the MassHealth member only once for multiple PT-1 requests. Save yourself extra paperwork—complete and submit the PT-1 online! Additional MassHealth communications will be issued in the coming weeks to let you know when you can start taking advantage of the PT-1 feature. Provider File Maintenance Instead of calling MassHealth Customer Service to update your provider information, save time and do it yourself through the Web! Whether it’s a change of mailing address or a new phone number, request the change whenever it is convenient for you, 24 hours a day, seven days a week. Online management of your contact information gives you control over your provider information. MassHealth will be issuing a provider bulletin and remittance advice message text in late June 2006 to let you know when this tool will become available for use. MassHealth Reminders Third Party Liability and Edit 503 Denials Are your third-party-liability claims denying for edit 503 (Services on Claim and EOB Differ)? Check out the billing tips flier, “Correcting Edit 503,” updated in May 2006, to learn why your claim might be denying, and how to correct it. Download the flier from the Billing Information link found in the MassHealth Customer Service for Providers section of the Information for MassHealth Providers link on our Web site. Attention Outpatient Hospitals: Avoid Error 655 Denials If you bill on the paper UB-92 claim form, enter the admission time in Item 18. Applicable codes for paper claims are listed in Subchapter 5 of your provider manual. If you bill electronically on the 837I, enter the time in Field DTP03, Loop 2300. HIPAA-compliant codes are available in the 837I Implementation Guide. This entry was always required for acute-inpatient-hospital claims. However, it was only recently made a requirement for outpatient hospitals, as stated in Acute Outpatient Hospital Bulletin 15, Chronic Outpatient Hospital Bulletin 2, and Psychiatric Outpatient Hospital Bulletin 1. These January 2006 provider bulletins are located in the provider library under the MassHealth Regulations and Other Publications link on www.mass.gov/masshealth. The 837P versus 837I for Community Health Center Providers When billing electronically, providers should use only the 837P (Professional) HIPAA transaction for community health center services. If billing for home health services, use the 837I (Institutional) transaction. For more information about these HIPAA-compliant transactions, refer to the MassHealth Companion Guides located in the Provider Library at www.mass.gov/masshealth. E-mail: providersupport@mahealth.net Web: www.mass.gov/masshealth MassHealth Customer Service P.O. Box 9118 Hingham, MA 02043 Phone: 1-800-841-2900 Fax: 617-988-8974 JUNE 2006 / VOLUME 6 / ISSUE 3 / Page