December, Volume 308

Rhode Island Medicaid Program

PROVIDERupdateVolume 308 September, 2018

THIS MONTH’S FEATURED ARTICLES

Attention:

Inpatient Hospital Providers

DRG Update on Page 9

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Inside This Issue:

See page 2 for

interactive

Table of Contents.

See page 9

Attending Provider Requirements

See page 3

Important Update

Ordering, Prescribing, Referring (OPR) Provider

Volume 308

Rhode Island Medicaid Program

Volume 308

TABLE OF CONTENTS

Article Page

Ordering, Prescribing, Referring Provider 3

Transition to DXC email 4

Healthcare Portal Reference Guides 4

Managing your Trading Partner ID 4

Healthcare Portal Eligibility 5

Patient Share on the Healthcare Portal 5

Provider Electronic Solutions Password Reset 6

Provider Electronic Solutions Software Version 2.10 6

Dental Changes 7

Home Care Information 8

Inpatient DRG Rate Increase 9

Attending Provider Requirement 9

Pharmacy Spotlight—Meeting Schedule 10

Pharmacy—Drug Prior Authorization Forms 10

Pharmacy—Tobacco Cessation 10

Pharmacy—Hepatitis C Policy 11

Back to School Means Sharing the Road 12

RI Medicaid EHR Incentive Program Update 13

RIQI—Stay Social 14

RIQI— TCPi—National Expert Panel Conference Roundup 14

RIQI— TCPi—Educational Events 15

PROVIDERupdate September, 2018 Volume 308

For quick access to an article, click on the title.

RI Medicaid

Customer Service

Help Desk for

Providers Available Monday—Friday

8:00 AM-5:00 PM (401) 784-8100

for local and long distance calls

(800) 964-6211for in-state toll calls

Page 3 September, 2018

Important Update - Ordering, Prescribing, Referring (OPR) Provider

What is happening? RI FFS Medicaid began requiring that this information be submitted on affected claims on October 1, 2015, to ensure all orders, prescriptions or referral for items or services for Medi-caid beneficiaries originate from appropriately licensed practitioners who have not been ex-cluded from Medicare or Medicaid. It is the responsibility of the RI FFS Medicaid provider rendering the service to obtain the NPI of the Ordering, Prescribing, and Referring Provider (OPR) and confirm that the OPR provider is enrolled in the RI FFS Medicaid Program.

Why is this happening? The Affordable Care Act (ACA) regulation at 42 CFR 455.410 requires ordering, prescribing or referring providers be enrolled in the Medicaid Program. The OPR requirement is for both the following scenarios: The claim is primary to RI FFS Medicaid.

The claim is secondary to RI FFS Medicaid.

What options are there for prescribers? If you are a prescriber, check your enrollment status. If you are currently enrolled as a RI FFS Medicaid Provider, you are all set! If you are not enrolled, you can:

Enroll as a “billing” provider.* Providers that submit claims for services rendered* Providers are eligible for reimbursement from RI FFS Medicaid.

Enroll as an “ordering, prescribing or referring” provider* Providers are not eligible for RI FFS Medicaid reimbursement.* Providers can “order, prescribe or refer” services. Examples include:

ordering lab work, writing a prescription or referring a beneficiary for a service.* Limited information is required for enrolling as an “OPR” provider

Where can I enroll? Providers interested in enrolling as a “billing” provider or an “OPR (non-billing)” provider can follow this link: https://www.riproviderportal.org to complete the online process. A digital signature is required. User guides for both types of enrollment, “billing” or “OPR (non-billing)” are available through the same link.

Questions? Please contact the Medicaid FFS Provider Customer Service Help Desk at 401-784-8100 and for in-state toll calls, 800-964-6211.

Page 4 Volume 308

Transfer of Trading Partner/Master User Privileges for the Health Care Portal If your Trading Partner Administrator is preparing to leave their current role of managing the HC Portal the Master User can complete a One Time Transfer of their privileges to the Health Care Portal by taking the following steps. Login to the portal select “Profile” on the home page and update the email on file to

the new email user’s address. Update the answers to the current security questions to be generic answers. Ex; Apple,

baseball, etc. Change the password to a generic password (passwords can only be updated once a

day). Ex; Pass2018 Give the new questions with generic answers to the new Admin. The new Admin/User can now login with the above information and update to reflect

their personal information.

Managing your Trading Partner Id

If you use email to contact individuals at DXC Technology, please note that the old

@hpe.com extension will not forward to your intended contact’s email box after

September 30, 2018.

Please begin using the person’s DXC email address by replacing @hpe.com with @dxc.com

as soon as possible.

All Providers

Healthcare Portal Reference Guides

If you are a new to Rhode Island Medicaid and need assistance enrolling as a Trading Part-ner for the Healthcare Portal then check out Self Paced Users Guides on the EOHHS web-site. If you are you a new or current user that needs assistance navigating the Healthcare Portal then check out the Quick Reference Guides on the EOHHS website.

Page 5 September 2018

Eligibility Search on the Healthcare Portal

Healthcare Portal Eligibility Search The Executive Office of Health and Human Services has made modifications to the eligibility function on the Healthcare Portal. The eligibility function will now display 2 months of pro-spective eligibility on the HC portal. The Effective To date cannot be more than 2 months into the future. For formatting pur-poses, please review the example of dates displayed below.

Eligibility must still be checked on the date the service is provided. Disclaimer Provider understands the prospective eligibility date is not a guarantee of future eligibility.

Also, the prospective eligibility, does not guarantee payment for services. Eligibility must be

rechecked on the date of service.

The Health Care Portal is used to access business actions with RI Medicaid such as verifying eligibility, accessing RA, checking claims, prior authorizations and is now also available to view patient share (cost of care). From the user’s home page, you will have access to Patient Share in the orange bar across the top of the page if you already had access to Eligibility and Claims Search. To begin the search the user must enter the member’s ID, Start Date and End Date. Then choose the Share Type (Assisted Living, Home Care, Nursing Home, Hospice, Pace, Shared Living) from the drop down list. The date range may be 12 months prior to today and up to 2 months in the future, with a maximum of a 3 month date span. Home Care members can receive services from more than one provider for the same peri-od of time. The single home care value displayed on the web is the amount for that period of time and is not specific to a provider.

Patient Share on the Healthcare Portal

Page 6 Volume 308

Provider Electronic Solutions Software (PES) Users

Are you ready to do your Medicaid billing but have forgotten your password to the PES billing software? Have you entered your password too many times? During these times, when you don’t know your password to access the PES software, the Provider Representative Team can provide you with a temporary password. Instructions for resetting your PES password can be found on the EOHHS website.

We are presently running PES version 2.10. There are two ways you can check which ver-sion you are on:

Upon logging in to the software the current version will be displayed. Once you have logged in to the software select “Help” and “About” from across the top toolbar and the current version will be displayed Please remember upgrades must be done in sequential order, or risk corruption of your database. Providers can retrieve Upgrades from the EOHHS website.

If you should need assistance with your upgrade, please email RI EDI Services.

All Provider Electronic Solutions Software (PES) Users

Page 7 September, 2018

Attention: Dental Providers

Rhode Island Medicaid implemented the following dental procedure changes effective for dates of service beginning July 1, 2018. Resin-based posterior restorations for Adults D2391 – Resin-based composite-one surface, posterior D2392 – Resin-based composite-two surfaces, posterior D2393 – Resin-based composite-three surfaces, posterior D2394 – Resin-based composite-four surfaces, posterior

The restriction of this benefit to under 21 is now removed

Frequency limitation for each tooth- once every 24 months, unless prior authorization is provided

No prior authorization is required unless being redone within the frequency limitation

May not be performed as a preventive procedure

Removal of non-carious or non-defective amalgam restorations and replacement with composite resin is not a covered benefit and subject to post-procedural review

Removal and replacement of amalgam restorations solely for esthetic concerns is not a covered benefit subject to post-procedural review

Removal and replacement of amalgam restorations based on a perceived health benefit is not a covered benefit and subject to post-procedural review.

Providers are advised that amalgam restorations have a strong record of longevity and composite restorations should be performed only if the anticipated longevity is comparable. As part of treatment decision, providers are advised to inform patients about the longevity of this type of restoration and the Medicaid billing limitation. The reimbursement for two extraction codes will be increased to $73.00: D7140 – Extraction, erupted tooth or exposed root (elevation and/or forceps removal) D7210 - Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth Periodontics for Adults D4341 - Periodontal scaling and root planing - four or more contiguous teeth or bounded teeth spaces per quadrant D4342 - Periodontal scaling and root planing – one to three teeth, per quadrant D4346—Scaling in presence of generalized moderate or severe gingival inflammation-full mouth

Scaling and root planing for adults is permitted with prior authorization. Approval will indicate which quadrant(s) are approved as applicable.

Prior authorization should be submitted to provide evidence of medical necessity and prognosis.

For D4341 and D4342, Prior authorization requires submission of probing depth and radiographs. Expectation is moder-ate bone loss with radiographic calculus

For D4346, radiographs only are required, with expectation of radiographic calculus. Photographs will also be accepted if radiographs do not adequately reflect the level of calculus

Only 2 quadrants are permitted per visit for D4341; It is anticipated that providers will perform 2 quadrants at a visit unless char notes reflect high degree of complexity. Applicable to all ages.

Claims for procedures D4341 and D4342 should be submitted with the total number of units for each date of service on one detail only.

Volume 308 Page 8

Attention: Dental Providers continued

Fluoride Treatment for Adults D1206 Topical Fluoride Varnish (prophylaxis not included) - Therapeutic application for moderate to high caries risk patients. D1208 Topical Application of Fluoride One of the following caries risk assessment procedure codes must be listed on claims submitted for topi-cal application of fluoride procedure code D1206 or D1208. The codes should be billed at zero dollars ($0). The assessment must have been performed within the six months directly preceding the date of service for D1206 or D1208. Providers should perform a caries risk assessment for patients using a Caries Risk Assessment form of their choice. In typical use, a copy is provided to the patient, and a copy is kept in the record. D0602 – Caries risk assessment and documentation, with a finding of moderate risk, as documented on Caries Risk Assessment form D0603 – Caries risk assessment and documentation, with a finding of high risk, as documented on Car-ies Risk Assessment form ADA Caries Risk Assessment Form can be found on here on the ADA website.

If you have questions please contact customer service at 401-784-8100 and for in-state toll calls, 800-964-6211. You may also contact Sandra Bates, Provider Representative at 401-784-8022 or sandra.bates@dxc.com.

The enacted state fiscal year 2019 budget included a 10% increase for Medicaid fee-for-service rates for personal care attendant services provided by home care providers, home nursing care providers, and hospice providers. It also included a 20% increase for Medicaid fee-for-service rates for skilled nursing, therapeutic services, and hospice care for these same providers. The Executive Office for Health and Human Services (EOHHS) has posted the State Plan Amendment (SPA) necessary to implement these rate increases for public comment. Once approved by the Centers for Medicare and Medicaid Services (CMS), EOHHS will implement these rate increases retroactively to July 1 as required by the enacted budget.

Home Care Information

Page 9 September 2018

The inpatient hospital DRG base rate has been increased to $11,723.00, effective 7/1/2018. The new base rate represents a 2.7% increase, (rounded to the nearest dollar), over the ex-isting base rate of $11,415.00. Previously DRG-paid inpatient claims with dates of service on and after 7/1/2018 will be adjusted and reprocessed at the new rate. The adjustment is scheduled for August 27, 2018 to be included in the September 14, 2018 remittance advice. The DRG Calculator located on the EOHHS website has been updated to reflect the change. If you have questions please contact the Customer Service Help Desk at 800-784-8100 or for in-state toll calls 800-964-6211 or your Provider Representative.

Attention: Hospital Providers—Inpatient

Attending Providers-Hospice, Inpatient, Nursing Home, Outpatient, Professional and Home Health The Rhode Island Medicaid program would like to remind providers that the Attending Provider field on claims is a required field. Any attending provider listed on a claim must be enrolled/registered with RI Medicaid. Hospice, Inpatient, Nursing Home, Outpatient, Professional and Home Health providers are re-quired to submit with an attending provider on all claims. RI Medicaid will soon begin editing claims for attending provider information. The exact date is still to be determined. After the confirmed date, claims submitted without an attending provid-er or with a provider not enrolled/registered with RI Medicaid will deny. Manual (paper) claim form instructions for placement of the attending provider information can be found here on the EOHHS website. Attending provider loop and segment information for X12 transactions can be found here. If you have questions please contact customer service at 401-784-8100 and for in-state toll calls, 800-964-6211.

Attending Provider Requirement

Volume 308 Page 10

The next meeting of the Drug Utilization Review (DUR) Board

is scheduled for: Date: September 11, 2018 Meeting: 10:30 AM Location: DXC Technology 301 Metro Center Blvd., Suite 203 Warwick, RI 02886

Click here for agenda

Pharmacy Spotlight

The next meeting of the Pharmacy & Therapeutics Committee (P&T)

is scheduled for: Date: September 11, 2018 Registration: 7:30 AM Meeting: 8:00 AM Location: DXC Technology 301 Metro Center Blvd., Suite 203 Warwick, RI 02886

Click here for agenda

Meeting Schedule: Pharmacy & Therapeutics Committee

Drug Utilization Review Board

Attention: RI Medicaid Drug Prior Authorization Forms

The RI Medicaid prior authorization (PA) program includes a Preferred Drug List (PDL) where Non-Preferred agents require a PA. Please be sure to use the Prior Authorization for a Non-Preferred Drug form not the General PA Form when requesting a Non-Preferred agent. There are also other drugs or classes of drugs that require clinical PAs. Some drugs have a specific PA form with unique criteria relevant to that drug. To ensure a quick turnaround time for your PA request please check the list of forms and select the form most appropriate for the drug you are requesting. Using the correct form first, means you will not have to waste your time doing it a second time and delay needed medication for a patient. Forms for prior authorization approval are available at the EOHHS Website

2018 Meeting Dates: December 11, 2018

Need information about tobacco cessation? The Tobacco Cessation Medicaid Benefits Matrix is now available at the Department of Health.

Page 11 September 2018

Pharmacy Updates—Hepatitis C Policy

Prior Authorization Guidelines

July 1, 2018

Introduction: Hepatitis C has been identified as a significant etiology of chronic liver disease, associated co-morbidities, need for liver

transplant and death. These guidelines document eligible beneficiaries, who may prescribe covered medications and the

information which must be submitted in order to obtain a coverage determination. Additions to the list of FDA approved

medications will require individual review. Detailed prescribing and drug warning information may be obtained at:

http://www.fda.gov/Drugs/DrugSafety/ucm522932.htm

Modifications to these guidelines will be issued as needed. Prior authorization is required.

General Approval Criteria:

A. Prescribers: a. Patients with Stage 3 and Stage 4 disease must be managed by a provider on the Rhode Island Medicaid Hepatitis

C Preferred Provider List who either assumes direct responsibility for care or who after consultation and establishing

a treatment plan co-manages the patient with the primary care provider. b. Patients with documented Stage 0, 1 or 2 disease may be managed by the primary care physician, advanced

practice nurse or physician assistant as described below.

B. Beneficiaries:

a. All patients with documented Chronic Hepatitis C Stages 0 through 4 are eligible for treatment.

C. Required Documentation;

a. The following must be included in the pre-authorization request:

i. Stage of disease and test used to determine disease stage. ii. Presence or absence of decompensated cirrhosis. Patients with decompensated liver disease must be referred

to a physician with experience in managing such disease – ideally at a center with liver transplant capabilities. iii. Hepatitis C genotype, quantitative viral load and date of testing. Date of testing must be within 90 days of

request.

iv. History of prior Hepatitis C treatment if relevant.

v. Treatment plan which includes:

1. Medication name, dose and duration.

2. Agreement to submit post treatment viral load data if requested.

D. Approval: a. Approval will be for a full course of treatment with medication being dispensed in 28 day increments. Evidence of

non-compliance may result in cancellation of approved medication refills.

b. Approval will be valid for 56 - 84 days from date of approval. c. Health plan Medical Directors will be responsible for monitoring in plan processes to insure compliance with this

policy. Documentation must be provided to Rhode Island Medicaid upon request.

d. Any request for a non FDA approved treatment will be denied.

E. Treatment recommendations as of July 1, 2018:

a. Preferred agents: MavyretTM or Vosevi®.

b. Non-preferred agents: All other agents, with the exception of ribavirin;

i. Will be approved if a patient is completing a cycle of therapy which was initiated prior to current policy

implementation, or

ii. Requests for non-preferred medications will be reviewed on a case by case basis. The PA request must include

supporting, detailed clinical documentation of need for an alternative, non-preferred agent.

F. Continuity of Treatment:

a. When transitioning between publicly funded delivery systems (e.g. between Fee for Service Medicaid and Managed

Care Medicaid, between Managed Care Medicaid and Fee for Service Medicaid or between the Department of Cor-

rections and the Medicaid program), any authorization granted by the prior delivery system will be honored for the

portion of the treatment that remains after the transition.

Page 12 Volume 308

Slow Down: Back to School Means Sharing the Road

School days bring congestion: Yellow school buses are picking up their charges, kids on bikes are hurrying to get

to school before the bell rings, harried parents are trying to drop their kids off before work.

It's never more important for drivers to slow down and pay attention than when kids are present – especially before and after school. If You're Dropping Off Schools often have very specific drop-off procedures for the school year. Make sure you know them for the safe-ty of all kids. More children are hit by cars near schools than at any other location, according to the National Safe Routes to School program. The following apply to all school zones:

Don’t double park; it blocks visibility for other children and vehicles

Don’t load or unload children across the street from the school

Carpool to reduce the number of vehicles at the school

Sharing the Road with School Buses If you're driving behind a bus, allow a greater following distance than if you were driving behind a car. It will give you more time to stop once the yellow lights start flashing. It is illegal in all 50 states to pass a school bus that is stopped to load or unload children.

Never pass a bus from behind – or from either direction if you're on an undivided road – if it is stopped to

load or unload children

If the yellow or red lights are flashing and the stop arm is extended, traffic must stop

The area 10 feet around a school bus is the most dangerous for children; stop far enough back to allow

them space to safely enter and exit the bus

Be alert; children often are unpredictable, and they tend to ignore hazards and take risks

Sharing the Road with Young Pedestrians

According to research by the National Safety Council, most of the children who lose their lives in bus-related

incidents are 4 to 7 years old, and they're walking. They are hit by the bus, or by a motorist illegally passing a

stopped bus. A few precautions go a long way toward keeping children safe:

Don't block the crosswalk when stopped at a red light or waiting to make a turn, forcing pedestrians to go

around you; this could put them in the path of moving traffic

In a school zone when flashers are blinking, stop and yield to pedestrians crossing the crosswalk or inter-

section

Always stop for a school patrol officer or crossing guard holding up a stop sign

Take extra care to look out for children in school zones, near playgrounds and parks, and in all residential

areas

Don't honk or rev your engine to scare a pedestrian, even if you have the right of way

Never pass a vehicle stopped for pedestrians

Always use extreme caution to avoid striking pedestrians wherever they may be, no matter who

has the right of way

Page 13 September 2018

Sharing the Road with Bicyclists On most roads, bicyclists have the same rights and responsibilities as vehicles, but bikes can be hard to see. Children riding bikes cre-ate special problems for drivers because usually they are not able to properly determine traffic conditions. The most common cause of collision is a driver turning left in front of a bicyclist.

When passing a bicyclist, proceed in the same direction slow-

ly, and leave 3 feet between your car and the cyclist

When turning left and a bicyclist is approaching in the opposite direction, wait for the rider to pass

If you're turning right and a bicyclists is approaching from behind on the right, let the rider go

through the intersection first, and always use your turn signals

Watch for bike riders turning in front of you without looking or signaling; children especially have a

tendency to do this

Be extra vigilant in school zones and residential neighborhoods

Watch for bikes coming from driveways or behind parked cars

Check side mirrors before opening your door

By exercising a little extra care and caution, drivers and pedestrians can co-exist safely in school zones.

Slow Down: Back to School Means Sharing the Road—Cont’d

Status with Submitting 2018 Applications

We are currently in the process of upgrading our MAPIR system to version 6.1 which will allow providers to attest to meaningful use in accordance to the 2018 program rules approved by CMS earlier this year. Our goal is to have this upgrade completed and available by mid-September to early October. Please bear in mind that if you are attesting for providers who are in program years 3-6, they will be required to attest their CQM measures for a full-year while the meaningful use objective attestation is for any 90-day period in 2018. Therefore, you will need to wait until the year, in this case 2018, is finished before you can attest for pro-gram year 3-6 applications. On the other hand, if you need to attest for a program year 2 application that is attesting to meaningful use for the first time, you will be able to submit these applications after we upgrade MA-PIR and you’ll be able to attest to meaningful use and CQM data for 90-days. In either case, providers can attest to Stage 2 or 3 meaningful use objectives for program year 2018. Feel free to click here to learn more. In addition, you can click here to understand 2018 CQM reporting requirements. We recognize that each year has some new differences, so please feel free contact us with any questions you may have at ohhs.ehrincentive@ohhs.ri.gov.

RI Medicaid EHR Incentive Program Update

Page 14 Volume 308

Finger on the Pulse –

Stay Social with Rhode Island Quality Institute Have you checked out RIQI on Facebook, Twitter or LinkedIn? Follow us to stay up-to-date on what we are doing in the community. We post updates on CMS regulation changes, the latest TCPi news, health awareness tips and information on upcoming events. Follow us: https://www.facebook.com/RIQI.Org/ https://twitter.com/riqi_org?lang=en https://www.linkedin.com/company/ri-quality-institute/

2018 TCPi National Expert Panel Conference Roundup Members of the RIQI TCPi practice transformation team travelled to Columbia, Maryland in Au-gust to attend the 2018 National Expert Panel Conference. The conference recognized Exemplar Practices in the TCPi program. RIQI brought representatives from CODAC Behavioral Health, South County Health, University Orthopedics and University Surgical Associates. Our clinicians did an amazing job sharing their successes and stories of how RIQI helps them with their prac-tice transformation. We are so honored that these Rhode Island practices are nationally recog-nized as outstanding organizations. Check out pictures from the conference! Questions? Get in touch: Susan Dettling 401.276.9141 x236 sdettling@riqi.org

Page 15 September 2018

Mark your calendar for upcoming Educational Events

Webinar: Thursday, September 20, 2018 ▪ 8:00 AM – 9:00 AM Security Risk Assessments – What You Need to Know REGISTER

If you participate in the Merit-based Incentive Payment System (MIPS) (part of the Medicare Quality Payment Program) or the Medicaid EHR Incentive Program, you are required to conduct an annual Security Risk Assessment (SRA) and implement security updates as necessary. Don Nokes, President and Co-founder, NetCenergy and Tom King, Security Consultant/Practice Man-ager, NetCenergy will discuss how to conduct a successful SRA and present best practices to protect yourself and your patients from potential breach of medical information.

Webinar: Friday, November 2, 2018 ▪ 7:30 AM – 9:00 AM

Hot HIPAA Topics with Linn Freedman REGISTER

RIQI’s annual live Webinar presentation with industry leading privacy and security attorney Linn Foster Freedman of Robinson & Cole LLP will focus on hot topics related to privacy and security and HIPAA compliance. This session will also offer certification to fulfill your annual HIPAA train-ing requirement. For more information about participating in TCPI, please contact us at info@riqi.org or

888.858.4815.