Presentation on theme: "WellCare Provider Training MLTSS 2014. Topics For MLTSS Provider Training Cape May Cumberland Atlantic Salem Gloucester Camden Ocean Burlington Mercer."— Presentation transcript:
WellCare Provider Training MLTSS 2014
Topics For MLTSS Provider Training Cape May Cumberland Atlantic Salem Gloucester Camden Ocean Burlington Mercer Monmouth Middlesex Union Somerset Hunterdon Hudson Essex Morris Warren Bergen Passaic Sussex What is Managed Long Term Services and Support Services under MLTSS How to qualify for MLTSS Member Eligibility Timely Claims Submission Claims Submission Requirements/Paper Claims Electronic Claims Submissions/Prompt Payment Coordination of Benefits/Hold Harmless Dual Eligible Credentialing Claims Appeals/Appeals/Grievances Nursing Facilities/Assisted Living Prior Authorization HIPPA Electronic Transactions and Code Sets Authorization Required for Long Term Care Services Critical Incident Reporting-MCO requirements Resources
What is Managed Long Term Services and Support Managed Long Term Services and Supports (MLTSS) refers to the delivery of long-term services and supports through New Jersey Medicaid's NJ FamilyCare managed care program. MLTSS is designed to expand home and community-based services, promote community inclusion and ensure quality and efficiency. Principles for Managed Long Term Services: MLTSS overall goal is to provide quality long-term services and supports to individuals of all ages in the most integrated setting appropriate to their needs.. Home and Community-Based Services is the preferred service delivery method for people receiving Managed Long Term Services and Supports (MLTSS). Person-centered service options should be available so that individuals of all ages who use MLTSS are enabled to live in the community, in their own homes if possible; Criteria for community living should include: privacy; autonomy; respect; personal preference; cultural differences; dignity; safety; choice and control within the residential setting; integration with the greater community; independent advocacy when appropriate; and personal control over moving to, remaining in or leaving the setting; and Consumer Choice selecting providers and living settings is the priority if MLTSS: People of all ages have the right to choose and, if they wish, direct their care plan; MLTSS works with individuals to ensure that quality of life is as important as quality of care. MLTSS will work to maintain or improve the health and functional state of seniors and people with disabilities.
Services under MLTSS includes: Personal Care Respite Care Management Home and Vehicle Modifications Home Delivered Meals Personal Emergency Response Systems Mental Health and Addiction Services Assisted Living Community Residential Services Nursing Home Care Behavioral Health participants in the Medicaid waiver programs listed below will be automatically enrolled in the Managed Long Term Services and Supports (MLTSS) program through their current Medicaid managed care organization (MCO), also known as a health plan: Global Options for Long-Term Care (GO); AIDS Community Care Alternatives Program (ACCAP); Community Resources for People with Disabilities (CRPD); or, Traumatic Brain Injury (TBI) Waiver
How to qualify for MLTSS Global Options for Long-Term Care (GO); AIDS Community Care Alternatives Program (ACCAP); Community Resources for People with Disabilities (CRPD); or, Traumatic Brain Injury (TBI) Waiver are automatically enrolled on July 1 st 2014 A person also can qualify for Managed Long Term Services and Supports (MLTSS) by meeting these established Medicaid requirements: Financial Requirements - These include monthly income, as well as total liquid assets. For more detailed information on Medicaid financial eligibility, click here.click here Clinical Requirements - A person meets the qualifications for nursing home level of care, which means that the person requires assistance with activities of daily living such as bathing, toileting and mobility. Age and/or Disability Requirements - These involve age requirements whereby one must be 65 years or older; and/or disability requirements whereby one must be under 65 years of age and determined to be blind or disabled by the Social Security Administration or the State of New Jersey.
Member Eligibility A member’s eligibility status can change at any time. Therefore, all providers should consider requesting and copying a member’s identification card, along with additional proof of identification such as a photo ID, and filing them in the patient’s medical record. Providers may do one of the following to verify eligibility: Access the secure, online Provider Portal of the WellCare website at Access WellCare’s interactive voice response (IVR) system; and/or contact the WellCare Provider Service Department. You will need your Provider ID number to access member eligibility through the avenues listed above. Molina Medicaid/Family Care Solutions at (you must have a Medicaid/Family Care provider number to use this provider line). Medicaid/Family Care FFS Services Enrolled Providers can also visit NJMMIS website at and select link on the left side of the page (contact Webmaster) once on the webpage complete request for username and password and access eMEVS ( the electronic Medicaid/Family Care Eligibility Verification System) or call www.NJMMIS.com REVS- You must be a Medicaid/Family Care Provider to have access to REVS TEL# the advantage of using REVS is that you can also confirm if a member has Medciare Parts A and B and MCO.
Timely Claims Submission Unless otherwise stated in the Provider Participation Agreement (Agreement), provider must submit claims (initial, corrected and voided) within six (6) months or 180 days from the Medicaid or primary insurance payment date, whichever is later) from the date of service. Unless prohibited by federal law or CMS, WellCare may deny payment for any claims that fail to meet WellCare’s submission requirements for Clean Claims or that are received after the time limit in the Agreement for filing Clean Claims. MCO will adjudicate MLTSS claims within 15 days of clean claim submission If the beneficiary is dually eligible; Medicare must be billed prior to Medicaid/Family Care if the service is covered by Medicare. Medicare balances may be billed to the Medicaid/Family Care MCO if the Medicare Benefit is exhausted. If the beneficiary is not enrolled in a MCO, or the beneficiary’s Medicaid/Family Care eligibility lapsed and service is a Medicaid/Family Care billable service the beneficairy may be covered by Medicaid/Family Care FFS REMEMBER: Medicaid/Family Care is the payer or last resort The following items can be accepted as proof that a claim was submitted timely: A clearinghouse electronic acknowledgement indicating claim was electronically accepted by WellCare; and A provider’s electronic submission sheet with all the following identifiers, including patient name, provider name, date of service to match Explanation of Benefits (EOB)/claim(s) in question, prior submission bill dates; and WellCare product name or line of business. The following items are not acceptable as evidence of timely submission: Strategic National Implementation Process (SNIP) Rejection Letter; and A copy of the Provider’s billing screen. (Continue on next page)
Electronic Claims Submissions WellCare accepts electronic claims submission through Electronic Data Interchange (EDI) as its preferred method of claims submission. All files submitted to WellCare must be in the ANSI ASC X12N format, version For more information on EDI implementation with WellCare, refer to the Wellcare Companion Guides which may be found on WellCare’s website. Because most clearinghouses can exchange data with one another, providers should work with their existing clearinghouse, or a WellCare contracted clearinghouse, to establish EDI with WellCare. For a list of WellCare contracted clearinghouse(s),for information on the unique WellCare Payer Identification (Payer ID) numbers used to identify WellCare on electronic claims submissions, or to contact WellCare’s EDI team at:
The information must be aligned within the data fields and must be: Typed; In black ink; Large, dark font such as, PICA, ARIAL 10-, 11-or 12-point type; and In capital letters. The typed information must not have: Broken characters; Script, italics or stylized font; Red ink; Mini font; or Dot matrix font. Paper Claims Submissions Cont’d
MLTSS time frames for claims processing WellCare is required to adjudicate (pay or deny) claims (for MLTSS members) for MLTSS services such as: assisted living providers, nursing facilities, special care nursing facilities, CRS providers, adult/pediatric medical day care providers, PCA and participant directed Vendor Fiscal/Employer Agent Financial Management Services (VF/EA FMS) claims within the following timeframes: 1. HIPAA compliant electronically submitted clean claims shall be processed within fifteen (15) calendar days of receipt; 2. Manually submitted clean claims shall be processed within thirty (30) calendar days of receipt; and 3. All claims shall be processed within forty-five (45) calendar days of receipt.
Coordination of Benefits (COB) WellCare shall coordinate payment for Covered Services in accordance with the terms of a member’s benefit plan, applicable state and federal laws and CMS guidance. Providers shall bill primary insurers for items and services they provide to a member before they submit claims for the same items or services to WellCare. Any balance due after receipt of payment from the primary payer should be submitted to WellCare for consideration and the claim must include information verifying the payment amount received from the primary plan as well as a copy of the Explanation of Benefits (EOB). WellCare may recoup payments for items or services provided to a member where other insurers are determined to be responsible for such items and services to the extent permitted by applicable laws. Providers shall follow WellCare policies and procedures regarding subrogation activity.
Balance Billing Providers shall accept payment from WellCare for Covered Services provided to WellCare members in accordance with the reimbursement terms outlined in the Agreement. Payment made to providers constitutes payment in full by WellCare for covered benefits, with the exception of member expenses. For Covered Services, providers shall not balance bill members any amount in excess of the contracted amount in the Agreement. An adjustment in payment as a result of WellCare’s claims policies and/or procedures does not indicate that the service provided is a non- covered service, and members are to be held harmless for Covered Services. For more information on balance billing, refer to the Provider Manual. Hold Members Harmless Those dual eligible members whose Medicare Part A and B member expenses are identified and paid for at the amounts provided for by DMAHS (Medicaid) shall not be billed for such Medicare Part A and B member expenses, regardless of whether the amount a provider receives is less than the allowed Medicare amount or provider charges are reduced due to limitations on additional reimbursement provided by DMAHS. Providers shall accept WellCare’s payment as payment in full or will bill New Jersey Medicaid if WellCare has not assumed the Agency’s financial responsibility under an agreement between WellCare and the Agency. For more information on holding harmless dual eligible members, refer to Medicaid Provider General Manual.
Please take note of the following credentialing process highlights: Primary source verifications are obtained in accordance with the state and federal regulatory agencies, accreditation, and WellCare policy and procedure requirements and include a query to the National Practitioner Data Bank Physicians, allied health professionals, and ancillary facilities/health care delivery organizations are required to be credentialed in order to be network providers of services to WellCare members. Satisfactory site inspection evaluations are required to be performed in accordance with state, federal, state and accreditation requirements. WellCare will complete credentialing activities and notify providers within 90 days of receiving a completed application. The notification to the provider will inform them as to whether they are credentialed, whether additional time to complete the credentialing process is needed, or that additional providers are not needed at the time. When additional information is needed t o complete a provider application, WellCare will make the request from the provider as soon as possible, and no later than 90 days from the receipt of the application. WellCare will also communicate with providers within these timeframes throughout the provider re-credentialing process. Credentialing Process Highlights
Claims Appeals Provider Claim appeals must be submitted within 90 days of the most recent adverse determination on a claim or claim appeal. (see provider manual) During all stage of the appeal process or Fair Hearing services will continue if all the requirements below apply. The appeal is filed on time The appeal involves a course of treatment that was authorized The services were ordered by an authorized network provider The written request to continue services is received within 10 days if the date of initial denial letter ( this only applies to Medicaid/Family Care Fair Hearings) Mail or fax medical appeals with supporting documentation to: WellCare Health Plans, Inc. Fax Attn: Appeals Department PO Box Tampa, FL A beneficiary or provider on behalf of a beneficiary (with beneficiary written consent) can request a Fair Hearing at any time during the appeals process. The Medicaid/Family Care Fair Hearing Dept. can be reached at: or , or via mail or fax to Department of Human Services Medicaid/Family Care Fair Hearing Dept. 7 Quakerbridge Rd. Mercerville NJ, Fax#
Grievances Member grievances may be filed verbally by contacting Customer Service or submitted via fax or mail. Providers may also file a grievance on behalf of the member with the member’s written consent. Mail or fax member grievances to: WellCare Health Plans, Inc. Fax Attn: Grievance Department PO Box Tampa, FL
NF, SCNF MLTSS Any Willing Provider status for NF, SCNF, AL and CRS will be for a two year period from the date that the service comes into MLTSS, dependent upon available appropriation in each Fiscal Year. For NF, SCNF, AL and CRS that would mean that Any Willing Provider status expires on June 30, Nursing Facility Level of Care (NF LOC)--The designation given to individuals who meet clinical eligibility for MLTSS services. This is assessed using the NJ Choice Assessment System and findings are validated by OCCO, in accordance with N.J.A.C. 8:85. Nursing Facility Services(NF) – shall be a covered benefit for Medicaid/NJ FamilyCare A, and the MCO shall be financially responsible for all nursing facility services for NJ FamilyCare A enrollees from the date the enrollee enters the nursing facility to the date of discharge. Special Care Nursing Facilities (SCNF) residents currently receiving NJ FamilyCare through Fee-for-Service will convert to managed care on July 1, Short term nursing facility stays are available for MLTSS Members receiving HCBS who require temporary placement in a nursing facility due to temporary illness, serious injury, wound care, or the absence of the primary caregiver and there is a reasonable expectation that the member will be discharged back to the community within 180 days. If, prior to the end of the 180 day period (post admission date) it is determined that the member will not be discharged from the nursing facility, the member shall be determined as custodial. The member is automatically converted to custodial status in the nursing facility if the member is in the nursing facility beyond 180 days. Current custodial nursing home residents on Medicaid will remain in a fee-for-service environment. Medicaid beneficiaries living in Special Care Nursing Facilities (SCNFs) as of July 1, 2014 will remain in the fee-for-service environment for two years. Any individual who is newly eligible for Medicaid and living in a nursing home after July 1, 2014 will have his/her care managed by a NJ FamilyCare MCO through the MLTSS program. Individuals who enter a SCNF after July 1, 2014 will have their acute and primary health care services and their nursing home care managed by a NJ FamilyCare MCO through the MLTSS program OCCO is responsible for issuing the final approval or denial letter to the Member. In the event the Member does not meet NF LOC OCCO will explain to the Member the reason(s) for denial, provide counseling on alternative HCBS and issue a determination letter which shall include the Member’s right to appeal and how to apply for a Medicaid fair hearing..
AL / AFC MLTSS Members residing in an Assisted Living (AL) or in an Adult Family Care (AFC) setting may have a cost share as calculated by the County Welfare Agency and are responsible to pay the provider of services the cost share. This is in addition to the Room and Board charge established by the state. MLTSS Members living in Assisted Living (AL) or in an Adult Family Care (AFC) setting, whose income is only derived from Supplemental Security Income (SSI), will not have a cost share. They will be required to pay the Room and Board charge established by the state Assisted Living: For individuals who are placed in an assisted living residence the Care Manager shall discuss room and board payments and any potential patient pay liability the Member may incur. Since New Jersey Medicaid does not cover room and board in a community alternative residential setting, this must be paid by the Member or other source (such as the Member’s family) directly to the facility. The State shall notify the Contractor annually of the room and board amount which shall be collected from the resident by the provider. In addition, the Care Manager shall discuss any patient payment liability for cost of care with the Member. The patient liability for cost of care is the portion of the cost of care that ALR, CPCH or AFC residents must pay based on their available income as calculated by the CWA. The State shall notify the Contractor of any applicable patient payment liability via the 834 eligibility/enrollment file. The Contractor shall delegate collection of both the room and board and patient payment liability for the cost of care to the provider. The Contractor shall pay the facility net of the applicable patient liability amount.
Prior Authorization MLTSS Prior authorization guidelines to note are: Prior authorization decisions for non-emergency services shall be made within 10 days. With complete medical information Wellcare responds to more than 90% of requests within three business days. Within 72 hours of the request, you may log into the website for update.www.wellcare.com Prior authorization Denials and limitations must be provided in writing in accordance with the Health Claims Authorization Processing and Payment Act, P.L. 2005, c.352. The prior authorization request should include the diagnosis to be treated and the CPT code describing the anticipated procedure. If the procedure performed and billed is different from that on the request, but within the same family of services, a revised authorization is not required. An authorization may be given for a series of visits or services related to an episode of care. The authorization request should outline the plan of care including the frequency and total number of visits requested and t he expected duration of care.
AUTHORIZATION IS REQUIRED FOR LONG TERM CARE SERVICES BELOW Adult Companion Services Adult Day Health Care Assisted Living Services PCA Pediatric Medical Day Care CSR Chore Services Consumable Medical Supplies Behavioral Management ( TBI) Environmental Accessibility Adaptation Services Family Training Services.
AUTHORIZATION IS REQUIRED FOR LONG TERM CARE SERVICES BELOW Homemaker Services Personal Emergency Response Systems Respite Care Services Occupational Therapy Physical Therapy. Respiratory Therapy Speech Therapy Nursing Facility Assisted Living Behavioral Health
Critical Incident Reporting - MCO Requirements In all MLTSS provider contracts, the Contractor shall require full adherence to the mandatory training and reporting requirements applicable to Adult Protective Services, office of Institutionalized Elderly, Department of Children and Families and the Division of Disability Services including but not limited to: 1.N.J.A.C. 8: N.J.A.C. 8: (A) 3.N.J.A.C. 8:43F N.J.A.C. 8:43J N.J.S.A. 52:27D N.J.A.C. 8:57
Critical incidents shall include but not be limited to the following incidents 1.Unexpected death of a member 2.Missing person or unable to contact 3.Suspected or evidenced physical or mental abuse (including seclusion and restraints, both physical and chemical) 4.Theft with law enforcement involvement 5.Law enforcement contact 6.Severe injury or fall resulting in the need of medical treatment 7.Medical or psychiatric emergency, including suicide attempt 8.Medication error 9.Inappropriate or unprofessional conduct by a provider involving the member 10.Sexual abuse and/or suspected sexual abuse; and abuse and neglect, including self-neglect, and/or suspected abuse and neglect
Timeframes for incident reporting Contracted MLTSS providers and their staff are required to report, respond to and document critical incidents as specified by the contractor as follows: 1.The maximum timeframe for reporting an incident to WellCare shall be 24 hours, the report might be submitted verbally, in which case the agency/person/entity making the initial report shall submit a follow-up written report within 48 hours 2.Suspected abuse, neglect, and exploitation must be reported immediately 3.WellCare is required to report to DMAHS any death and any incident that could significantly impact the health or safety of a member within 24 hours of detection or notification 4.Timeframe for submitting reports shall be as soon as possible, may be based on the severity of the incident (see # 2,3) but shall not exceed more than 30 calendar days from the day of the incident
CIR and MLTSS Self-Direction Consider whether incidents involving members who self direct are tagged and tracked separate from the traditional systems Definitions of critical incidents may need to differ for individuals who are self directing and those in the traditional agency model Important to determine whether reported incident has a direct correlation to the fact that the individual was self directing and make sure appropriate staff are apprised of this Ensuring critical incident reporting is challenging when services are self directed and provided in the members home or family home, additional considerations include: Relying on redundant systems such as grievance/complaint reporting to identify incidents Sensitizing care managers/support brokers on how to elicit serious risk issues when visiting with members/representatives/family Providing hotlines for members to call to report problems Analyzing incident data related to self direction to detect trends Direct service workers and providers of goods and services become mandatory reporters
RESOURCES Forms and Documents: newjersey.wellcare.com/provider/formsnewjersey.wellcare.com/provider/forms Quick Reference Quick Reference Guides: newjersey.wellcare.com/provider/resourcesnewjersey.wellcare.com/provider/resources Clinical Practice Guidelines: Clinical Coverage Guidelines: WellCare Companion Guide: newjersey.wellcare.com/provider/claims_updatesnewjersey.wellcare.com/provider/claims_updates Provider Training: newjersey.wellcare.com/Provider/ProviderTrainingnewjersey.wellcare.com/Provider/ProviderTraining EDI team: Forms and Documents: newjersey.wellcare.com/provider/formsnewjersey.wellcare.com/provider/forms Quick Reference Quick Reference Guides: newjersey.wellcare.com/provider/resourcesnewjersey.wellcare.com/provider/resources Clinical Practice Guidelines: Clinical Coverage Guidelines: WellCare Companion Guide: newjersey.wellcare.com/provider/claims_updatesnewjersey.wellcare.com/provider/claims_updates Provider Training: newjersey.wellcare.com/Provider/ProviderTrainingnewjersey.wellcare.com/Provider/ProviderTraining EDI team: