Provider Bulletin 2016 Fourth Quarter

Transcription

1 PCMH Provider Bulletin 2016 Fourth Quarter A bulletin for the Molina Healthcare of Texas Network Questions? Call Provider Services (855) a.m. 5 p.m. Monday through Friday Connect with Us Behavioral Health Services Update Effective January 1, 2017 Beginning January 1, 2017, Molina Healthcare of Texas and our growing network of providers will be responsible for managing behavioral health services for members in the Dallas Service Area. The NorthStar Program will no longer be providing Dallas members with behavioral health services. Member benefits have not changed as part of this transition. To ensure continuity of care for our members, Molina has been diligently working to grow our behavioral health provider network in Dallas. We have been able to successfully contract with many providers who participated in the NorthStar program. However, if a member s current provider has not contracted directly with Molina as part of this transition; the member will be able to remain with that provider for up to 6 months while they locate a provider within Molina s network. Providers who are interested in joining Molina s behavioral health network can complete the Contract Request Form, located on Join our Distribution List To receive this bulletin via , contact MHTXProviderServices@ to send us your: Group Name TIN NPI Service Locations Contact Name Contact Phone and Fax Medical Benefit Drug Prior Authorizations Please submit all Clinician Administered Drug Prior Authorization requests for Medicaid, CHIP and Marketplace members to Molina s Pharmacy Department via fax at (888) MHTPS_Q4Bulletin_ TX1116

2 , and send it along with a current W-9 to MHTContractRequest@. Important Phone Numbers: Behavioral Health Customer Service Line: (866) Behavioral Health Crisis Line: (800) , available 24 hours a day, 7 days a week (this number is included on the back of member ID cards) If you have any questions about this transition, please contact your Provider Services representative. Medicaid Provider Re-enrollment The Patient Protection and Affordable Care Act (PPACA) and Title 42 Code of Federal Regulations (CFR) require state Medicaid agencies to revalidate Medicaid providers enrollment information by September 24, 2016, and at least every five years thereafter. TMHP has published several provider notifications asking providers to submit their revalidation application by September 24, If TMHP did not receive a revalidation application from you by September 24, 2016, your enrollment in Texas Medicaid will be terminated effective January 31, The following actions will occur in the coming weeks leading up to your termination date: TMHP will inform all Medicaid clients who have an open authorization with you that they can contact you for help choosing a new provider or a new provider will be assigned to them. TMHP will inform all Medicaid clients who receive regularly scheduled (e.g., monthly) services or supplies that do not require prior authorization that they can contact you for help choosing a new provider or a new provider will be assigned to them. TMHP may transfer open prior authorizations for recurring (e.g., monthly) services or supplies that were approved for a period that extends past January 31, 2017, to another provider who has completed the validation process. Claims submitted for dates of service on or after February 1, 2017 will be denied even if a current prior authorization is in effect for the service. If TMHP receives a revalidation application from you after September 24, 2017, it will be processed. However, the termination actions listed above will not stop. If your application has not been processed by January 31, 2017, you will be terminated effective January 31, If your enrollment is terminated, then your enrollment eligibility will have a gap from February 1, 2017, until the application has been approved and finalized. Terminated providers will not be eligible to participate as network providers in Medicaid managed care organizations (MCOs) or dental maintenance organizations (DMOs). If you are being terminated due to not submitting your application by the deadline, you will receive a letter from TMHP. You will also receive a separate letter from Molina terminating your participation in our network as a result of failing to revalidate your enrollment information. If you have any questions or need assistance, please call the TMHP Contact Center at (800) or the TMHP-CSHCN Services Program Contact Center at (800)

3 Molina Welcomes Memorial Hermann Health System Molina is proud to announce the addition of the Memorial Hermann Health system as its newest partner in delivering high quality health care in the Harris Service Area. With this partnership, Molina members* now have access to the following facilities: Houston Memorial Hermann Hospital Children s Memorial Hermann Hospital Memorial Hermann Orthopedic and Spine Hospital Memorial Hermann - Southeast Hospital Memorial Hermann - Southwest Hospital Memorial Hermann Heart & Vascular Institute Southwest Memorial Hermann - Memorial City Medical Center Humble Memorial Hermann - Northeast Hospital Katy Memorial Hermann - Katy Hospital Pearland Memorial Hermann - Pearland Hospital Sugar Land Memorial Hermann - Sugar Land Hospital The Woodlands Memorial Hermann Hospital - The Woodlands *Excludes Marketplace, STAR and CHIP members.

4 Documenting Texas Health Steps (THSteps) Comprehensive Health and Developmental Histories and Comprehensive Unclothed Physical Examinations Documenting each component of a THSteps checkup is essential to keeping accurate, up-to-date medical records. THSteps checkups are made up of six primary components, many of which include individual components. Comprehensive Health and Developmental History and Comprehensive Unclothed Physical Exams are two important aspects of a child s medical checkup and should always be properly documented in the medical record. A comprehensive health and developmental history includes: Developmental and mental health screening: review of milestones and mental health, including: gross and fine motor skills, communication skills, speech-language development, self-help/care skills and social, emotional and cognitive development Nutritional screening: assessment of dietary practices to identify unusual eating habits Tuberculosis (TB) screening: a TB questionnaire administered annually beginning at 12 months of age A comprehensive unclothed physical examination includes: Measurements: assessment of length/height, fronto-occipital circumference, body mass index (BMI) and blood pressure Sensory screening: assessment of hearing and vision Oral health services: limited oral screening for caries and general health of the teeth and oral mucosa Immunizations: asses the immunization status of the patient at every medical checkup. Vaccines must be administered according to the current Advisory Committee on Immunization Practices. Laboratory screening: may include various tests appropriate to age and risk, including blood lead level, anemia screening, or other risk-based screenings such as dyslipidemia Health education: counseling designed to help parents and caregivers understand what to expect in terms of the child s development and to provide information for all ages about the benefits of health lifestyles, as well as accident and disease prevention The medical record must contain documentation on all screening tools used for TB, growth and development, autism, and mental health screenings. The results of these screenings and any necessary referrals must also be documented in the medical record. THSteps checkups are subject to retrospective review and recoupment if the medical record does not include all required documentation. To assist providers in properly completing all THSteps checkup documentation, a THSteps Child Clinical Health Record form can be used. This form is not required, but was developed to help providers document all components of the medical checkup. This form can be found at Health-Clinical-Record-Forms.pdf.

5 Flu Season is Here! Talk to Your Patients about Vaccination, Today! According to the Centers for Disease Control and Prevention, between 5% and 20% of the U.S population will get the flu each year*. As we move forward into the winter months, the flu virus will start to spread throughout our communities. As health care professionals, we have a responsibility to inform our patients of preventative measures to keep them healthy during the flu season. The best way to prevent the seasonal flu is by getting a flu vaccine. However, far too often, patients do not take action until it is too late. This is where you come in. As you interact with our members during their exams, check-ups and other procedures, start the conversation about getting the flu vaccine. Talk to them about the importance of the vaccine, where they can get it and why is important to that they get it sooner, rather than later. By opening these lines of communication, hopefully we can keep as many patients as possible healthy and happy during this flu season. Talk to your patients about the flu vaccine, today! *Source:

6 Marketplace Annual Open Enrollment Open enrollment for Marketplace takes place from November 1, 2016 December 15, Molina Healthcare of Texas is expecting our Marketplace membership for 2017 to grow during this open enrollment season. As a valued partner participating in serving Molina members, we want to provide you with information to help prepare you for this growth. Below, we have compiled a few points of interest to help guide you through the next few months as we prepare to onboard these new members. Molina Marketplace is growing. For the 2017 coverage year, we are expecting many Texas residents to choose Molina Healthcare of Texas as their Marketplace health plan. If you currently participate in Molina s Marketplace network, your information is being included in the Molina Marketplace Provider Directory. Please anticipate phone calls from prospective and new members regarding your availability to accept new patients. Please make every effort to work with these members, advise them of your availability, and schedule them for an appointment when needed. If you are not currently participating in Molina s Marketplace network and would like to join, complete the Contract Request Form and submit it along with a current W-9 via fax at (877) or via at MHTContractRequest@. If you have a billing or claims question, please reach out to Provider Services at (855) or MHTXProviderServices@ We are excited about the growth of our Marketplace program and thank you for your continued support in providing access to quality healthcare to our members. Please feel free to reach out to Molina Provider Services at any time with comments, questions or concerns.

7 Improving Quality Care Using HEDIS Each year, managed care plans are required to report on clinical quality measures to the Centers of Medicaid & Medicare Services (CMS). As required, Molina uses the Healthcare Effectiveness Data and Information Set or HEDIS scores, developed by NCQA, as the tool to measure the quality performance of the care and services our members are receiving. Molina is committed to improving the health of our members. Communicating with our members and educating them on the importance of timely services is just one way Molina works to increase the quality of the care our members receive. By working closely with our network of providers, Molina hopes to further increase the quality of care and timeliness of services received by our members. If you have identified members who are missing age/gender specific preventive screenings such as: breast cancer screenings, colorectal cancer screenings, or annual child/adolescent well exams, we ask that you look for ways to include these services during the member s next visit. We also ask that members with chronic conditions such as diabetes or high blood pressure are receiving appropriate screenings and treatment for their conditions. Provider Complaints and Appeals To ensure timely resolution of complaints and appeals, completed Provider Complaint/Appeal Request Forms should only be sent to: Molina Healthcare of Texas Attn: Provider Complaints & Appeals P.O. Box Irving, TX Complete forms can also be faxed to (877) If a member missing a needed service is not scheduled for a visit before the end of the year, we encourage you to contact the member for a 2016 appointment. By working together, we can continue to make a different in the lives of our members. For more information or questions about Quality initiatives or HEDIS, please contact the Quality Improvement Department at (877) You can also view Molina s latest HEDIS results at Provider Demographic Updates In an effort to maintain data integrity and up-to-date records, Molina asks that providers complete the Provider Data & Demographic Form once a quarter. The Provider Data & Demographic form can be found at Completed forms can be faxed to (877) or ed to MHTXProviderServices@. Please Note: Providers should notify Molina 30 days in advance of any demographic changes. This includes changes to office location and office hours, contact information, tax ID numbers, NPIs, additions or terminations of an office location or provider, and the opening or closing of PCP practices to new patients.

8 Molina Healthcare of Texas Attn: Provider Services 5605 MacArthur Blvd., Suite 400 Irving, TX 75038