Update Volume 5, Issue 2 May 2005 A Newsletter for MassHealth Providers New Customer Services Support Contract The Commonwealth of Massachusetts Executive Office of Health and Human Services (EOHHS) is delighted to announce that MassHealth has signed a contract with MAXIMUS, Inc., for the integration of its Medicaid member and provider services. MassHealth currently employs two separate vendors for customer services, one responsible for provider relations and another for member relations. The integration of these vendor relationships on July 1, 2005, into one comprehensive customer-service model will improve efficiency, facilitate information retrieval, cut administrative costs, and foster a stronger partnership between MassHealth and all of its customers. MAXIMUS, Inc., based in Reston, Virginia, has 5,500 employees located in more than 280 offices around the country. MAXIMUS provides complete program management and operations services to state and local governments, as well as the federal government. Key partners in the new contract are Electronic Data Systems (EDS) and Vecna Technologies, Inc. EDS provides a broad portfolio of business and technology solutions to help its clients worldwide improve their business performance. EDS has approximately 117,000 employees located in 60 countries throughout the world. Vecna Technologies is a privately held enterprise architecture, software engineering, and research and development firm, headquartered in College Park, Maryland. Medicaid Director Beth Waldman praised the new partnership. “Fundamentally, this new model represents a better and more efficient way for MassHealth to serve its members and providers,” said Waldman. “MAXIMUS, EDS, and Vecna Technologies have put together a team that combines a dedication to the basics of customer support with new, cutting-edge innovations that will make MassHealth a more welcoming program for our members and a more user-friendly business partner for our providers.” This streamlined and enhanced service is only the first step. In accordance with the administrative simplification goals of the Health Insurance Portability and Accountability Act (HIPAA), a number of new customer-service enhancements will be implemented in the upcoming months to improve the ways MassHealth relates to its members and providers. A key component of this integration is the implementation of self-service functionality via the Commonwealth’s Web portal, mass.gov, allowing both providers and members to “help themselves” to information, apply online to be a MassHealth provider, update demographic data, and more. MassHealth is working with providers, provider associations, and other stakeholders between now and the contract start date to provide additional details about the new, integrated approach to customer services. Statewide Educational Sessions MassHealth is conducting a series of educational sessions statewide during May and June to explain the transition and new services that will now be available to you. The forums will also include information about the enhancements in provider services and details about electronic claims submission through the mass.gov Web site. We look forward to this opportunity to answer your questions and provide you with more detailed information. Please refer to All Provider Bulletin 144 (May 2005) for the times and locations. Call 1800-441-0323 to register for a forum near you. Initial Enhancement: Conversion of BBS to Web Effective June 23, 2005, MassHealth will discontinue the use of the Bulletin Board System (BBS) as a means for submitting electronic claims. In its place, we are pleased to announce the implementation of a new, secure, Web-based claims submission solution through the mass.gov/masshealth Web site. This change is designed to meet the HIPAA goals of administrative simplification and standardized claim submission. In addition, it will afford providers the opportunity to enjoy a greater level of service from the additional Internet capabilities for claims submission. Beginning June 23, 2005, the BBS will be disabled, and all submitters who previously used the BBS to submit their claims will now be able to submit them via the Web portal. There will be no change to the HIPAA-compliant 837-file format that MassHealth currently accepts. The only portion of the process that will change is the claim-submission method. Submitters will continue to use their existing BBS User ID, but will receive a new password before the conversion. We will also continue to accept claims on hard media such as diskette, and will now accept claims on CD-ROM. We are working closely with providers to help them understand the necessary steps for this transition. MassHealth Customer Service Representatives have contacted all BBS users to coordinate the submission of an electronic claims test file. In order to prepare for this transition, and the submission of a test file, we make the following suggestions: If you rely upon a billing intermediary or software vendor, confirm their involvement in this change; and Confirm your Internet access. We will continue to contact providers via e-mail throughout this process. If you need to update your e-mail address, or other contact information, or if you have general questions about this change, please call us at 1-800-441-0323. We will also provide important updates about this transition on our Web site at www.mass.gov/masshealth. New Contact Information Effective July 1, 2005, there will be new contact information for some MassHealth processes. Please refer to All Provider Bulletin 144 (May 2005) for the MassHealth Provider Quick Reference Directory for the new contact information. Your current business processes and contacts will stay the same through June 30, 2005, except for the submission of claims to the BBS as noted on page two. Please continue to use the current addresses and telephone numbers. We encourage you to begin using the new toll-free number beginning on July 1, 2005. Please note, however, that the toll-free telephone numbers that you currently use will also be answered by the new Customer Services Center to ensure continuity of service. In addition, any mail that you send or that is delivered to the current MassHealth addresses in Somerville, MA after July 1, 2005, will be forwarded to the new address for a transition period. Additional New Services Over the next several months, we will offer more Web-based services that will significantly improve the way MassHealth supports you. These services, which will be accessible at www.mass.gov/masshealth, will include: online provider enrollment; online maintenance of provider profile file demographic information (address, phone number, and contact information); online, chat-style customer support for MassHealth providers and members; and online training courses for new providers. Information about the availability of these services and how to use them will be found at the “News and Updates” section of our Web site as the options are implemented. MassHealth Guidelines for Medical Necessity Determination online, chat-style customer support for MassHealth providers and members; and online training courses for new providers. Information about the availability of these services and how to use them will be found at the “News and Updates” section of our Web site as the options are implemented. MassHealth Guidelines for Medical Necessity Determination MassHealth recently added the Guidelines for Medical Necessity Determination (Guidelines) to our Web site at www.mass.gov/masshealth/guidelines. These Guidelines identify the clinical information MassHealth needs to determine medical necessity for certain products and services that require prior authorization. MassHealth developed these Guidelines and associated forms via an ongoing process that included a rigorous review of the most current evidence-based literature and input from clinical and program staff, and often from external clinical experts. Members Affected by the MassHealth Guidelines These Guidelines apply to members enrolled in MassHealth fee-for-service programs, the Primary Care Clinician (PCC) Plan, and, in some instances, MassHealth-contracted managed care organizations (MCOs). Providers serving members enrolled in MassHealth-contracted MCOs (currently Neighborhood Health Plan, BMC HealthNet Plan, Network Health, and Fallon Community Health Plan), Senior Care Options (SCO), or Program of All-Inclusive Care for the Elderly (PACE) should refer to the health plan’s medical policies for covered services. To determine which guidelines apply to your patients enrolled with MassHealth MCOs, SCO, or PACE, please contact the appropriate MassHealth health plan. Purpose of the MassHealth Guidelines The Guidelines and their associated forms are intended to clarify the specific medical information that MassHealth needs to determine medical necessity. They are not intended to replace or supersede program regulations. Over time, MassHealth will publish Guidelines for a number of products and services that require prior authorization. Each set of Guidelines has links to supporting information, such as product-specific or service-specific Medical Necessity Review forms and the MassHealth Automated Prior Authorization System (APAS). These Guidelines may be downloaded and printed. Signup for E-mail Alerts Since evidence-based clinical standards and medical practices are advancing at a rapid rate, MassHealth will update the Guidelines as necessary. To receive notice of updates to the Guidelines and the availability of related forms, you can sign up for e-mail alerts on the site. Questions If you have questions or comments about the MassHealth Guidelines for Medical Necessity Determination, call MassHealth Provider Services at 617-628-4141 or 1-800-325-5231.