March 2021 Provider News
Date: 03/24/21
In This Issue
- Quality - Postpartum/Newborn Visit/LSC Evidenced Based Practices
- Payment Integrity - DRG Audit - Technical Denials Policy
- Apple Health Core Connections - Upcoming workshops and webinars
- Updates/Trainings - UM PA and Clinical Policy updates; documentation needed for Prior Authorizations, UM IP Change in Condition Reminder, COVID-19 Special Edition Faxblast, Washington State Cell Phones Companies providing Lifeline services to eligible clients, HCA Telehealth Webinar, HCA Behavioral Health Facilities (BHF) round three funding application is open
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Notice 1: Quality
ADHD FOLLOW-UP in KIDS:
Children with a new prescription for ADHD medication should receive a follow-up visit within 30-days of starting the medication.
ASTHMA and 90-DAY MEDICATION REFILLS:
Moving members with asthma to 90-day refills may increase their maintenance medication adherence.
MAMMOGRAMS:
"If possible, and when it does not unduly delay care, consider scheduling screening exams prior to the first dose of a COVID-19 vaccination or 4-6 weeks following the second dose of a COVID-19 vaccination."
The Society for Breast Imaging advised that COVID-19 vaccine may cause lymph nodes to swell, creating false-positive findings and increasing patient anxiety
Society for Breast Imaging full guidelines (PDF).
Better Patient Outcomes through Evidence Based Practices
This Month: Parent-Child Interaction Therapy (PCIT) (EPA Number: 870001578, SERI 860186000)
Who benefits: Children 2-7 years old and parents and/or caregivers
Improves/helps with these outcomes:
- Decrease in child disruptive behaviors
- Increased appropriate parenting skills
- Increased appropriate discipline
- Increased supportive family communication and improvement in relationships
- Increased placement stability
- Improvement in parent/child bond accomplished through positive interactions between parent/child
Brief description of intervention: Parent-child interaction therapy (PCIT) is an evidence-based treatment for young children with emotional and behavioral disorders that places emphasis on improving the quality of the parent-child relationship and changing parent-child interaction patterns. Children and their caregivers are seen together in PCIT. Most of the session time is spent coaching caregivers in the application of specific therapy skills. Therapists typically coach from an observation room with a one-way mirror into the playroom, using a “bug-in-the-ear” system for communicating to the parents as they play with their child. Concluding each session, therapist and caregiver together decide which skill to focus on most during daily 5-minute home practice sessions the following week.
Cultural adaptations available? YES
If you are a provider practicing an EBP make sure and use the accompanying EPA or SERI number when you bill Coordinated Care.
Mental Health providers should use the Reporting Guide for Evidence-based Practices
Physical health providers who deliver these services should include the appropriate EPA number from the HCA Provider Billing Guides and Fee Schedules, Mental Health Services.
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Notice 2: Payment Integrity
DRG Audit – Technical Denials Policy
This is a new policy that was approved and effective as of 7/1/2021 for both Apple Health and Ambetter
Policy Overview
The purpose of this policy is to define criteria for when a post-payment technical denial and claim recovery will occur when a provider does not respond to requests for medical records to complete a post-pay Diagnosis-Related Group (DRG) audit of inpatient hospital claims.
The scope of this policy encompasses all contracted and non-contracted providers that bill Coordinated Care of Washington, Inc. and Coordinated Care Corporation (collectively CCW) for services performed on members of CCW across all markets: Medicaid, Marketplace, and Medicare.
Application
CCW or our contracted vendors conduct retrospective reviews for inpatient claims to ensure claims were paid in accordance with national correct coding standards, based on ICD-10-CM Official Guidance for Coding and Reporting. These guidelines have been approved by the organizations that make up the Cooperating Parties for ICD-10-CM: The American Hospital Association (AHA), the American Health Information Management Association (AHIMA), the Centers for Medicare and Medicaid Services (CMS), and the National Center for Health Statistics (NCHS). The guidelines are published by the AHA and ICD-10-CM Coding Clinic publications.
To facilitate these reviews, we require that providers send in medical records for cases selected for post-payment DRG audits. WAC 182-502-0020(5) requires all MCO-contracted providers must: “make charts and records available to the Medicaid agency, its contractors or designees, and the United States Department of Health and Human Services (DHHS) upon request, for six years from the date of service or longer if required specifically by federal or state law or regulation.”
Failure to submit medical records upon request may result in a technical denial and recovery of payments made on the claim.
Procedure
CCW or our vendor will send a written request for medical records for DRG-paid claims selected for post-payment review. Provider must return all documents requested to address noted in the written request within 30 calendar days.
If records are not received, a reminder notice will be sent to providers allowing an additional 30 calendar days to submit medical records.
If records are not received after the second request, CCW may issue a technical denial on the claim and recover any payments made.
After the technical denial is issued and claim payments are recovered, the provider may appeal the technical denial by providing the requested medical records for the greater of 6 months or remainder of their allotted timely adjustment window from the date of the second reminder letter.
After 6 months or timely adjustment window has expired from the date of the second reminder letter, medical records will no longer be accepted and the technical denial will stand.
Documentation Requirements
Coding and Modifier Information
This payment policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT® codes and descriptions are copyrighted 2020, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this payment policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.
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Notice 3: Apple Health Core Connections
On January 1, 2019, Coordinated Care became the single managed care organization to administer the Integrated Managed Care Apple Health Foster Care program in collaboration with the Health Care Authority and Department of Children Youth and Families. This program serves children and youth in foster care, adoption support, alumni of foster care (ages 18-26), and children reunified with their parents. Coordinated Care’s program is named “Apple Health Core Connections.” You can reach us at 1-844-354-9876 or AHCCTeam@coordinatedcarehealth.com.
WEBINARS/TRAININGS:
The Coordinated Care Community Education Team serves providers and their staff with training to support the needs of the Medicaid population. The CE Team can offer training on topics such as Adoption Success, Trauma Informed Care, ACEs, Resilience, and Secondary Trauma and Self Care. To request more information or to schedule no-cost training please email: communityeducation@coordinatedcarehealth.com.
Visit Centene’s Clinical Provider Training website to find upcoming National Provider Webinars. These webinar events are available to any Centene provider, stakeholder, community member and/or staff. Webinars are on clinical topics appropriate for web learning and usually offer free continuing education hours. Click on the “National Provider Webinars” button on the right side of the page and scroll down to find a complete listing. Here are a few coming up in February:
- Suicide Risk- A Clinical Perspective Module 1. Clinicians learn to identify warning signs and risks of suicide. They also learn about protective factors, which ensure vulnerable people are supported and connected with others during difficult times, thus making suicidal behaviors less likely. 1.5 CE hours available for NBCC. April 7, 2021, 8am-10am. Register Here.
- Moving from Cultural Competence to Cultural Humility. This training is designed to create an understanding of Cultural Humility and how it relates to Cultural Competence. Specific attention will be given to the role of implicit and explicit bias in interpersonal interactions. 2 CE hours for NBCC. April 8, 2021, 12pm-2pm. Register Here.
- Co-Occurring Substance Use and Mental Health Disorders. Behavioral health providers learn the relationship between substance use and co-occurring mental health disorders and methods to screen and assess co-occurring disorders. The course also offers guidance on treatment options. 1.5 CE hours available for NBCC. April 14, 2021. 9am-10:30am. Register Here.
Using Integrated Behavioral Health to Reduce Healthcare Disparities: Primary Care Behavioral Health Strategies Serving Rural Populations. The Northwest MHTTC is excited to collaborate with Dr. Phillip Hawley from the Yakima Valley Farm Workers Clinic to deliver a live webinar as part of our Integrated Care webinar series. This training will outline the foundations of the primary care behavioral health (PCBH) model of integration and discuss a variety of clinical applications to why meeting patients where they are at and working within the primary care system provides holistic and quality to patient care. The presenter will also provide statistics and case examples highlighting how this approach covers gaps in our healthcare system and works towards true population health strategies. March 25, 2021 2pm-3pm. Register here.
Washington Chapter American Academy of Pediatrics. Educating Providers in Equity and Racism. Register here. March 31, 2021 7am-8am
Seattle Children’s Presents: A Virtual CME Event. Caring for Gender Diverse Youth. Register here. April 6, 2021 6pm-7:30pm
Interoperability: Removing Barriers to Value-Based Success. Join Bree Collaborative and the Washington Health Alliance as we tackle the topic of “interoperability” for the second of a four-part “Framework for Action” webinar series on the accelerators for change to drive value-based success. Hear from national and local leaders to understand how we move interoperability from an “obstacle” to an “enabler” of value-based success for providers and patients in Washington State. April 15, 2021, 10am-11:30am. Register here.
Snohomish County Human Services Behavioral Health presents: Helping Children, Families and You Cope with Crisis During the COVID-19. This session, intended for health care providers and other community-based professionals, will summarize the principles of psychological first aid and common reactions that may be seen in any crisis event, including the current pandemic. Practical advice will be shared on how to provide support to children and families during the current pandemic. The session will underscore the need for professional self-care and highlight some of the barriers as well as some potential solutions. May 4, 2021, 9:30am-11am. Register here.
Washington State Saying it Out Loud Conference. The conference is sponsored by the Health Care Authority Division of Behavioral Health and Recovery. The Annual Saying It Out Loud (SIOL) Conference focuses on information sharing and networking to improve behavioral health services and decrease disparities faced by lesbian, gay, bisexual, transgender, and questioning (LGBTQ+) individuals. Featured speaker: Justice G. Helen Whitener, Associate Justice, Washington State Supreme Court. May 26, 2021. Registration is free. Register here.
INTERESTING ARTICLES & RESOURCES:
April is National Child Abuse Prevention Month. See the Children’s Bureau’s 2021 Outreach Toolkit here for resources.
- National Hispanic and Latino Mental Health Technology Transfer Center Network. Trauma-Informed Care Model for Immigrant Hispanic and Latino Clients. (15 March 2021). The trauma-informed care model acknowledges the prevalence and impact of trauma on clients and the importance of developing culturally responsive and trauma-informed mental health services.
- Reach Out and Read. Diverse and Inclusive Books. This list features a sampling of titles to assist families in selecting books to share with their young children.
- The AIMS Center is offering All Patients Safe: Suicide Prevention Training for Medical Professionals at no-cost to Washington State providers and client facing staff through November 2021. $25 cost for CME/CNE credit. All Patients Safe offers an engaging and informative option for providers and client-facing staff to become better skilled at suicide prevention. Perspectives of real patients coupled with practical skills help medical providers transfer what they learn to their practice and community. This training meets Washington State's licensure requirements for health care providers to assist in reducing suicide through improved trainings. Learn more and register here.
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Notice 4: Updates/Reminders
HCA has updated its COVID-19 vaccine administration policy in outpatient hospital savings:
COVID-19 vaccine administrations for dates of service prior to February 15, 2021, performed in an outpatient hospital (OPPS) setting should be billed with the revenue code specific to the location in which the vaccine was administered, not the vaccine administration revenue code.
COVID-19 vaccine administrations with dates of service on or after February 15, 2021, performed in an outpatient hospital (OPPS) setting may be billed using revenue code 0771.
This policy does not apply to other vaccines. This policy is applicable to both fee-for-service (FFS) providers and Health Care Authority (HCA)-contracted managed care organizations (MCOs).
HCA revised the Apple Health (Medicaid) COVID-19 vaccine clinical policy to reflect this change.
Home Health, Physical Therapy, Occupational Therapy and Speech Therapy
Any visits occurring between December 1, 2020 through April 30, 2021 do not require prior authorization for all providers. Authorization requirements are temporarily suspended in an effort to better support the needs of our members during this time.
On May 1, 2021, the prior authorization requirement for Home Health, Physical Therapy, Occupational Therapy and Speech Therapy will resume.
Interpretation of ESHB 2642
The HCA would like to provide additional detail to our interpretation of ESHB 2642—this additional guidance allows for voluntary prior authorizations (PA) for admissions into residential as well as withdrawal management substance use disorder treatment. For residential SUD treatment, the first two business days, excluding weekends and WA State holidays, are automatically covered, therefore a prior authorization must authorize the period after that. For withdrawal management, the first three calendar days are automatically covered, therefore a prior authorization must authorize the period after that. Any prior authorization granted must be for days after the initial required payment period i.e. for RTF PA for 5 days means, 5 days after the initial 2 business days so a total of 7 days would be paid for by the plan & the clinical material provided by the referring provider obtaining PA, would need to support medical necessity for the level of care being requested for those 5 days being pre-authorized.
Note: prior authorization cannot be required, and it is up to the payer to determine if prior authorization is appropriate.
Per the legislation there are no exclusions for outlined expectations & requirements. Per Section 4 (2)(c)(i)-(iii) the admitting behavioral health agency is required to provide the health plan with notice of admission within 24 hours, its initial assessment, and initial treatment plan for the client; This is to be provided within two business days of admission into residential treatment, excluding weekends and WA State holidays, or within three days in the case of a behavioral health agency that provides withdrawal management services.
Enteral Nutrition Prior Authorization Changes coming for all Enteral Formulas starting on June 1, 2020
Starting June 1, 2020, Coordinated Care will require Prior Authorization for enteral nutrition that are administered orally and/or thru a feeding tube. By having this authorization in place, it will help assist with the claims issues that some providers are having when their patients are receiving both oral and tube formula for nutritional support.
Change in Condition Reminder
If a member remains inpatient on medical necessity denied status and has a change in their medical condition (i.e. stroke, cardiac arrest, fall with injury, etc.), providers are able to use the Notice of Change in Condition form (included with the denial letter) to notify Coordinated Care and request a review for medical necessity based on new medical conditions. We request within 5 business days of the identified change back to inpatient status. Please provide notification within 5 business days of the event (change in condition).
References
Washington State Health Care Authority. Enteral Nutrition Billing Guide (PDF).
Revision effective January 1, 2020.
The authorization forms can be found in the Provider Resources section of Coordinatedcarehealth.com & should be faxed to (877) 212-6669, or submitted electronically via the secure provider portal.
Therapy Prior Authorization Changed for all Members 20 years and younger effective 3/1/2020.
As of March 1, 2020, Coordinated Care is now allowing providers to request up to 48 visits for each therapy (PT/OT/ST) for a 6 month span after initial visits have been completed for members that are 20 years and younger.
Fax information received by providers to Coordinated Care for Prior Authorization requests
As a reminder, Coordinated Care does require provider orders with either a handwritten or electronic signature. Also please ensure all clinical including patient identifiers are present in request for HIPAA verification by Coordinated Care.
Clinical Policy Updates
Below are policies that received updates as part of our regular monthly review.
Effective July 1, 2020, our policies for Outpatient Testing for Drugs of Abuse will change and HCPCS G0482 and G0483, definitive drug tests of 15 or more drug classes, will be considered not medically necessary. You will find the policies, including a description of the revisions, posted on the policy site.
Policy Number | Policy Title | Line of Business |
WA.CP.MP.50 | Outpatient Testing for Drugs of Abuse | Apple Health |
CP.MP.50 | Outpatient Testing for Drugs of Abuse | Ambetter |
The below policy changes are effective May 1, 2020. You will find the policies, including a description of the revisions, posted on the policy site.
Policy Number | Policy Title | Line of Business |
|---|---|---|
CP.MP.31 | Cosmetic and Reconstructive Surgery | Apple Health & Ambetter |
CP.MP.89 | Genetic Testing | Apple Health & Ambetter |
CP.MP.109 | Panniculectomy | Apple Health & Ambetter |
CP.MP.142 | Urinary Incontinence Devices and Treatments | Apple Health & Ambetter |
CP.MP.145 | Electric Tumor Treating Fields | Ambetter |
CP.MP.183 | Novel Coronavirus Testing | Apple Health & Ambetter |
Washington Partnership Access Line
The Partnership Access Line (PAL) supports primary care providers (doctors, nurse practitioners and physician assistants) with questions about mental health care such as diagnostic clarification, medication adjustment or treatment planning. Our child and adolescent psychiatrists are available to consult during business hours.
Partnership Access Line (PAL)
The Partnership Access Line (PAL) is Washington State’s telephone-based child mental health consultation system funded by the state legislature. PAL employs child psychiatrists, child psychologists, and social workers affiliated with Seattle Children’s Hospital to deliver consultation services. The PAL team is available to any primary care provider throughout Washington State.
Primary Care Providers (PCP) may call 866-599-7257 between the hours of 8:00 a.m. and 5:00 p.m. for any type of child mental health issue that arises with any child, not just Coordinated Care members. Network prescribers can bill HCA for their time spent engaging in a Second Opinion Network (SON) review by submitting a claim using procedure code 99441. Additional information regarding the PAL may be found here.
PAL Family Referral Assistance Line
PAL services include Washington’s Mental Health Referral Assist Service. This program facilitates referrals to children’s mental health services and other resources for parents and guardians with concerns related to the mental health of their child. Facilitation activities include assessing the level of services needed by the child within one to two weeks of receiving a call from a parent or guardian, and identifying mental health professionals who are in network with the child’s health plan and accepting new patients. This service coordinates contact between the family and mental health provider and provides post-referral reviews to determine if the child still has unmet needs. The PAL Family Referral Line is (833) 303-5437.
PAL for Moms
PAL for Moms provides psychiatric consultation to health care providers on any mental health-related questions for members who are pregnant, in the first year postpartum, or who have pregnancy-related complications (e.g. pregnancy loss, infertility). PAL for Moms is staffed to respond to calls between 1:00 p.m. and 5:00 p.m. on weekdays. The PAL for Moms line is (203) 685-2924. Additional information.
Washington State Cell Phones Companies providing Lifeline services to eligible clients
Link.
Lifeline is the FCC's program to help make communications services more affordable for low-income consumers. Lifeline provides subscribers a discount on monthly telephone service, broadband Internet access service, or voice-broadband bundled service purchased from participating providers.
Lifeline is available to eligible low-income consumers in every state, commonwealth, territory, and on Tribal lands. The Lifeline program is administered by the Universal Service Administrative Company (USAC). USAC is responsible for data collection and maintenance, support calculation, disbursements, and assisting consumers with Lifeline eligibility and enrollment for the program. USAC's website (https://www.usac.org/lifeline) provides additional information regarding the program, including program requirements.
The following Lifeline service providers are active in Washington:
- Access Wireless
- Assurance Wireless
- Budget Mobile
- enTouch Wireless
- Life Wireless
- Safelink Wireless
- Total Call Mobile
- Yourtel Wireless
Below is the list and of cell phone companies and their websites, are Lifeline services providers in WA:
Access Wireless | https://www.freegovernmentcellphones.net/free-cell-phone-providers/access-wireless |
Assurance Wireless | |
Budget Mobile | https://www.freegovernmentcellphones.net/free-cell-phone-providers/budget-mobile |
enTouch Wireless | https://www.entouchwireless.com/states/washington-lifeline-free-phone-service |
Kroger Wireless | |
Life Wireless | https://www.freegovernmentcellphones.net/free-cell-phone-providers/life-wireless |
Q Link Wireless | |
Safe Link | |
Solix/Assurance Wireless | |
Tag Mobile | |
YourTel America | https://www.freegovernmentcellphones.net/free-cell-phone-providers/yourtel-wireless |
How Do Clients Apply For The Lifeline Subsidy?
Federal regulations (47 CFR Part 54, sec. 54.400) allow one Lifeline subsidy per household. This means that client must choose whether they want the subsidy applied to a landline or cell phone.
Landline – The client contacts their local landline phone service provider and requests a Lifeline Application. Upon determination of this client’s eligibility, the local phone company will apply Lifeline subsidy to the client’s phone bill.
Cell phone – The client must apply with one of 9 Lifeline cell phone providers in Washington. Upon completion of a phone company’s application and determination of the client’s eligibility for Lifeline services, the client will receive a cell phone by mail.
In response to Governor Jay Inslee’s directive, the Washington State Department of Health, Health Care Authority, and members of the Hep C Free Washington Coordinating Committee are striving to eliminate hepatitis C by 2030. Baby Boomers (those born from 1946 to 1964), people who inject drugs, people who have experienced incarceration, people living with HIV, African Americans, and Native Americans are disproportionately impacted by Hepatitis C more than others.
Hepatitis C (HCV) cases among people who use drugs, including people who inject drugs, continue to rise, so we are calling on health care providers to test and treat people who use drugs (active or prior use) as a primary strategy to eliminate HCV in Washington.
Learn more about Washington’s plan to eliminate HCV by 2030 online at DOH Hep C Free and HCA Eliminating Hepatitis C. Here you can learn about:
- How to participate in the Hep C Free Washington planning and implementation.
- The state of HCV in Washington.
- Best practices related to treating people who use or inject drugs for HCV.
- The latest clinical guidance and best practice recommendations.
Apple Health (Medicaid) coverage for curative treatment. Health Care Authority (HCA) Telehealth Webinar
Telehealth has become an important way for providers to continuing providing services in the context of the COVID-19 pandemic. HCA is holding this webinar to:
- Provide an overview of telehealth for Apple Health (Medicaid)
- Discuss billing and policy
- Discuss tools you can use
- Answer questions that may be concerning you
Who is the webinar for?
The webinar is for any Apple Health provider that wants to learn more about how to effectively offer these services.
When is it, and how do I register?
The webinar will be held Thursday, April 30, 2020 at noon (Pacific). Participants can register directly through this notification.
You can also register by visiting HCA’s COVID-19 information page. You will see several webinars in our resource section. This webinar is titled: Apple Health (Medicaid) telehealth policy.
Behavioral Health Facilities (BHF) round three funding application is open
The Department of Commerce is soliciting applications from eligible behavioral health facility organizations. Awardees will receive funds to implement behavioral health capital projects.
A total of $6 million is available for this round in two categories:
- $4 million is provided solely for competitive community behavioral health grants to address regional needs.
- $2 million is provided solely for enhanced service facilities (ESF) for long-term placement of patients discharged or diverted from the state psychiatric hospitals and that are not subject to federal funding restrictions that apply to institutions for mental diseases.
The Behavioral Health Facilities (BHF) Program’s competitive funding rounds are open to nonprofits, public entities, tribes and for-profit businesses. Nonprofit and for-profit business applicants must be registered in the state of Washington.
Smoking and Tobacco Cessation
Coordinated Care (Apple Health) and Apple Health Core Connections (Foster Care) have smoking and tobacco cessation programs. For our members who are ready to quit, we have health coaches to provide support.
Members may refer themselves or providers can refer members to these programs by calling the numbers below:
Washington Apple Health (Medicaid) – 1-866-274-5791
Apple Health Core Connections (Foster Care) – 1-844-882-3827
Tobacco cessation medications are outlined on pages 204-205 of the Preferred Drug List (PDL) located on our website under Pharmacy. A prior authorization is required for some of these medications.
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Remember to check the Provider News section of the Coordinated Care website to refer back to previous fax notices as well as many other informational updates!
To be removed from these notices or to request to be added to our email list for these notices, please reply to CoordinatedCareProvider@centene.com.
Thank you for being our partner in care and helping us collectively improve the health of our members. Please reach out to your Provider Services team if you have questions about any of these announcements or need more information.
Coordinated Care Provider Services: (877) 644-4613.