1. 2018 Spring Provider Workshop
WV Bureau for Medical Services, WV
Children’s
Health Insurance Program, &
Molina
Medicaid
Solutions

2. Molina Operations Statistics
Statistics YTD 2018
Enrollment:
Number of Enrolled Providers:
32,576
Number of Enrollment Applications Received:
Average 365 weekly
Number of Enrollment Applications Completed:
Average 320 weekly
Enrollment Application Review Time for Clean/Completed Applications:
Average 5 days
Number of Applications Incomplete:
Currently 2,765

3. Molina Operations Statistics
Statistics YTD 2018
Calls:
Provider Inquiry:
Average 1,879 weekly with a 99.6% answered within 30 seconds
EDI:
Average 76 weekly with 100% answered within 30 seconds
Pharmacy:
Average 126 weekly with 100% answered within 30 seconds
Provider Enrollment:
Average 419 weekly with a 99% answered within 30 seconds
Recipient/Member:
Average 569 weekly with a 99% answered within 30 seconds

4. Molina Operations Statistics
Statistics YTD 2018
Claims Processing:
Number of paper checks issued:
Average of 292 weekly (M) 73 weekly (C)
Number of EFT’s issued:
Average of 2,984 weekly (M) 725 weekly (C)
Number of Claims Processed:
Average 946,961 weekly (M) 5,031 weekly (C)
Number of Claims Denied:
Average 127,595 weekly (M) 269 weekly (C)
Key: (M)=Medicaid
(C)=CHIP

5. Molina Website and EDI Portal
Molina Medicaid Solutions website & EDI Web Portal provides significant functionality for the WV Medicaid and WVCHIP provider community.
Molina Website and EDI Portal
WVMMIS.com
Web portal for WV Medicaid and WVCHIP.
Provides information to providers, trading partners, and some information for the public.
Contains many useful website links and documents.
Latest news and announcements.
Billing Instructions, User Guides, Companion Guides.
Learning Management System (LMS) web based training documents and eLearning videos.

6. Web Portal Sign In
In the Health PAS-Online banner click the ‘Sign In’ hyperlink.
Enter the trading partner:
User Name
Password
Read the ‘Attention HIPAA PHI’ statement and select the check box.
Click ‘Sign In’
If an incorrect password is entered five times, the account will be locked out.

7. Health PAS-OnLine Sign In
If your account becomes locked, the Account Self Unlock and Reset Password “Click here” link will assist with unlocking your account or you may contact the EDI Helpdesk.

8. Checking Member Eligibility
It is a best practice to verify eligibility for all Medicaid participants before a service is rendered by a provider.
This ensures the provider that the participant is eligible on the date the services will be rendered.

9. Eligibility continued…
Always make certain that the correct Billing Provider is selected. This is important for TPA accounts that manage multiple billing providers.
Find Member:
Enter two of the following criteria:
Member Identification (ID)
Name (Last and First Name)
Date of Birth
Social Security Number
After the search criteria has been submitted, the Eligibility Verification screen appears.

10. Eligibility continued…
After the search criteria have been submitted, the Eligibility Inquiry section verifies whether a member was eligible for a Medicaid program on the date(s) of service submitted in the request. This information does not guarantee eligibility or payment for the service rendered.

11. Eligibility continued…
According to the selected coverage code, the details of the coverage code are listed. If further clarification is needed, call Provider Services between 7:00a.m. to 7:00p.m.
Link to the WV User Guide for Eligibility Verification:
20Trading%20Partner%20Account%20-%20Eligibility%20Verification%20User%20Guide.pdf

12. PEA Portal
To access the enrollment application links, sign into the trading partner account (TPA) located at
Click Account Maintenance for a drop-down list and click Provider Enrollment hyperlink.

13. Provider Enrollment Updates
Online Provider Enrollment Limited Maintenance:
Addition/Removal:
Service Locations
Rendering Providers
Ordering/Referring/Prescribing Providers
Must be currently enrolled and active with WV Medicaid and/or WVCHIP.
Original documents must be received within 60 days.
Enrollment Tool – We have an address just for enrollment questions or assistance

14. Enrollment Updates continued…
Revalidation:
June of 2018
Based on your NPI
Five years from your most recent effective date
Physician Assistants:
Effective March 1, 2018
ORP to Rendering
To enroll as a Direct Provider, please contact Provider Enrollment
EFT (Electronic Fund Transfer)
Unenrolled Prescribers:
January 2019
Medicare requirement
Applies to all providers who prescribe medication
Including Nurse Practitioners, Physician Assistants, and Residents
WVCHIP Provisional Provider Enrollment:
Outreach
Updated Provider Agreement

15. MCO Provider Screening
Effective January 1, 2018 all providers rendering services to WV Medicaid members must be actively enrolled in the Molina system. This includes services rendered to members with an MCO. If you are a provider who is in this category, you must enroll with Molina or your claims submission and payment will be impacted.
All MCO “only” provider applications will follow the same federal and state enrollment guidelines currently in place for WV Medicaid and WVCHIP provider. Please choose MCO In-State or MCO Out-of- State Provider Enrollment link.

16. Claim Denials - Medicaid
Week Ending 04/08/2018 Weekly Top 10 Med/Dent Denied Claims Edits Report
Edit Code
Short Edit Description
Sum of Unduplicated Number of Claims with Edit
Sum of Total Billed Amount
205
Benefit requires UM
14393
$10,833,312.64
522
Duplicate Claim Line (Same Provider/Member/DOS/CPT(Rev))
3981
$ 3,643,922.86
532
Duplicate Mem/DOS/Service code/Pay To/Rendering Phys/Modifier
3932
$ 3,616,121.10
238
Invalid Medicare Action Code
3369
$ 1,793,096.18
153
PCP is solely responsible for service: pay as capitated
2498
$ 1,221,569.68
378
No COB Amount on claim
1646
$ 1,235,546.23
202
No Benefit for Service
1411
$ ,423.59
6037
Medicare Crossover QMB processing rules applied
817
$ ,057.39
272
Member does not have coverage code required on benefit
748
$ ,906.60
606
UM Not found
414
$ ,090.02

17. Claim Denials - WVCHIP
Week Ending 04/08/2018 Weekly Top 10 CHIP Denied Claims Edits Report
Edit Code
Short Edit Description
Sum of Unduplicated Number of Claims with Edit
Sum of Total Billed Amount
522
Duplicate Claim Line (Same Provider/Member/DOS/CPT(Rev))
138
$ 94,967.52
532
Duplicate Mem/DOS/Service code/Pay To/Rendering Phys/Modifier
111
$ 84,715.12
376
Contract Term Restriction Group Validation Failed 22
$ 2,658.95
203
Benefit is excluded from benefit plan 20
$ 29,842.37
205
Benefit requires UM 14
$ 69,640.43
202
No Benefit for Service
$ 3,963.82
606
UM Not found 11
$109,006.12
367
Contract term requires UM 10
$ 2,385.72
150
No contract term found for service 9
$ 17,628.35
507
Revenue Code Requires HCPCS
$ 25,560.77

18. Claim information continued…
Long Term Care:
Members eligible for Long Term Care services will have a different eligibility coverage code.
LTC claims will be denied if the member is not eligible for either of the following two Rate Codes:
AMLTN
AMLTI

19. Contact Information
Our website provides valuable contact information as well as office hours and office closures.
Phone Support: Local and toll-free phone numbers
(304) or (888)
Secure Messaging: Send a secure
Call Back: Request a call back from a call rep who can review the issue ahead of time
Web Chat: Chat real time via the internet with a call rep during business hours
Grievance & Appeals: Submit online, by mail, or fax

20. Provider Field Representative Map

21. 2018 Fall Provider Workshop
Dates and Locations
September 10th: Waterfront Hotel, Morgantown
September 11th: Holiday Inn, Martinsburg
September 13th: Oglebay Resort/Pine Room, Wheeling
September 14th: Grand Pointe Conference Center, Vienna
September 17th: St. Mary’s Conf. Center, Huntington
September 18th: Tamarack, Beckley
September 19th: Holiday Inn & Suites, South Charleston
September 20th: Days Inn, Flatwoods