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					                                                                                    All Plan Meeting - QMCO questions April 5, 2012
    Q#         Group   SME         Page                        Question                          Response                                                    New Answer since last posting

1            834                          It is our understanding that HCA will be sending       Medicaid: Including the MCOs, are always payers of last                  X
                                          COB information in the 834 enrollment files. We'd      resort. If a client has comparable private health
                                          like to know if HCA has a specific list of carrier     insurance, HCA verifies the benefit and terminates the
                                          codes they will be sending. We'd like a copy of this   client from the managed care enrollment eligibility. The
                                          list to ensure we have all carriers mapped             only exception to this is for maternity care which allows
                                          appropriately.                                         females between the ages of 15-45 to be enrolled if
                                                                                                 their private insurance does not cover maternity
                                                                                                 services. The MCOs are required to notify HCA that an
                                                                                                 enrollee has other insurance within 15 days of
                                                                                                 becoming aware of other insurance.

                                                                                                 When applicable, HCA does include COB information in
                                                                                                 the 834 transaction in accordance with the 5010
                                                                                                 Technical Specification Guide found at
                                                                                                 http://hrsa.dshs.wa.gov/dshshipaa/.

                                                                                                 The list of carrier codes used by HCA can be found at
                                                                                                 http://maa.dshs.wa.gov/LTPR/Providers.html. A client’s
                                                                                                 private insurance information can be found in the
                                                                                                 ProviderOne Benefit Inquiry screen.




         2             Contracts          How will we gain access to the CMS providers           Managed Care Plans will not have access to the CMS
                                          screening portal in order to verify whether or not     providers screening portal referred to as PECOS. Page
                                          SSI providers have completed their                     3 of the Informational Bulletin states only 4 “read only”
                                          'credentialing/background check'? Per CMCS             portal access permissions will be given to each state
                                          Informational Bulletin December 23rd-                  Medicaid office. The background check language in the
                                          Medicaid/CHIP Provider Screening and Enrollment.       contract has been edited. Please refer to the new
                                          here is the link http://www.medicaid.gov/Federal-      language.
                                          Policy-Guidance/downloads/CIB-12-23-11.pdf




                                                                                                          1
                                                                                      All Plan Meeting - QMCO questions April 5, 2012
    Q#         Group   SME         Page                         Question                          Response                                                         New Answer since last posting

         3             Contracts          What is the process for American Indian payments?       The PCCM (Primary Care Case Management) is a
                                           Need a definition of PCCM from the State - i.e. will   managed care program that is provided solely through
                                          State pay for all benefits (Straight FFS)? We           tribal clinics and Urban Indian Centers (UIC)- the
                                          believe Encounters will go 100% to HCA with no          program pays contracted tribes and UIC's a per
                                          capitation.                                             member per month fee to manage care for enrollees
                                                                                                  and pays for all medical services on a fee for service
                                                                                                  basis for UIC's and using the encounter rate for tribal
                                                                                                  clinics. If a tribal AI/AN client is enrolled with a Managed
                                                                                                  Care Organization (MCO) and services are provided by
                                                                                                  a tribal facility the tribe must first bill the MC entity. The
                                                                                                  MC entity is only obligated to pay the usual and
                                                                                                  customary rate to a tribal clinic. The tribal clinic must
                                                                                                  then bill Medicaid as a secondary coverage including
                                                                                                  the EOB with the claim. Under the federal law tribes do
                                                                                                  not have to have a contract with the MCO.

         4             Contracts          For American Indians/HCTC: Do we have a need to HO--There is a need to identify the AI/ AN clients as
                                          separately report on AI and members with HCTC?  they are exempt from cost sharing. AI/ AN clients are
                                          If so, How do we report on them? (ID them)      NOT obligated to receive their services from a tribal
                                                                                          clinic. There are many AI/AN clients that will choose to
                                                                                          be in a HO assignment as they may need access to
                                                                                          specialty care that may not be available in their area
                                                                                          FFS. ACES will be updated in July of 2012 to include all
                                                                                          the federally recognized tribes in the US and an
                                                                                          identifier for Canadian First nation members. Once
                                                                                          these are in ACES, clients will be able to be identified
                                                                                          through ACES and P1. BH-AI/AN members enrolled in
                                                                                          Basic Health will be identified as such on the enrollment
                                                                                          files the MCO receives each month. This is also true for
                                                                                          HCTC members enrolled in Basic Health.

         5 FQHC        Rates              Do we need to generate any kind or file            Yes, the MCOs are required to post a file to our secure
                                          feed/member roster or FQHC member file back to     website each month. The address for the site is
                                          HCA? If so, in what format? and reconcile process? https://sft.wa.gov. We can obtain access for the new
                                                                                             MCOs so they can login and upload their files.

6            834                          Confirm with state that PCP assignment will come        Medicaid: We do not assign at the PCP level. If a client
                                          on initial enrollment file only and not monthly with    chooses a PCP we will pass that information on the 834
                                          every 834. How do we communicate our PCP                audit file. The provider choice will remain on the 834
                                          assignments back to the state?                          audit file each month until there is a change. For the
                                                                                                  most part you don’t report your PCP assignments. For
                                                                                                  your enrollees that you assign to a FQHC or RHC there
                                                                                                  is a process to exchange that information so the
                                                                                                  enhanced payment goes to the FQHC or RHC. A
                                                                                                  training session will be provided.


                                                                                                            2
                                                                                      All Plan Meeting - QMCO questions April 5, 2012
    Q#         Group   SME          Page                        Question                          Response                                                   New Answer since last posting

         7             Contracts           Do the services listed for coverage generally apply    Basic Health Plus and Maternity Benefit Program
                                           in the COC to Basic Health Plus and Maternity          receive the Healthy Options benefit and are therefore
                                           Benefit Program, and then in addition they get the     not in the COC. They are included in the HO exhibit.
                                           coverage noted for their specific program?

         8             Rates               Please share payment guidelines and billing            Pg 50 of Physician Related billing instructions
                                           instructions for e-visits.                             http://hrsa.dshs.wa.gov/download/Billing_Instructions/Ph
                                                                                                  ysician-Related_Svcs/Physician-
                                                                                                  Related_Services_BI.pdf
9            RIN                           Can HCA define the Reference Identification            Medicaid: The cell that explains is on pg 7-8, Loop 2000
                                           Number? Is this the member's SSN, Medicaid ID?         Subscriber Number REF02 = “This field is populated
                                           Pg 7 of 834 companion guide                            with Medicaid’s ProviderOne Client Identification
                                                                                                  Number in the following. 9-digit numeric and digit alpha
                                                                                                  e.g. 123456789wa.”
     10 Contracts      Contracts           We find in many markets OB/Gyns and GYNS act           Generally ob/gyn will not act as PCP, unless an enrollee
                                           as PCPs, will HCA allow OB/Gyns and Gyns               with special healthcare needs elects to have an ob/gyn
                                           participate as PCPs?                                   or other specialist as their primary care provider.

11           NPI                           What is HCAs preferred method for claim                Medicaid: MCO’s do not submit claims to HCA. If the
                                           submission for non-NPI providers?                      question is related to encounter data submissions by
                                                                                                  the MCOs, the information regarding A-typical non-NPI
                                                                                                  provider information can be found on page MCO-4 in
                                                                                                  the Encounter Data Reporting Guide at
                                                                                                  http://hrsa.dshs.wa.gov/HealthyOptions/NewHO/Provider
                                                                                                  /EncounterDataReportingGuide.pdf

     12 Reports        Monitoring          Please provide a comprehensive list of required        Required reports will be addressed in trainings to be
                                           reports and the submission schedule as well as         announced.
                                           technical specifications and layouts.
     13                Rates               Are there state specific codes other than the HIPPA    There are a few codes specific to Washington State.
                                           compliant codes? Can HCA forward list if available?    The codes are available in the HIPAA companion
                                                                                                  guides found at http://hrsa.dshs.wa.gov/dshshipaa/.
                                                                                                  Training will be scheduled.


     14                Contracts           Please provide the three COCs for the Basic            No COC for HO which includes HOBD, the COC for
                                           Health, Healthy Options and ABD                        Basic Health will be included as an exhibit to the
                                                                                                  contract.
     15                Contracts           When does the state expect to release the final        The State expects to release the finalized contract
                                           contract to the successful bidders for review prior to within the next two weeks, there will be changes from
                                           execution? Are significant changes expected from       the draft contract.
                                           the draft contract materials released with the RFP?




                                                                                                            3
                                                                                    All Plan Meeting - QMCO questions April 5, 2012
Q#    Group   SME            Page                            Question                            Response                                                       New Answer since last posting

 16           Monitoring              For plans that are new to the Washington program,          This information is being put together and will be
                                      will HCA please provide detailed information               provided to all MCO’s in the near future.
                                      regarding the TEAMonitor process, including a list
                                      of required review items, desk audit deliverables, on-
                                      site review topics, etc.?
 17           Monitoring              In preparation for the TEAMonitor reviews, should          The MCO’s can use that as a guide although the format
                                      plans prepare documentation in accordance with             of the tool that will be used will be different, the content
                                      the TEAMonitor Preassessment tool provided in              will be similar.
                                      Addendum #4, Attachment #2? Is there additional
                                      guidance that HCA can provide for plans preparing
                                      for this review?

 18           Monitoring              Will the state provide a detailed timeline of activities A calendar with the dates for the Readiness Review has
                                      and milestones associated with the contract              already been released.
                                      execution and readiness review process?

 19           Monitoring              Will the TEAMonitor on-site review take place solely       All on-site readiness review activities will be performed
                                      in the plan’s Washington office, or will additional        in the MCOs Washington office. The only reason we
                                      reviews take place in any other office locations           would review the offsite (out of state) functions would be
                                      supporting operations such as claims payment or            if there was an identified concern.
                                      call center functions?
 20           Contracts               In addition to the Friday calls, will the State consider   The state has set up these meeting and released the                         X
                                      holding regularly scheduled meetings with each             schedule to the health plans.
                                      health plan individually to address plan-specific
                                      implementation and readiness questions?

 21           Contracts               Will the State consider establishing subgroup teams Yes, the state is considering subgroups and will be
                                      to discuss questions/issues regarding topics such   establishing a first subgroup on IT/Technology. This
                                      as Benefits, IT/Technology, Marketing, etc.         decision will be announced on February 24, 2012.

 22           Monitoring   pg 14 RFP What will the readiness review site visit include?          This information has been given to the MCOs                                 X
 23           Contracts    pg 14 RFP When will contract negotiations begin? What will            The bidders were to submit any contract changes they
                                     the process be? Will MCOs receive a draft contract          wanted HCA to consider with their RFP submissions.
                                     for review?                                                 The State received no such submissions. The State is
                                                                                                 making updates to the contract and will release it in the
                                                                                                 next two weeks to the apparently successfull bidders. In
                                                                                                 addition to the final contract for signature, the MCOs will
                                                                                                 receive a red line, strikeout version of the contract
                                                                                                 along with clarifying comments.

 24           Contracts    pg 14 RFP If MCOs have operational changes from what was        MCOs should inform HCA of any changes they intent to
                                     stated in their RFP response and it is not a contract make to what they originally proposed.
                                     requirement, does the MCO need to notify HCA?
                                     For example, our RFP response indicates
                                     Compliance Committee meets monthly, and would
                                     like to change to every other month.

                                                                                                          4
                                                                                     All Plan Meeting - QMCO questions April 5, 2012
Q#     Group      SME           Page                           Question                           Response                                                   New Answer since last posting

 25 Section       Contracts   pg 83      Do background checks need to be completed on all         The 8.14.12 section of the contract has been re-written
    8.14.12.6                            providers by July 1, 2012 or can MCOs begin to           to align with the new federal provider risk categories.
                                         complete them on all practitioners starting on July 1,   Only the two provider types listed in the high risk
                                         2012?                                                    category need to have background checks upon
                                                                                                  credentialing and recredentialing. The two types are
                                                                                                  Home Health Agencies (HHAs) and Durable Medical
                                                                                                  Equipment, Prosthetics, Orthotics, and Supplies
                                                                                                  (DMEPOS). HCA is requiring a Medicare enrollment
                                                                                                  verification letter for HHAs and DMEPOS provider types
                                                                                                  issued after March 23, 2011.

 26 Section       Contracts   pg 83      Do background checks need to be completed                See response to question 25 above. For the two high
    8.14.12.6                            during each recredentialing decision, or only during     risk provider types the background checks need to be
                                         the initial credentialing decision?                      completed during initial credentialing and upon
                                                                                                  recredentialing.
 27 Section 11.5 Contracts    pg 97-101 We would like to request provider payment                 Complete information on this topic will be provided in a
                                        suspensions be included as a Transition meeting           later training
                                        topic.
 28 Addendum      Contracts   pg 4      The answer to RFP Q&A #16 related to new           Please refer to question 25 and 26 above.
    5 Q. 16                             requirements for criminal background checks states
                                        “HCA will accept the State’s check to meet the
                                        requirement providing the Contractor has current
                                        verification of the background check.” Can HCA
                                        confirm MCOs should provide evidence of annual
                                        confirmation of the applicable WAC and annual
                                        written confirmation from DOH they are completing
                                        background checks?

 29 Addendum      Contracts   pg 36      Will HCA continue to send the generic combined      HCA will continue to produce a combined HO
    5 Exhibit c                          HO Handbook or will MCOs be required to send HO handbook. This will be mailed to all new enrollees with
                                         handbooks?                                          their plan choices based on the client’s zip-code. Per
                                                                                             1.5.5 of the Basic Health Provisions exhibit, the
                                                                                             Contractor must send their own COC to Basic Health
                                                                                             enrollees.
 30 Addendum      Contracts   pg 40      Do we need to include wording regarding second      Information about second opinion should be included in
    5 Exhibit c                          opinion in appeals and grievance documents or is it grievance system policies and procedures in addition to
                                         sufficient to include it in the member handbook?    letters sent to enrollees such as the notice of action
                                                                                             (denial) letter.
 31               Contracts   pg 105     Will second opinion information be included on the At this time there is no plan to add information about
                                         new grievance and appeals template HCA will         second opinion. It is not in the grievance system
                                         provide to MCOs?                                    template .
 32 Addendum      Contracts   pg 104     Can HCA confirm appeal acknowledgement will be The contract has always stated that appeals are
    5 Exhibit c                          changed to 72 hours?                                acknowledged in writing within seventy – two (72)
                                                                                             hours. Please see the original (the document name
                                                                                             submitted with the question) and most updated version
                                                                                             of the contract.

                                                                                                           5
                                                                                    All Plan Meeting - QMCO questions April 5, 2012
Q#     Group      SME           Page                          Question                           Response                                                    New Answer since last posting

 33 Addendum Contracts        pg 10    Can HCA provide more information regarding the            Open enrollment for BH is being released May 11th and                    X
     5Q&A                              timing of the mailing informing enrollees of their        will close June 4th. HO information will be sent out by
      Q.38                             plan choices and how to choose a plan prior to July       the end of May.
                                       2012?
 34 Addendum      Contracts   pg 45    If the inpatient stay for a SSI client is at one of the   Yes. The MCO is responsible for the professional
    5 Exhibit c                        CPE hospitals, are MCOs responsible for the               component. Only the inpatient hospital claim is carved
                                       professional components?                                  out.
 35 Addendum      Contracts   pg 45    Who manages the member’s care for inpatient               HCA will authorize inpatient hospital claims under it
    5 Exhibit c                        stays at CPE hospitals for SSI members, HCA or            utilization management rules. The plans ability to
                                       the MCO? Does the MCO have the ability to                 manage the care is through their relationship with the
                                       approve/deny authorizations since we are at risk?         health care professionals that manage the enrollees
                                                                                                 overall utilization including the need for hospital care.

 36 Addendum      Contracts   pg 45    Will MCOs receive quarterly updates regarding our         The Health Care Authority will work with the MCOs to
    5 Exhibit c                        budget status on the CPE expenditures noted in            develop a reporting process to provide quarterly
                                       Section 4.6.4 of the contract? It is important for us     updates on the CPE benchmark.
                                       to know whether we are meeting our expected SSI
                                       CPE budget.
 37 Addendum      Contracts   pg 120   Can HCA clarify if the top 5% refers to top 5% of         The top 5% of the entire population.
    5 Exhibit c                        total MCO population or top 5% of Special Health
                                       Care Needs population?
 38 Addendum      Contracts   pg 120   Currently in PRISM, MCOs only have the ability to         MCOs will be granted the ability to pull reports from
    5 Exhibit c                        look up clients individually. In order to stratify the    PRISM.
                                       top 5%, will HCA be providing a report or will the
                                       MCOs be granted the ability to pull reports in
                                       PRISM?
 39 Addendum      Contracts   pg 124   We would appreciate that collaborative efforts            This topic will appear as a future Transitions meeting
    5 Exhibit c                        surrounding screening tools be added as a                 agenda item.
                                       Transition meeting topic for general discussion
                                       regarding expectations, etc.
 40 Addendum      Contracts   pg 35    Should contract section 2.37.4 refer to contracted        No, Covered Services is the appropriate wording.
    5 Exhibit c                        services instead of covered services?

 41 Addendum      Contracts   pg 54    Exhibit C states potential HO clients who do not   The contract will be updated to reflect December
    5 Exhibit c                        choose a plan will be assigned per the methodology 31,2013 instead of June 30, 2013
                                       stated in the RFP through June 30, 2013.

 42 Addendum      Contracts   pg 29    The RFP states this methodology will be in place          December 31, 2013 is the correct date
    6 RFP                              through December 31, 2013. Please clarify which is
                                       the correct date
 43 Addendum      Contracts   pg 2     Exhibit H includes 365 days to reconcile newborn          Both are correct as they relate to separate instances.
    5 Exhibit c                        premium. Exhibit C includes 60 days to reconcile
                                       enrollment file.
 44 Addendum      Contracts   pg 43    Can HCA confirm MCOs must submit all PARFs                Yes, each MCO must submit all PARFs within 60 days
    5 Exhibit c                        within 60 days except for newborns?                       with the exception of newborns.


                                                                                                          6
                                                                                    All Plan Meeting - QMCO questions April 5, 2012
Q#     Group      SME           Page                         Question                            Response                                                    New Answer since last posting

 45 Addendum      Contracts   pg 4     It has come to MHW’s attention diagnosis code             No, the rate was developed using the current
    5 Exhibit H                        286.4 (von Willebrand disease) is considered a            contractual understanding of the diagnoses considered
                                       form of hemophilia and is not included our contract       to be hemophilia.
                                       regarding stop loss for hemophiliac drugs. Will
                                       HCA consider adding this to the list of covered
                                       diagnosis codes for hemophiliacs as people with
                                       this diagnosis would be treated with the blood
                                       product covered under the stop loss protection?

 46 Addendum      Contracts   pg 5     Can HCA confirm the eligible client groups for the        G02-SSI related will also be covered
    5 Exhibit H                        new SSI enrollees include S01 and S02 ACES
                                       coverage groups? Will any other client groups be
                                       included?
 47 Addendum      Contracts   pg 17    At the September 2011 All Plan meeting MCOs               The carve-out for dental services is for dental codes                    X
    5 exhibit H                        were told when the adult dental benefit was cut           provided by a dental provider type. Those are the only
                                       effective 1/1/11, adults still have a FFS emergency       dental services that are carved-out. The rates are
                                       oral health benefit which impacts how the managed         calculated for the carve-out and there is no change to
                                       care emergency dental benefit is covered. Exhibit         the carve-out between the current and July 1st contracts.
                                       H reads MCOs pay for emergency dental services
                                       when not performed by a dentist or oral surgeon. If
                                       the emergency dental service is provided by a
                                       dentist or oral surgeon it is covered by FFS.
                                       However, at the All Plan meeting we understood
                                       within the emergency oral health benefit there will
                                       be cases (likely restricted to specific CPT codes)
                                       where FFS will pay for emergency dental services
                                       performed by a non dentist/oral surgeon. Is this still
                                       a correct interpretation of the benefit? If so, will it
                                       be included in the RFP contract?


 48               Contracts            Can HCA provide the list of Recipient Aid                 See RAC crosswalk attached.
                                       Categories (RACs) for the eligible Healthy Options
                                       population (distinguishing TANF from SSI)?

 49               Contracts            We learned CMS released an update on Feb 2,           Please refer to questions 25, 26, & 28 above.
                                       2012 temporarily relaxing the requirement of
                                       completing background checks on practitioners,
                                       limiting it only to those with a 5% or more ownership
                                       in a company. Will HCA be taking a similar
                                       approach and relaxing the requirement until further
                                       guidance from CMS?




                                                                                                          7
                                                                                   All Plan Meeting - QMCO questions April 5, 2012
Q#     Group      SME           Page                         Question                           Response                                                      New Answer since last posting

 50               Contracts            Please clarify what should be included in denial         HCA is currently revising contract language that will
                                       letters regarding “Washington’s designated               help interpret this area. Contact the OIC directly about
                                       ombudsman’s office”. Would it be appropriate to          how to provide information about the appropriate
                                       include this resource:                                   ombudsman references.
                                       http://www.atg.wa.gov/OpenGovernment/Ombudsm
                                       an.aspx?
 51 Addendum      Contracts   pg 112     Transitional care requires plans to enter facilities   Our staffing is very limited, tell us what you might expect
    5 Exhibit C                        on a regular basis to see members. Most facilities       HCA do to assist the MCOs with this clearance. Plans
                                       have a set of requirements for anyone entering their     are encouraged to coordinate efforts with existing
                                       hospital on a regular basis. Getting the clearance       Transition programs as defined in the contract
                                       can take time and cooperation on the part of the         language, i.e., Qualis Health or WSHA.
                                       facilities staff. Can HCA reach out to the facilities
                                       and assist the MCOs with this clearance?

 52 Addendum      Contracts   pg 3     Currently newborns identified as SSI can be              No, the baby would not be retrorecouped and placed on
    5 Exhibit H                        retroactively recouped and placed on FFS. In the         FFS. The baby would be treated like any other baby
                                       new RFP contract newborns identified as SSI will         born to a Healthy Options-enrolled mother and would be
                                       remain on managed care and the MCO will receive          HO from date of birth, and would move to HOBD
                                       a SSI premium prospectively the next month. Do           prospectively the first of the month following HCA's
                                       we have the correct understanding of how this            notification of HOBD eligiblity. The Healthy Options
                                       process will work as it spans both contracts?            rates contemplate this arrangement.
                                       Please take the following example: Baby is born
                                       5/25/2012 and qualifies for SSI on 7/10/2012 in
                                       HCA’s SDX system. Would May and June be
                                       retrorecouped so baby is FFS for those months,
                                       baby remains a Molina TANF Healthy Options
                                       member for July, and becomes a Molina SSI
                                       Healthy Options member prospectively in August?

 53 Addendum Contracts        pg 101    The RFP contract indicates this requirement is for      HCA’s intention is that this requirement pertain to all
    5 Exhibit H                        all subcontractors. Is the intention for MCOs to         contractors, subcontracts and providers, which means
    Ownership                          obtain this information from subcontractors such as      both vendors and practitioners. The CFR states any
    & control                          vendors, our PBM, etc? The CFR appears to be             person (individual or corporation). Please refer to the
    interest                           more specific to providers, so we want to clarify        definition of 'provider' in the contract. The MCO should
    Information                        HCA’s intention surrounding this requirement.            maintain this information so it is available upon request.




                                                                                                         8
                                                                                  All Plan Meeting - QMCO questions April 5, 2012
 Q#       Group      SME        Page                        Question                          Response                                                       New Answer since last posting

54      Claims                         Is there any limit on the number of claims per file for Medicaid: Testing process and file requirement
        submission                     testing? What is the minimum date that HCA will be information is available within the 837 Encounter
                                       ready to accept test files?                             Companion Guide available at
                                                                                               http://hrsa.dshs.wa.gov/dshshipaa/ on pages 8-9 and
                                                                                               15-17 respectively.

                                                                                              There is no limit to the number of claims/encounters per
                                                                                              file for testing. HIPAA standards limit transaction sets
                                                                                              (ST-SE segments) to a maximum of 5000 CLM
                                                                                              segments (claims/encounters), however a file can
                                                                                              contain multiple transaction sets. Overall test file size is
                                                                                              limited to 100MB via SFTP.

55      837                            It is mentioned on the state site that you will need   Medicaid: Yes.
                                       837's to be submitted in 5010. Does this mean that
                                       NCPDP encounters must be submitted in D.0?

     56 Operations/ Contracts          What is the definition of a Newborn? (ex: 30 day       Newborn Premiums are paid as follows:                                       X
        Eligibility/                   from date of birth). How long typically until          The baby is reported to ACES by Mom or anyone else
        Benefits                       Newborn receives ProviderOne client id? If there is    with knowledge of the birth. This can be a phone call to
                                       a delay between the birth and the time that the baby   the Central CSO Customer Service line at 877-501-
                                       gets their own ID, how are claims to be processed?     2233. These eligibility cases are handled on a priority
                                                                                              basis and done very quickly. ACES interfaces with
                                                                                              ProviderOne system and process enrollment of the
                                                                                              newborn immediately. The ProviderOne system enrolls
                                                                                              the baby in the same plan as the Mom or others on the
                                                                                              same case effective the first of the month following the
                                                                                              date in which the newborn eligibility is reported. The
                                                                                              system then looks at the child’s DOB and processes the
                                                                                              newborn enrollment segment to pay the MCO Newborn
                                                                                              Premiums for the months in which the first 21 days of
                                                                                              life occur. In rare cases a newborn may not be reported
                                                                                              to ACES. If the Mom was enrolled with the MCO,
                                                                                              MCOs must pay for services for the baby under the
                                                                                              Mom’s ID for the months in which the first 21 days of life
                                                                                              occurred. MCOs may inquire about newborn premiums
                                                                                              after 6 months have passed and eligibility has not
                                                                                              processed in ProviderOne.
                                                                                              Once newborn premiums are paid to the MCO, the baby
                                                                                              is no longer a “newborn”.




                                                                                                        9
                                                                                         All Plan Meeting - QMCO questions April 5, 2012
 Q#            Group     SME         Page                         Question                           Response                                                    New Answer since last posting

57        Transaction                       What transaction types will the state use to respond Medicaid: Submitted encounter files will be validated
          s                                 to us with the results of encounter processing? e.g. and standard HIPAA file acknowledgements will be
                                            999, U277                                            returned for file status, i.e. TA1 response, 999 response
                                                                                                 and an HTML custom Report. Once encounters are
                                                                                                 processed and adjudicated by ProviderOne, Managed
                                                                                                 Care Organizations will receive an Encounter
                                                                                                 Transaction Results Report (ETRR) with specific
                                                                                                 encounter status. Basic Health does not do encounter
                                                                                                 processing.

     58                  Contracts          Since we do not have the historical information on       PATIENT REVIEW AND COORDINATION
                                            members, is there any indicator that the state will      GUIDELINES FOR MANAGED CARE
                                            provide that will tell the plans that a member should    ORGANIZATIONS
                                            be part of the PRC program?                              Page 8
                                                                                                     http://hrsa.dshs.wa.gov/HealthyOptions/NewHO/Provider
                                                                                                     /PRCGuidelines4MCOs.pdf

                                                                                                     NEW MCO ENROLLEE ALREADY IN PRC
                                                                                                     A situation where an enrollee’s assigned providers are
                                                                                                     entered in Provider One and then the enrollee changes
                                                                                                     to another MCO, the new MCO may locate the PRC
                                                                                                     enrollment information in Provider One.
                                                                                                     MCOs will need to check the site at
                                                                                                     https://www.waproviderone.org/ to determine if a new
                                                                                                     PRC enrollee has joined their MCO. Specifically, a PRR
                                                                                                     indicator is passed to the MCO on the 834 file. It can be
                                                                                                     found in the 2300 loop in the HD segment on the 9th
                                                                                                     data element. This results in a monthly enrollment
                                                                                                     roster with the indicator Y for PRR (PRC) or N for not
                                                                                                     restricted on the file.
                                                                                                     The MCOs are responsible to determine if the assigned
                                                                                                     providers are network providers. The MCO should send
                                                                                                     a “New Enrollee/ Already in the PRC Program” letter to
                                                                                                     the assigned provider (s). If the assigned providers
                                                                                                     need to be changed, MCOs must work with the enrollee
                                                                                                     to make the necessary changes to comply with the
                                                                                                     guidelines as established by WAC 182-501-0135.
59        Operations/                       Can a sample layout of the ID card be provided?          Medicaid: Link to ProviderOne ID Card fact sheet-
          Eligibility/                                                                               http://hrsa.dshs.wa.gov/providerone/Providers/Fact%20
          Benefits                                                                                   Sheets/P1PR002-
                                                                                                     Service%20Card%20will%20Replace%20MAID%20050
                                                                                                     708.pdf
60        IT                                Is there an indicator on the 834 file to give us         Basic Health: For the Basic Health program, the HCTC
                                            indication that a member is part of the HCTC             members are indicated on the BH 834 eligibity file
                                            program?                                                 (roster) as 'HCTC'.


                                                                                                               10
                                                                                   All Plan Meeting - QMCO questions April 5, 2012
 Q#       Group     SME         Page                         Question                          Response                                                    New Answer since last posting

     61 Operations/ Contracts          Pertaining to the requirement to exclude women'         HCA needs these lists from each MCO. If you choose                       X
        Eligibility/                   healthcare services from EOBs, how should these         to use EOBs, please share with HCA the exclusion list
        Benefits                       services be identified - by diagnosis, procedure        of diagnoses and procedures you will exclude to protect
                                       code etc? Can a list be provided of the codes that      the confidentiality of clients seeking women’s health
                                       need to be excluded?                                    care, family planning and behavioral health.

62      834                            Will both monthly (audit) and weekly IB 834 contain     Medicaid: For Medicaid Programs the monthly 834 will
                                       termination records, or should we assume that           not include termination records. All records on the audit
                                       members not present in the monthly IB 834 are           with have the Maintenance Type Code (Loop 2000
                                       terminated?                                             INS03) 030 – Audit to deliver eligible members for the
                                                                                               month. Weekly 834 update files will include termination
                                                                                               records in addition to Adds, Changes, Terminations and
                                                                                               Reinstatements. If a member is not present on the
                                                                                               Monthly 834 Audit the assumption should be made that
                                                                                               they either Termed or Changed Plans. The termination
                                                                                               or change would have been delivered on one of the
                                                                                               weekly update 834s leading up to the Audit file creation.

                                                                                               Monthly 834 Audit File:
                                                                                               Loop 2000 INS03 Maintenance Type Code = 030 Audit
                                                                                               Weekly 834 Update Files:
                                                                                               Loop 2000 INS03 Maintenance Type Code;
                                                                                               • 001 – Change
                                                                                               • 021 – Addition
                                                                                               • 024 – Termination
                                                                                               • 025 – Reinstatement
                                                                                                                             For Basic Healthe INS04.
                                                                                               Code values used:
                                                                                               07=Termination of Benefits;
                                                                                               14=Voluntary Withdrawal;
                                                                                               20=Active;
                                                                                               41=Re-enrollment;
                                                                                               AI=No Reason Given or Ineligible, Not Enrolled or Not
     63 Readiness   Contracts          Referring to contract section 8.9.2: we understand      The MCO will need to file the incentive plan and obtain
        Review                         that physician incentive plans are important to         HCA approval prior to utilization.
                                       improving the quality of care our members receive.
                                       We have an incentive program that we are ready to
                                       start circulating among providers. Can we
                                       immediately start using the incentive plan (in the
                                       form of a payment appendix) and have it reviewed
                                       during the readiness review process/when most
                                       efficient for HCA in the future or do we need to file
                                       the plan and obtain approval before starting to
                                       utilize?



                                                                                                         11
                                                                                         All Plan Meeting - QMCO questions April 5, 2012
 Q#          Group       SME          Page                         Question                          Response                                                  New Answer since last posting

     64 IT               Contracts           Is it HCA's intention to submit PCP assignment on    HCA Healthy Options will send PCP choice if provided                      X
                                             initial enrollment records only and PCP changes will by the enrollee. Enrollee may also work with the MCO
                                             go through the health plan?                          directly.                        HCA Basic Health-
                                                                                                  NO. We do not track PCP. PCP is between the
                                                                                                  enrollees and the MCOs.

65        File layout                        Can you provide the requirements and layout for the Medicaid: The submission format for the pre contract
                                             monthly provider file submission                    submissions will be provided in the next week. There is
                                                                                                 no other monthly submission requirement at this time.

66        File layout                        Can you provide a provider directory layout             Medicaid: HCA needs clarification of this question. Is
                                             including required fields?                              the question addressing the MCO’s publicly assessable
                                                                                                     provider directory or is the question addressing the
                                                                                                     submission mentioned above?
     67 Operations/ Contracts                What are the specialties to be excluded/included        Please see answer to #66, need clarification on what
        Eligibility/                         for the WA provider directory?                          this question is referring to.
        Benefits

     68 Readiness        Monitoring          What is the preference on documents for the           All documentation will be requested electronically.
        Review                               readiness review? Should all materials be printed or
                                             can they be available electronically?
     69                  Contracts           If the health plan is using a shared savings model , The incentives paid to providers would be considered                      X
                                             will the savings be accrued to medical costs?         the same as direct payments for purposes of
                                                                                                   calculating the loss/ratio
70        File layout                        Is there a sample file layout of the benefit          Medicaid: Yes, there will be a test environment for
                                             enrollment file that can be provided?                 MCOs to evaluate their system needs.
                                                                                                   Training was on March 9th.
                                             4.1.2 The Contractor shall reconcile the electronic   Basic Health: BH will provide sample test file to the
                                             benefit enrollment file with the premium payment      health plans as specified in the contract.
                                             information and submit differences it finds to HCA
                                             for resolution within sixty (60) calendar days of the
                                             first day of the subject month.

     71    Contract, Contracts               What specifically are HCA's methods and key             More than likely we will use HEDIS measures, but at
           Page 54,                          performance measures that will be utilized for          this point it is still in process for completion.
          Section 5.14                       enrollee assignments?
           Enrollee
          Assignment                         5.14 Assignment of Enrollees
                                             5.14.1.2 In any subsequent extension to the
                                             Contract, HCA will make assignments based on
                                             cost and performance measures and by methods
                                             designed and selected by HCA.
72        Prior                              Can HCA confirm the timing of when MCOs can             Medicaid: Unable to do this at this time. MCOs will be                 X
          Authorizatio                       expect to receive Prior Auth files and validate the     able to access Prism only. Future training will be held
          n File                             file format (i.e. 278)?                                 on this


                                                                                                               12
                                                                                   All Plan Meeting - QMCO questions April 5, 2012
Q#      Group     SME          Page                         Question                           Response                                                    New Answer since last posting

 73 Exhibit B-3 Monitoring            Can HCA confirm if the Basic Health performance          The provisions of Exhibit B-3 have been incorporated
        Basic                         standards listed in this exhibit apply to the Healthy    into the main body Contract and the applicability of each
       Health                         Options line of business as well?                        depends on the placement; some are specific to Basic
      2012-13                                                                                  Health, others apply to both Basic Health and Healthy
     Performanc                                                                                Options, as indicated in the Contract.
          e
     Standards
    (v. 10/31/11)

 74 Coinsurance Contracts             For Basic Health, do MCOs have the ability to            No, an MCO may not deviate from the BH member cost
     and Copay                        adjust the coinsurance and copay amounts or are          sharing as described in the Certificate of Coverage (the
      Amounts                         these defined by HCA?                                    Basic Health Member Handbook)

 75      General   Contracts          Does HCA have a timeline of key activities for the       The Health Care Authority (HCA) has developed the
      Implementat                     overall project to ensure all of us are operating with   following website to address questions related to the
       ion Process                    the same expectations regarding deadlines?               Basic Health – Health Options Managed Care contract.
                                                                                               http://www.hca.wa.gov/managed_care HCA is in the
                                                                                               process of updating it with additional information and
                                                                                               Frequently Asked Questions (FAQs).

 76      General   Communica          Does HCA have a defined process for                      HCA is developing this process now, and we will                          X
      Implementat     tion            communicating with the MCOs?                             communicate it to the health plans when it is complete.
       ion Process

 77      General   Contracts          Who will provide final resolution / approval of          HCA is still in the process of developing a
      Implementat                     decisions and what is the escalation process the         communication plan and will share this with the health
       ion Process                    Plans should follow when issues arise?                   plans in the future.

 78 Member / Contracts                What is HCA’s communication plan for educating           Brooke has shared her timeline and it has been posted                    X
     Provider                         the members, community agencies and provider             on the intranet
     Outreach                         groups?
 79 Contracting Network               What is the target date the networks will need to be     May 16th is the date that new plans should have their
                                      converted from LOIs to fully executed contracts?         networks within contract requirements.

 80 Contracting     Network           How frequently will HCA be providing the MCOs     Currently there is no plan to provide this information.
                                      with a list of current enrolled providers?        There is no vehicle that would provide the MCO’s a list
                                                                                        of Providers currently holding Core Provider
                                                                                        Agreements.
 81      General   Communica          Are there materials that we can submit in advance You can submit materials you would like us to review to                         X
      Implementat     tion            of an executed contract for approval? Such as web hcamcprograms@hca.wa.gov
       ion Process                    content, media plan or provider materials.




                                                                                                         13
                                                                                      All Plan Meeting - QMCO questions April 5, 2012
Q#      Group         SME         Page                         Question                            Response                                                     New Answer since last posting

 82 Transferring Contracts               How will the state be providing YTD deductible and HCA continues to work on resolving this questions                                X
       of YTD                            out-of-pocket costs to the MCOs? Will the MCOs be
    Deductibles                          required to provide this information back to the state
    and Out-Of-                          on a regular basis? (in the event that a member’s
       Pocket                            eligibility changes or switches plans)
        Costs
 83 Contract,     Contracts              Please clarify if the definition of subcontract           Subcontracts include any agreement between a
      Page 18,                           includes both subcontractor agreements and                contracted MCO and a provider, whether the provider is
    Section 1.81                         provider agreements.                                      a single provider, clinic, hospital, pharmacy or any other
     Definition -                                                                                  provider.
    "Subcontrac                          Subcontract
          t"                             “Subcontract” means any separate agreement or
                                         contract between the Contractor and an individual
                                         or entity (“Subcontractor”) to perform all or a portion
                                         of the duties and obligations that the Contractor is
                                         obligated to perform pursuant to this Contract.

 84    Contract,      Contracts          Please clarify if the provision "any action by the   (1) All actions. (2) Anything that would affect or relate                      X
       Page 33                           insurance commissioner" is referring only to actions to the Contractor's contractual obligation's under the
       Section                            relating to solvency, or all actions.               Contract.
        2.32.5
       Solvency                          Please clarify what is meant by the provision “may
                                         affect the relationship of the parties"

                                         2.32.5
                                         The Contractor shall notify HCA within 24 hours
                                         after any action by the Insurance Commissioner
                                         which may affect the relationship of the parties
                                         under this Contract.
 85     Contract,     Contracts          What interpreter agencies is HCA currently                HCA contracts for Interpreter Services (IS) with the                      X
        Page 41,                         contracted with for outpatient medical visits and         contractors listed on our website (please see link
         Section                         hearings?                                                 below), who in turn contract with language agencies.
         3.3.1.3                                                                                   Language agencies contract with individual (freelance)
       Utilization                       3.3.1.3                                                   interpreters.
        of State                         HCA is responsible for payment for interpreter            http://hrsa.dshs.wa.gov/InterpreterServices/SpokenLang
       contracted                        services provided by interpreter agencies                 uageVendor.htm
      Interpretatio                      contracted with the state for outpatient medical
       n Services                        visits and hearings.




                                                                                                            14
                                                                                    All Plan Meeting - QMCO questions April 5, 2012
Q#      Group        SME         Page                         Question                          Response                                                 New Answer since last posting

 86    Contract,     Contracts          The following questions all pertain to section 4.2      (1) The disputes process is described in the contract.                X
       Page 43,                         Medical Loss Ratio Limitation                           (2) We not have MLR requirements for the period July
      Section 4.2                                                                               1, 2012 - December 31, 2012.
        Medical                         1) What rights do we have as the Contractor to
      Loss Ratio                        challenge any determination by HCA that we did not
       Limitation                       hit the MLR 83% threshold.

                                        2) Does HCA provide MLR guidance for 2012 (7/1-
                                        12/31)

                                        4.2 Medical Loss Ratio Limitation
                                        The Contractor medical loss ratio for each program
                                        is limited to eighty-three percent (83%) in calendar
                                        year 2013. Medical loss ratio shall be as defined by
                                        the Office of the Insurance Commissioner (OIC) in
                                        RCW 48.43.049 with the additional inclusion of any
                                        quality incentive payments made directly to
                                        Participating Providers prior to the end of the year.
                                        If the Contractor’s actual medical loss ratio as
                                        determined by HCA and its actuaries using the
                                        Contractor’s financial information, is less than
                                        eighty-three percent (83%) percent, HCA will
                                        calculate an amount due from the Contractor by
                                        subtracting the Contractor’s actual medical loss
                                        ratio related to its performance under this Contract
                                        in the calendar year from eighty-three percent
                                        (83%) percent and multiplying the result by the total
 87    Contract,     Contracts          What is the process by which HCA notifies the         HCA Healthy Options – Weekly 834 Update files will be                   X
       Page 54,                         contractor of enrollment and disenrollments?          sent providing the transactions that occurred the
      Section 5.14                                                                            previous week. HCA Basic Health – 834 Update files
       Enrollee                         What are the timeframes around retroactive            will be sent on the 7th, 14th, and 3 working days before
      Assignment                        disenrollments?                                       end of month.

                                        5.14 Assignment of Enrollees
                                        5.14.1 Potential HO enrollees who do not select a
                                        HO plan shall be assigned to a HO Contractor by
                                        HCA as follows:
                                        5.14.1.1 For the period July 1, 2012 through June
                                        30, 2013
                                        assignments will be made as described in the
                                        Request for Proposals that resulted in this Contract.




                                                                                                          15
                                                                                     All Plan Meeting - QMCO questions April 5, 2012
Q#      Group        SME         Page                         Question                           Response                                                     New Answer since last posting

 88     Contract,    Contracts          Will HCA be facilitating discussions between peer      We will facilitate initial conversations with the health                    X
        Page 58,                        MCOs to conduct a non-clinical state PIP?              plans to initiate this project. At this time, we don’t
         Section                                                                               anticipate ongoing facilitation activities and expect the
          6.2.5                         6.2.5                                                  health plans to identify staffing resources to facilitate
       Performanc                       The Contractor shall collaborate with peer Medicaid the work defined in contract.
            e                           managed care organizations to conduct one non-
      Improvemen                        clinical statewide PIP on Transitional Healthcare
             t                          Services (THS) focused on enrollees with special
                                        health care needs or at risk for re-
                                        institutionalization, rehospitalization or substance
                                        use disorder recidivism. The Contractor will
                                        collaborate with peer Medicaid managed care
                                        organizations, primary care providers, state
                                        institutions, long-term care providers, hospitals, and
                                        substance use disorder programs to plan, execute
                                        and evaluate the project.

 89    Contract,     Contracts          Will HCA be facilitating discussions between peer        We will facilitate initial conversations with the health                  X
       Page 66,                         MCOs to develop a common practice guideline on           plans to initiate this project. At this time, we don’t
        Section                         the use of standardized screening tools?                 anticipate ongoing facilitation activities and expect the
      6.2.2Practic                                                                               health plans to identify staffing resources to facilitate
      e Guidelines                      6.6.2                                                    the work defined in contract.
                                        The Contractor, in collaboration with peer managed
                                        care organizations shall develop a common practice
                                        guideline on the use of standardized screening
                                        tools for: development in young children and for
                                        mental health and substance use disorders in
                                        children, adolescents and adults. The practice
                                        guideline will be completed and distributed to all
                                        Contractor and peer managed care organization
                                        primary care providers by June 30, 2013.



 90   Contract,      Contracts          In the below provision, what is the definition of        Group means any group of providers to which an an                          X
       Page 71                          "group"?                                                 enrollee may be restricted. Plans at times have
       Section                                                                                   provider contracts that restrict enrollees assigned to the
        8.6.1.5                         8.6.1.5                                                  group of providers to seeing providers within the group.
      Definition,                       Whether referrals for enrollees will be restricted to    Please note that this is not permitted for women's health
       "Group"                          providers affiliated with the group and, if so, a        care.
                                        description of those restrictions.




                                                                                                           16
                                                                                   All Plan Meeting - QMCO questions April 5, 2012
Q#      Group      SME         Page                         Question                           Response                                                    New Answer since last posting

 91    Contract,   Contracts          1) Please confirm that HCA would like for the            (1) Yes, the Contractor will repay the enrollee for any
       Page 86                        contractor to pay the enrollee back for any              inappropriate charges if its efforts to have the provider
       Section                        inappropriate charges if unsuccesful at getting the      repay the enrollee fail. (2) The Contractor may re-pay
         9.5.4                        provider to repay.                                       the enrollee directly by check.
       Enrollee                       2) How would HCA prefer that the contractor re-pay
        charges                       the member?

                                      9.5.4
                                      If an enrollee has paid inappropriate charges, the
                                      Contractor will make every effort to have the
                                      provider repay the enrollee the inappropriate
                                      amount. If the Contractor’s efforts to have the
                                      provider repay the enrollee fail, the Contractor will
                                      repay the enrollee the inappropriately charged
                                      amount.
 92    Contract,   Contracts          1) Who will be participating in the purchaser wide       Monthly meetings will take place with identified program
       Page 93,                       forum (who’s been invited)?                              integrity staff, we anticipate these meetings to begin in
       Section                        2) When will the discussions begin?                      July or August. The purchaser-wide forum will be part of
        11.2.1                                                                                 the monthly program integrity meetings. More
      Purchaser                       11.2.1.2                                                 information will be provided at a later date.
      Wide-Forum                      Participation in the development of a purchaser-
                                      wide forum to develop best practices, performance
                                      metrics, provider risk assessments, analytics,
                                      algorithms, audit processes, case development,
                                      and lessons learned.




                                                                                                         17
                                                                                      All Plan Meeting - QMCO questions April 5, 2012
Q#      Group        SME         Page                          Question                             Response                                                   New Answer since last posting

 93    Contract,     Contracts          1) Are the provisions in 11.6.1 referring only to           1) The provisions in 11.6.1 refer to both contracted
       Page 101,                        subcontractors or all contracted providers?                 providers and subcontractors. 2) An attestation would
        Section                                                                                     not be sufficient for the 11.6.1, 11.6.1.1, 11.6.1.2, or
         11.6.1                         2) Would attestation qualify as sufficient                  11.6.1.3 portions of the contract and would not meet the
       Excluded                         administration?                                             requirements cited in the contract.
      Individuals
      and Entities                      11.6.1 The Contractor shall monitor for excluded
                                        individuals and entities by.
                                        11.6.1.1 Screening Contractor and subcontractor
                                        individuals and entities with an ownership or control
                                        interest for excluded individuals and entities during
                                        the provider application, credentialing and
                                        recredentialing processes and prior to entering into
                                        a contractual or other relationship where the
                                        individual or entity would benefit directly or indirectly
                                        from funds received under this Contract.
                                        11.6.1.2 Screening monthly newly added Contractor
                                        and subcontractor individuals and entities with an
                                        ownership or control interest for excluded
                                        individuals and entities that would benefit directly or
                                        indirectly from funds received under this Contract.
                                        11.6.1.3 Screening monthly Contractor and
                                        subcontractor individuals and entities with an
                                        ownership or control interest that would benefit from
                                        funds received under this Contract for newly added
                                        excluded individuals and entities.

 94    Contract,     Contracts          Is it the intent of HCA to disallow a provider from         A provider may act on behalf of an enrollee and file
       Page 104                         acting on behalf of the member insofar as a                 either a grievance or an appeal, with the consent of the
      Section 12.2                      grievance (not an appeal) is concerned?                     enrollee.
       Grievance
        Process                         12.2.1
                                        “Only an enrollee or the enrollee’s authorized
                                        representative may file a grievance with the
                                        Contractor; a provider may not file a grievance on
                                        behalf of an enrollee (42 CFR 438.402(b) (3)).”

                                        However, the CFR which is sited states: “(ii) A
                                        provider, acting on behalf of the enrollee and with
                                        the enrollee’s written consent, may file an appeal. A
                                        provider may file a grievance or request a State fair
                                        hearing on behalf of an enrollee, if the State permits
                                        the provider to act as the enrollee’s authorized
                                        representative in doing so. “



                                                                                                            18
                                                                                    All Plan Meeting - QMCO questions April 5, 2012
Q#      Group        SME         Page                         Question                           Response                                                  New Answer since last posting

 95    Contract,     Contracts          Please clarify the discrepancy in timing regarding       The contract language is inconsistent. We will modify                  X
       Page 113                         the delivery of home health services.                    13.3.4. in a future contract modification to align with
        Section                                                                                  13.2.2.9.
        13.2.2.9                        13.2.2.9
      Transitional                      13.2.2 - An individual enrollee plan for interventions
         Care                           to mitigate the risk for reinstitutionalization, re-
                                        hospitalization or treatment recidivism to include:
       Contract,
       Page 114                         13.2.2.9 - Scheduled outpatient mental health
       Section                          and/or primary care visits within seven (7) calendar
        13.3.4                          days of discharge and/or physical or mental health
      Coordinatio                       home health care services delivered within seven
       n of Care                        (7) calendar days of discharge ;

                                        13.3.4
                                        The Contractor shall ensure enrollees at high risk of
                                        re-hospitalization and/or substance use disorder
                                        treatment recidivism have a documented, individual
                                        plan for interventions to mitigate risk. Care plans
                                        shall include scheduled outpatient mental health
                                        and/or primary care visits within seven (7) calendar
                                        days of discharge; and/or physical or mental health,
                                        home health services delivered within fortyeight
                                        (48) hours of discharge .



 96      Your        Contracts          Please confirm whether or not the Healthy Options        Yes – MCOs will continue to provide the outpatient
       Medical                          membership, come July 1, 2012 and regardless of          mental health services according to the new HO
        Benefit                         MCO, will maintain the mental health benefits listed     Contract for enrollees who do not meet the access to
      Book, Page                        on page 9 of the "Your Medical Benefit Book" to          care standards of the RSN. Please see Section D of the
           9                            include psych evals, psych testing, 12 hours of           Physician Related/Healthcare Professional Services
                                        treatment per calendar year for adults 19 and up         Medicaid Provider Guide and the Psychologist guide for
        Mental                          and 20 hours of treatment per calendar year for          additional information.
      Health Care                       children 18 and below. Please provide a listing of
        Needs                           the billing codes/provider types for these services.

 97 Professional     Contracts          For Healthy Options, inpatient mental health and         Inpatient psychiatric services are excluded from the
       Services                         detox services are not covered by the MCOs. Does         MCO HO contract this includes professional services
     Coverage                           this also extend to professional services performed      obtained through the RSN. Please see Section D of the
     related to                         by psychiatrists and psychiatric nurse practitioners     Physician Related/Healthcare Professional Services
      Inpatient                         in the inpatient setting for the inpatient mental        Medicaid Provider Guide
       Mental                           health and detox services? For example, a
    Health and                          psychiatrist billing standard E&M code like 99221 or
        Detox                           the discharge service like 99238.
       Services

                                                                                                          19
                                                                                    All Plan Meeting - QMCO questions April 5, 2012
 Q#       Group       SME         Page                        Question                          Response                                                     New Answer since last posting

  98 Responsibili     Contracts          For Health Options, if a chemical                      Please see the Section D of the Inpatient Hospital
     ty of Detox                         dependency/substance abuse diagnosis code is           Services Medicaid Provider Guide instructions on what
         Stay                            primary on an inpatient claim, would that detox stay   services are covered by HCA and excluded from the HO
                                         be the state, RSN or DASA responsibility and not       contract.
                                         the MCO's?
  99      IVR -       Contracts          Does HCA have specific transfer phone numbers          Nonemergency Medical Transportation (NEMT)
       Dental and                        that the MCOs can program into their Interactive       HCA contracts with six different agencies as
       Transportati                      Voice Response (IVR) systems to redirect Dental        transportation brokers; these six brokers cover 13
            on                           and Transportation calls?                              broker regions, which cover all 39 counties in the state.
                                                                                                There is no one telephone number statewide. See
                                                                                                additional information at the following websites. Here is
                                                                                                a link to the index of transportation brokers:
                                                                                                http://hrsa.dshs.wa.gov/Transportation/Phone.htm Here
                                                                                                is a link to our website (general):
                                                                                                http://hrsa.dshs.wa.gov/Transportation/


 100      General     Contracts          Will HCA designate a primary and backup contact        For Contract administration after July 1st the Contractor                 X
       Implementat                       within HCA (or other agencies/vendors) that MCOs       will be assigned to a particular contact. At this time the
        ion Process                      should be working through?                             palns will be working with a transition team of multiple
                                                                                                individuals. The point of contact is through the e-mail
                                                                                                box provided.
101    Membership                        For the SSI (blind disabled) members who become        Medicaid: Yes
                                         eligible for services after the initial enrollment
                                         period, will HCA apply the same algorithm (as
                                         described in RFP) to assign membership to a
                                         participating MCO?
102    Interface                         Are there any systems or programs that HCA will        Medicaid: Yes. HCA will contact each MCO to set up
                                         require MCOs to interface, reference or integrate      necessary access
                                         with that will require the MCO to submit access
                                         requests?




                                                                                                          20
                                                                                     All Plan Meeting - QMCO questions April 5, 2012
Q#      Group        SME          Page                         Question                          Response                                                   New Answer since last posting

103    Contract,     Monitoring          New 2012 NCQA standards for urgent and                  The Contract requires enrollees to exhaust all levels of
       Page 108                          concurrent appeal allows for members (or providers      resolution and appeal within the MCO Grievance
        Section                          acting on behalf of a member) to access both            System prior to filing a request for an administrative
       12.5.6 &                          internal MCO appeal process and external State          hearing.
         12.6                            Fair Hearing at the same time.
       External
        Appeal                           Please confirm HCA will maintain its current
       Reviews                           requirement that enrollees must exhaust all MCO
                                         internal levels of appeal prior to requesting a
                                         hearing with HCA or an Independent Review.

                                         12.5.6 The enrollee must exhaust all levels of
                                         resolution and appeal within the Contractor’s
                                         grievance system prior to filing a request for a
                                         hearing with HCA (42 CFR 438.402(b) (2) (ii)).

                                         12.6 After exhausting both the Contractor’s appeal
                                         process and the hearing process an enrollee has a
                                         right to independent review in accord with RCW
                                         48.43.535 and WAC 284-43-630.



104    Contract,     Contracts           Please provide or direct us to Ombudsman contact        HCA is currently revising contract language that will
       Page 92                           information to be included in the denial of service     help interpret this area. Contact the OIC directly about
        Section                          notice to members.                                      how to provide information about the appropriate
      10.3.3.2.2.7                                                                               ombudsman references.
      Ombudsma                           The notice shall meet the following requirements:
           n                             10.3.3.2.2.7 The availability of Washington’s
                                         designated Ombudsman’s office as referenced in
                                         the Affordable Care Act (Public Law 111-148).




                                                                                                           21
                                                                                  All Plan Meeting - QMCO questions April 5, 2012
Q#      Group     SME          Page                         Question                            Response                                                  New Answer since last posting

105       HCA      Contracts          Are the MCOs required to implement the existing           For family planning – YES.                                             X
       Medicaid                       prescription exception processes for over-the-            For Smoking Cessation – Fee-for-service HCA pays
       Provider                       counter Family Planning Products and Nicotine             only if client gets Nicotine Replacement Therapy
       Guide – A                      Replacement Products as outlined in the HCA               through the Quite Line… Alere, formerly Free and Clear.
       Guide to                       Medicaid Provider Guide – A Guide to Prescription
      Prescription                    Drug Program manual?
          Drug
       Program                        Page C.7 - Over-the-Counter Family Planning
        manual,                       Products
       Page C.7                       The Agency reimburses specific OTC family
       WAC 182-                       planning drugs, devices, and supplies without a
      530-2000(4)                     prescription. The following OTC contraceptives may
      Exceptions                      be dispensed without a prescription to any
         to the                       Agency client with a current Services Card:
      Prescription                    • Condoms (including female condom);
      Requiremen                      • Vaginal spermicidal foam with applicator and refills;
            ts                        • Vaginal jelly with applicator;
                                      • Vaginal creams and gels; and
                                      • Vaginal suppositories.

                                      Emergency contraception (Plan B) is also available
                                      without a prescription for females age 18 and older.

                                      Page C.7. Over-the Counter Nicotine Replacement
                                      Therapy (NRT) The Agency reimburses for specific
                                      OTC NRT products without a prescription (see page
                                      F.1) when distributed by a Agency-approved




                                                                                                        22
                                                                                    All Plan Meeting - QMCO questions April 5, 2012
Q#      Group        SME         Page                         Question                           Response                                                   New Answer since last posting

106      HCA       Contracts            Can the MCO set up a system to allow WA                  Yes                                                                     X
       Medicaid                         Pharmacists with prescriptive authority for ECP so
       Provider                         that they may prescribe and bill for selected anti-
       Guide – A                        emetics only when they are dispensed in
       Guide to                         conjunctions with ECPs?
      Prescription
         Drug                           Page F.6 - Anti-emetics Pharmacists with
       Program                          prescriptive authority for emergency contraceptive
        manual                          pills may prescribe and bill for selected anti-emetics
       Page F.6                         only when these drugs are dispensed in conjunction
      Prescribing                       with ECPs. The Agency reimburses the following
      Anti-emetics                      only when they are prescribed and dispensed in the
                                        strength/dose form listed:
                                        Meclizine hydrochloride 25 mg tablets
                                        Diphenhydramine hydrochloride 25 mg
                                        tablets/capsules
                                        Dimenhydrinate 50 mg tablets
                                        Promethazine hydrochloride 25 mg tablets or 25 mg
                                        suppository
                                        Metoclopramide 5 mg, 10 mg tablets
                                        Prochlorperazine 25 mg suppository


107       HCA        Contracts          Are the MCOs allowed to establish criteria for           The MCO's would follow the PRC WAC 182-501-0135
       Medicaid                         administering the pharmacy lock in program that are      criteria to adminster the program. Providers are
       Provider                         different from those outlined in the HCA Medicaid        assigned on a case by case basis. The MCO can
       Guide – A                        Provider Guide – A Guide to Prescription Drug            assign all or a combination of the providers listed on a
       Guide to                         Program manual, page F.7?                                case by case basis.
      Prescription
          Drug                          Page F.7. Patient Review and Coordination
       Program                          Program (PRC)
        manual,                         PRC is a health and safety program for FFS and
       Page F.7                         managed care clients needing help in the
       [Refer to                        appropriate use of medical services.
       WAC 182-                         Clients assigned to the PRC program are identified
       501-0135]                        as such in ProviderOne. A client in the PRC
        Patient                         program may be restricted to any of the following:
      Review and                        • Primary care provider (PCP);
      Coordinatio                       • Narcotic prescriber;
      n Program                         • Pharmacy;
         (PRC)                          • Hospital (for non-emergency medical services); or
                                        • Another qualified provider type, as determined by
                                        the Agency or managed care organization (MCO)
                                        staff on a case-by-case basis.



                                                                                                          23
                                                                                 All Plan Meeting - QMCO questions April 5, 2012
Q#      Group       SME         Page                        Question                         Response                                                    New Answer since last posting

108 ProviderOne Contracts              Are the MCOs expected to exchange Pharmacy            Yes MCO's are expected to exchange pharmacy info
                                       information with ProviderOne? If yes, how will this   with ProviderOne, submit them using standard NCPDP
                                       be done?                                              D.0 files.
109    Copays /     Contracts          Could you please confirm the copays/cost sharing      Basic Health Plus does not require enrollee cost
        Cost                           for the Basic Health Plus population? The Basic       sharing. The purpose of BH Plus is to allow Medicaid-
      Sharing for                      Health handbook says that policies apply to all       eligible children to be enrolled with the same MCO as
        Basic                          Basic Health Members, but the additional              their Basic Health-enrolled parent(s). While there is
      Health Plus                      information says that copays/cost sharing does not    some limited information in the BH Member Handbook
                                       apply to children under the age of 19.                about Basic Health Plus, it is a separate program and is
                                                                                             detailed in another handbook.

110 suspended       Contracts          Can HCA confirm that May and June 2012                Yes, as per RFP assignments will be held for May and                     X
    payments                           assignments will be suspended for the current         June 2012.
                                       Healthy Options program, however MCOs will
                                       continue to receive reconnects and clients who
                                       actively choose the MCO?
111 HO blind        Contracts          As mentioned in the last All Plan meeting, the        See attached implementation schedule for the                             X
    disabled                           Healthy Option Blind Disabled population will have    Blind/Disabled program
    staggered                          a staggered enrollment by region. Can HCA
    enrollment                         provide clarification on what counties will be
                                       considered “Western” vs. Eastern” Washington?

112 client      Contracts              Will HCA mail out any communication to clients        HCA will send a Member Alert to all Basic Health
    communicati                        currently assigned to CHP/MHW? Will HCA mail          members the end of March alerting them of upcoming
    ons                                out any communication to FFS clients moving to        changes and the Open Enrollment period. We will send
                                       managed care? If so, what is the timing of these      a similar generic alert around the same time to
                                       mailings?                                             ~140,000 Healthy Options clients who will be displaced.
                                                                                             These alerts will be followed by member specific Open
                                                                                             Enrollment Notices or Healthy Option Assignment
                                                                                             letters in early April. Later in the spring, we will send
                                                                                             alerts to the new Blind/Disabled population and all
                                                                                             remaining Healthy Options clients informing them of
                                                                                             changes to the programs.

113 addendum        Contracts pg 84    Are “high categorical risk” providers considered   please see answers to 25-28
    5 exh C                            exempt from background checks if they are enrolled
    Section                            and screened by Medicare?
    8.14.14
    Background
    Checks




                                                                                                       24
                                                                               All Plan Meeting - QMCO questions April 5, 2012
Q#    Group      SME         Page                        Question                          Response                                                       New Answer since last posting

114 addendum     Contracts pg 104   Can HCA please clarify whether a provider can be       please see response to question 94
    5 exh C                         an authorized representative for an enrollee in filing
    Section                         a grievance? It appears HCA chooses not to permit
    12.2.1                          providers to be authorized representatives for
    Grievance                       grievances. 12.2 Grievance Process
    Process                         The following requirements are specific to the
                                    grievance process:
                                    12.2.1 Only an enrollee or the enrollee’s authorized
                                    representative may file a grievance with the
                                    Contractor; a provider may not file a grievance on
                                    behalf of an enrollee (42 CFR 438.402(b) (3)).CFR
                                    42 438.402: General requirements. (Title 42: Public
                                    Health, Part 438 Managed Care, Subpart F –
                                    Grievance System(b)(ii) A provider, acting on behalf
                                    of the enrollee and with the enrollee's written
                                    consent, may file an appeal. A provider may file a
                                    grievance or request a State fair hearing on behalf
                                    of an enrollee, if the State permits the provider to
                                    act as the enrollee's authorized representative in
                                    doing so.



115 addendum     Contracts pg 111   How does HCA plan on helping MCOs fulfill              Plans will be given access to PRISM for their capitated
    5 exh c                         continuity of care responsibilities with PRISM? Will   population, which will assist plans with their continuity of
    Section                         access for additional PRISM users be granted?          care requirements. We do not anticipate at this time that
    13.1.5.1                                                                               there will be a limit on the number of Plan staff who will
    Continuity                                                                             be allowed access to PRISM for approved uses.
    of Care

116 addendum     Contracts pg 118   Does HCA have an estimate of approximately how         We do not have these estimates                                              X
    5 exh c                         many members will qualify as Special Healthcare
    Section                         Needs Members that do not have a PRISM risk
    13.5                            score of 1.5 or higher? We are reviewing our
    Intensive                       staffing needs to meet the Intensified Care
    Care                            Management requirements and appreciate any
    Managemen                       available information.
    t for
    Enrollees
    with Special
    Health Care
    Needs




                                                                                                     25
                                                                                   All Plan Meeting - QMCO questions April 5, 2012
Q#     Group       SME          Page                         Question                          Response                                                   New Answer since last posting

117 addendum,      Contracts pg 4      This section states that for eligibility changes,       Eligibility category changes will be prospective                        X
    5 exh H                            premium changes will be prospective. Will MCOs          consistent with the premium payments. No retro
    Section 1.6                        receive eligibility category changes prospectively      changes.
    Retroactive                        only as well? If eligibility category changes are
    Premium                            retrospectively passed on to the MCO, when the
    Payments                           payment is not, it will significantly complicate our
    for Enrollee                       premium reconciliation process.
    Categorical
    Changes


118 addendum       Contracts pg 5      Can HCA confirm in writing the new managed care         The following are the names of the Healthy Options                      X
    5 exh H                            SSI population will be called Healthy Options- Blind    populations as identified in ProviderOne.
    Section 2.3                        Disabled?                                               Healthy Options (HO)
    Eligible                                                                                   State’s Childrens Health Insurance Program (SCHIP)
    Client                                                                                     Basic Health Plus (BHP)
    Groups                                                                                     Healthy Options – Blind/Disabled (HOBD)
                                                                                               Healthy Options – Foster Care (HOFC)


119 addendum       Monitoring pg 29    What information will be requested in the annual        This will be provided in a future posting.                              X
    5 exh                              TPL report?
    H3.7.3
    Annual TPL
    Report

120 Operations/    Contracts           Is smoking cessation covered by HCA for Healthy         It is covered for HO but not under Basic Health
    Eligibility/                       Options? For Basic Health?
    Benefits

121 Operations/    Contracts           If something in the Healthy Options Handbook is         No, the Basic Health benefit package is described in the
    Eligibility/                       listed as covered by HCA, not the Health Plan (e.g.     COC and members receive no other services, unless
    Benefits                           school medical services, genetic counseling) and is     the MCO provides it at no cost to the member.
                                       silent in the Basic Health COC, is it covered by
                                       HCA?
122 Operations/ Communica              Is it acceptable to provide the Healthy Options         If members request a copy of the Healthy Options
    Eligibility/   tion                handbook electronically and send post cards to          Medical Benefit Book, the expectation is for the MCO to
    Benefits                           members to request paper copies? Similar to the         print and mail the handbook. MCOs may send
                                       process for Basic Health                                postcards to notify members of the availability of the
                                                                                               general Medical Benefit Book on line, but if requested
                                                                                               must provide a paper copy of the book.
123 Operations/ Communica              Can you provide language percent breakdowns             Please see the attached spreadsheet which lists the                     X
    Eligibility/ tion                  (other than English) for the population?                primary language for the head of households for the
    Benefits                                                                                   population.




                                                                                                         26
                                                                             All Plan Meeting - QMCO questions April 5, 2012
Q#    Group     SME         Page                        Question                          Response                                                      New Answer since last posting

124 Operations/ Rates              Do you have any state specific codes that              HCA requires that encounters utilize National Standard
    Eligibility/                   encounters must utilize vs. National                   Code Sets. There are no state specific/local codes
    Benefits                       Standard such as NDC, POS, etc. None we                required for use with specific regard to NDCs, HCPCS,
                                   identified in the companion guide                      POS, ICD-9 Codes, etc… The Encounter Data
                                                                                          Reporting Guide along with the national standard 5010
                                                                                          Implementation and Companion Guides provide the
                                                                                          HCA requirements for encounter data reporting.

125             Contracts          Are there are any automatic disenrollment criteria     No                                                                         X
                                   for NICU infants? Some states have <1200gms at
                                   birth or LTC placement for >30days as an automatic
                                   disenrollment
126             Rates              Does the state have a list of all of the services      Basic Health members on the Maternity Benefits
                                   defined by code or other indicators, to denote those   Program receive the same services as Medicaid
                                   services that are to be covered by Maternity           Healthy Options members. The clients are Medicaid
                                   Benefits Program. If not, can we develop this          eligible.
                                   ourselves for approval?
127 Operations/ Contracts          2.3.2 states “HCA shall not pay any claims for         This is intended to define the timely filing for encounter
    Eligibility/                   payment for services submitted more than twelve        data claims submitted to HCA. Encounter Data
    Benefits                       (12) months after the calendar month in which the      received more than 365 days after Date of Service is
                                   services were performed.” Is this intended to define   rejected back to the plan. Health plans are expected to
                                   our timely filing to HCA for encounters or the         define their own timely claim filing timelines.
                                   provider's timely filing to the health plan for
                                   payment?
128 Operations/ Contracts          Should we assume that the Expected Delivery Date       1.      NO – The Expected Delivery Date is a date
    Eligibility/                   ends the Member's pregnancy status? Is Pregnancy       provided by the ACES eligibility system when a client is
    Benefits                       Due Date sent through the duration the Member's        enrolled on the Pregnancy Medical Program. If the
                                   pregnancy? Should a populated Pregnancy Due            client is on a different eligibility medical program ACES
                                   Date be our indicator of a member's pregnant           would not have the Expected Delivery Date even though
                                   status?                                                the client is pregnant.
                                                                                             2. If ProviderOne has a Pregnancy Due Date in the
                                                                                          system, the information is provided to the MCO in the
                                                                                          834 file per the Enrollment Companion Guide.
                                                                                                                        3. Both the Expected Delivery
                                                                                          Date and the Pregnancy Due Date are dates to be used
                                                                                          by the MCO to provide care coordination as needed.


129 Operations/ Communica          When is the first date that a health plan's phone      HCA will begin publishing the health plans’ contact
    Eligibility/ tion              number and website will be published to enrollees?     information in early April as part of Basic Health Open
    Benefits                                                                              Enrollment materials and Healthy Options
                                                                                          assignments. To prepare for Open Enrollment and
                                                                                          assignments, the contact information may go up on the
                                                                                          website before April.




                                                                                                   27
                                                                              All Plan Meeting - QMCO questions April 5, 2012
Q#    Group    SME          Page                        Question                          Response                                                   New Answer since last posting

130            Contracts           In what cases would a pregnant member who              Basic Health members who apply for maternity benefits
                                   applied for BMP be denied entry into that program?     through the S-Medical program must meet the income
                                   Is there an indicator on the 834 file to identify      and citizenship status requirements for that program.
                                   members who are in BH and have applied for BH          Those who are denied for reasons other than
                                   Maternity Benefits Program but were denied?            noncompliance with established information
                                                                                          requirements are identified in the enrollment file as
                                                                                          eligible for maternity services through Basic Health.

131 Operations/ Communica          If we identify a community partner / CBO, how could The State does not delegate enrollment functions;
    Eligibility/ tion              they become an enrollment center? What are the        however, community partners may assist enrollees in
    Benefits                       qualifications for a community center to do this?     completing the enrollment process, as long as the
                                                                                         enrollee has freedom to choose.
132            Monitoring          Can you point us to the certification and licensing   Practice guidelines are to be based on valid and reliable
                                   requirements for physicians as relevant to:           clinical evidence or a consensus of health care
                                   -the creation of clinical guidelines                  professionals in a particular field. They are to be
                                   -the creation of clinical coverage criteria           adopted with consultation with contracted health care
                                   -UM non coverage (denial) decisions for lack of       professionals and reviewed and updated periodically.
                                   medical necessity                                     The MCO is expected to use board certified consultants
                                                                                         to assist in making medical necessity determinations. A
                                                                                         current unrestricted license to practice in the State of
                                                                                         Washington is required for health care professionals
                                                                                         (including physicians) who make denials of care based
                                                                                         on medical necessity. Additionally, any decision to
                                                                                         deny a service authorization request or to authorize a
                                                                                         service in an amount, duration or scope that is less than
                                                                                         requested, must be made by a health care professional
                                                                                         who has appropriate clinical expertise in treating the
                                                                                         enrollee’s condition or disease. NOTE: MCO review
                                                                                         matches can be MCO physician-requesting physician;
                                                                                         MCO physician-requesting PT; MCO PT-requesting PT;
                                                                                         MCO physician-requesting pharmacist or MCO
                                                                                         pharmacist-requesting pharmacist, etc.. Specialty
                                                                                         match should occur in unique situations (e.g., transplant
                                                                                         specialist for provider requesting a transplant;
                                                                                         psychologist for provider requesting psychological or
133            Contracts           Does the MCO have to send a plan specific HO          Yes, every member must receive a plan specific ID
                                   identification card to each member within a specific within 15 days of enrollment.
                                   timeframe?
134 Contracting Network            Section 5.1.4 – This requires all Contractors to have The contract language will be changed to reflect
                                   networks in place by May 16, 2012. If the             “service area or this contract”.
                                   Contractor fails to secure a network for any
                                   contracted service area, HCA has the right to
                                   immediately terminate this contract. Can this
                                   language be changed to immediately terminate the
                                   “service area or this contract”, instead of “this
                                   contract”?

                                                                                                    28
                                                                           All Plan Meeting - QMCO questions April 5, 2012
Q#    Group   SME         Page                        Question                          Response                                                    New Answer since last posting

135           Finance            Exhibits A-1a and A-1b - Please help us understand The January 25, 1012 letters to Thuy from Milliman
                                 why the rates for Healthy Options and Healthy      regarding the rate adjustments were provided to the
                                 Options SSI differ from the rates we bid in the    apparently successful bidders on March 7, 2012.
                                 RFP? Please let us know whether the rates

136           Network            5.1.4 – Network Capacity – During our meeting          These mailings have been postponed. Basic Health                         X
                                 today with Preston Cody (and in the February All       Open Enrollment materials will not be sent until May
                                 Plan meeting) an April member mailing was              11th. Health Options materials will be sent at the end of
                                 mentioned. We understand this will be the              May
                                 displaced member assignment mailing for 7/1/12. If
                                 this contract section allows plans until May 16th to
                                 secure a network, will the April mailing be
                                 postponed until after the May 16th confirmations
                                 are received? We are concerned members will be
                                 assigned prior to final networks being secured.

137           Contracts          Section 2.34.3 – This gives HCA the right to           The contract language will remain as stated.                             X
                                 terminate our contract with 30 days notice.
                                 Currently our HO contract includes 120 days notice,
                                 and our BH contract includes 60 days notice. Can
                                 this be changed to 120 days, or at least 60 days
                                 notice?
138           finance            Please forward any documentation and policies          The January 25, 1012 letters to Thuy from Milliman
                                 around updates made prior to base rate calculation     regarding the rate adjustments were provided to the
                                 related to the bulleted items below. HCA reduced       apparently successful bidders on March 7, 2012.
                                 rates paid to managed care plans in late 2011 in
                                 anticipation of the limited ER visits. How does this
                                 reconcile with HCA’s new ER visit policy?

138           Contracts          Section 4.6.3.5 – This indicates HCA will authorize    HCA responded to this question during the RFP Q&A
                                 inpatient CPE hospital claims, which the Contractor    process
                                 will have to honor. Can this language be changed
                                 to “The Contractor will be authorizing inpatient
                                 claims at CPE hospitals…”?




                                                                                                 29
                                                                              All Plan Meeting - QMCO questions April 5, 2012
Q#    Group   SME         Page                         Question                            Response                                          New Answer since last posting

139           Contracts          Section 2.16.3 Records: Clarification of the              HCA has reviewed this request for change to the
                                 provisions in Section 2.16 for Records and 2.30 for       contract, at this time HCA declines to make the
                                 Proprietary Data and Trade Secrets.                       requested change.
                                                                    2.16.3 The
                                 Contractor acknowledges the HCA is subject to the
                                 Public Records Act (chapter 42.56 RCW). This
                                 contract will be a “public record” as defined in
                                 chapter 42.56 RCW. Except for proprietary data or
                                 trade secrets referred to in Section 2.30 , Any
                                 documents submitted to HCA by the Contractor
                                 may also be construed as “public records” and
                                 therefore subject to public disclosure under chapter
                                 42.56 RCW.
140           Finance            Section 4.2 Medical Loss Ratio Limitation: Clarify        HCA has reviewed this request for change to the
                                 that medical management and provider incentive            contract, at this time HCA declines to make the
                                 payments are included in medical Loss Ratio               requested change.
                                 calculations.              4.2 Medical Loss Ratio
                                 Limitation The Contractor medical loss ratio for
                                 each program is limited to eighty-three percent
                                 (83%) in calendar year 2013. Medical loss ratio
                                 shall be as defined by the Office of the Insurance
                                 Commissioner (OIC) in RCW 48.43.049 with the
                                 additional inclusion of all program medical
                                 management expenses, Physician Incentive Plans
                                 and any other quality incentive payments made
                                 directly to Participating Providers prior to the end of
                                 the year. If the Contractor’s actual medical loss ratio
                                 as determined by HCA and its actuaries using the
                                 Contractor’s financial information, is less than
                                 eighty-three percent (83%), HCA will calculate an
                                 amount due from the Contractor by subtracting the
                                 Contractor’s actual medical loss ratio related to its
                                 performance under this Contract in the calendar
                                 year from eighty-three percent (83%) and
                                 multiplying the result by the total premiums paid to
                                 the Contractor for the calendar year, including the
                                 Delivery Case Rate. The Contractor shall remit to




                                                                                                    30
                                                                             All Plan Meeting - QMCO questions April 5, 2012
Q#    Group    SME        Page                         Question                           Response                                          New Answer since last posting

141            Contract          Section 4.7 Payment for Services by Non-                 HCA has reviewed this request for change to the
                                 Participating Providers: In order to best serve          contract, at this time HCA declines to make the
                                 enrollees, incent providers to participate in network,   requested change.
                                 and standardize non-network payments, clarify
                                 floor.                                  4.7.2 Except
                                 as provided herein for emergency services, the
                                 Contractor shall pay a non-participating provider
                                 that provides a service to enrollees under this
                                 Contract no more than the lesser of the lowest
                                 amount paid for that service under the Contractor’s
                                 contracts with similar providers in the state or
                                 ninety percent (90%) of HCA’s, Medicaid Fee-For-
                                 Service (FFS) program (Deficit Reduction Act of
                                 2005, Public Law No. 109-171, Section 6085. For
                                 the purposes of this subsection, “contracts with
                                 similar providers in the state” means the
                                 Contractor’s contracts with similar providers to
                                 provide services under the Healthy Options
                                 program when the payment is for services received
                                 by a Healthy Options enrollee. For payment for
                                 services received by a Basic Health enrollee,
                                 “contracts with similar providers in the state” means
                                 the Contractor’s contracts with similar providers to
                                 provide services under the Basic Health Plan.
142 Contracting Network          Section 5.1.4 Network Capacity: Contractors              HCA has reviewed this request for change to the
                                 should have opportunity to cure network; if not          contract, at this time HCA declines to make the
                                 cured within agreed timeframe, contract should           requested change.
                                 terminate only for specific Service Area impacted.
                                                                5.1.4 In the event the
                                 Contractor fails to secure a network of medical
                                 providers by May 16, 2012 or fails to maintain an
                                 adequate provider network for any contracted
                                 service area which, in the sole opinion of HCA, will
                                 ensure adequate access to care in that service
                                 area, and Contractor fails to submit an acceptable
                                 corrective action plan and cure the default within
                                 ninety (90) calendar days after receipt from HCA of
                                 a written notice, then HCA reserves the right to
                                 immediately terminate this contract the impacted
                                 service area . Further, HCA retains the right to
                                 immediately terminate this contract if the Contractor
                                 fails to maintain an adequate provider network.




                                                                                                   31
                                                                             All Plan Meeting - QMCO questions April 5, 2012
Q#    Group    SME         Page                         Question                          Response                                          New Answer since last posting

143 Assignment Contracts          Section 5.14 Assignment of Enrollees: Contracts         HCA has reviewed this request for change to the
                                  should contain criteria for auto assignment of          contract, at this time HCA declines to make the
                                  Healthy Options enrollees to prevent confusion          requested change.
                                  between Contract and Request for Proposal (RFP)
                                  and be consistent with RFP.

                                  5.14.1 Potential HO enrollees who do not select a
                                  HO plan shall be assigned to a HO Contractor by
                                  HCA as follows:

                                  5.14.1.1 For the period July 1, 2012 through
                                  December 31, June 30, 2013, assignments will be
                                  made as follows: described in the Request for
                                  Proposals that resulted in this Contract.

                                  5.14.1.1.1 Fifty percent (50%) of assignments in a
                                  Service Area will be made to Contractor if
                                  Contractor has not provided managed care
                                  services to enrollees in that Service Area at any
                                  time in the twelve months prior July 1, 2012. If more
                                  than one Contractor enters a new Service Area, the
                                  assignment will be apportioned based on the
                                  weighting described herein.

                                  5.14.1.1.2 The remainder of the assignments in the
                                  service area (100% if there are no new entries) will
                                  be apportioned between all Contractors providing




                                                                                                   32
                                                                           All Plan Meeting - QMCO questions April 5, 2012
Q#    Group   SME         Page                         Question                        Response                                           New Answer since last posting

144           Contracts          Section 8.7 Health Homes: Provide flexibility in light HCA has reviewed this request for change to the
                                 of evolving nature of services.                        contract, at this time HCA declines to make the
                                                                                        requested change.
                                 8.7 Health Homes
                                 The Contractor shall use best efforts to subcontract
                                 with community entities sufficient in quantity and
                                 type to provide the intensive services defined in
                                 Section 13 of this contract. The Contractor shall
                                 provide health home services as part of a qualified
                                 health home, or may enter into subcontractor
                                 agreements with Health Homes, qualified by the
                                 State to deliver health home services for child and
                                 adult enrollees with special health care needs, but
                                 must have a network of providers sufficient to
                                 provide defined services. Subcontractor
                                 agreements shall contain elements defined by the
                                 State and which may include:

                                 light of evolving nature of services.




                                                                                                 33
                                                                                    All Plan Meeting - QMCO questions April 5, 2012
Q#      Group       SME          Page                         Question                           Response                                                   New Answer since last posting

145     Basic       Contracts           How will the state notify the plan a member has          Plans are notified via the monthly enrollment rosters of                X
        Health                          applied and been approved for the Basic Health           members who begin Maternity Medical via S-Medical.
       Maternity                        Maternity Program?
       Program                                                                                  If a BH member is denied Medicaid Maternity Benefits
                                        If the member applies and does not qualify for the      for any reason other than non-compliance with the
                                        maternity program will the plan be expected to          application process, the member may continue to
                                        continue coverage under the Basic Health Program receive maternity benefits from Basic Health; this is
                                        or will the state notify us of termination of coverage? usually caused by differences between the way certain
                                                                                                types of income and family composition are determined
                                        We understand if the member applies and does not between the programs.
                                        qualify for the maternity plan they will continue their
                                        eligibility under the Basic Health Program. Please      Yes, this is correct see above.
                                        confirm.
                                                                                                Plans are notified via the monthly enrollment rosters of
                                        Once a member has delivered how will the state          members who return to BH after Maternity Medical via S-
                                        notify us a member has transitioned back to the         Medical.
                                        Basic Health program?
                                                                                                BH members have 30 days of coverage after
                                        If the health plan identifies a member is pregnant,     notification of pregnancy. During this time the member
                                        should/how should this notice be sent to the state? needs to apply for maternity medical benefits. Members
                                                                                                are responsible for reporting the need for maternity
                                        Please confirm encounter acceptance will not be         medical coverage and for applying for coverage.
                                        dependant on the appropriate benefit package if the
                                        state has not notified us the member has changed Plans are not required to report encounter data for
                                        from one package to the next?                           Basic Health members.


146     Basic        Contracts          The Basic Health Plus information states HCA will        Yes, there will be no changes to the BH plus program.                   X
      Health Plus                       determine eligibility into the Basic Health Plus         The HCA provides the services card through the
       Services                         program and members will receive a Services card         Provider One system.
         Card                           from HCA, will that continue?

                                        Will the health plan provide the services card or will
                                        HCA?
147     Basic       Contracts           The Basic Health Maternity information states HCA        There are no changes to the process for maternity                       X
        Health                          will determine eligibility into the Basic Health         medical application for BH members.
       Maternity                        Maternity program and members will receive a
       Services                         Services card from HCA, will that continue?
         Card




                                                                                                          34
                                                                                   All Plan Meeting - QMCO questions April 5, 2012
Q#      Group     SME          Page                         Question                           Response                                                     New Answer since last posting

148    Referral   Contracts            Do the MCOs have flexibility to waive the referral       Per the Basic Health member handbook page 26                             X
       Waivers                        requirements that are referrenced in the Basic           paragraph 1
                                      Health member handbook?                                  “ Costs, providers and facilities, covered prescription
                                                                                               drugs, and referral practices, may differ by health plan.”

                                                                                               For more information, refer to the following subsections
                                                                                               in the main Contract:
                                                                                               • 3.2, Information Requirements for Enrollees and
                                                                                               Potential Enrollees.
                                                                                               • 5.12, Access to Specialty Care
                                                                                               • 10.3.4.6, related to BH referrals

149     PCP       Contracts           The Basic Health member handbook mentions that           Unlike plan changes, which may only become effective                      X
       Changes                        PCP changes take place the first day of the              on the first of a given month (and only under limited
                                      following month. Can the MCOs make the change            circumstances outside open enrollment), PCP changes
                                      immediate?                                               are allowed at any time
150    Eligibility Contracts          Will providers verify benefit packages and eligibility   Providers will verify benefit packages and eligiblity                     X
      Verification                    through the state or through each MCO?                   through the ProviderOne system

151 Community Contracts               The Basic Health member handbook indicates               To answer this question HCA assumes the question                          X
    and Home-                         Community and Home-Based services for older and          refers to the HO handbook.
      Based                           physically disabled persons such as Community                                 1. COPES information is not stored
     Services                         Options Program Entry System and Personal Care           in ProviderOne, the MCO would have to get access to
                                      Services are covered FFS.                                view the CARE assessment tool.
                                      1. How will the MCOs know when a member is part                                             2. The MCO would not
                                      of COPES?                                                be providing any personal care services, these services
                                      2. What personal care services are considered FFS        are not considered medical.           3. There are no
                                      responsibility?                                          services that would be covered by the MCOs that would
                                      3. Are there services covered by the MCOs that            be considered FFS because the member is part of the
                                      would be considered FFS because the member is            COPES program.
                                      part of the COPES program?                               Coordination with community based organizations and
                                                                                               Home and Community Services would be required as
                                                                                               part of the Section 13.3.5 of the contract for any
                                                                                               enrollee.
152 Medically        Rates            Are there any dental codes or services that are to       Please see answer to #47                                                  X
    Covered                           be covered by the medical health plan (i.e. dental
     Dental                           services performed by Ambulatory Surgery Center,
   Codes/Servi                        dental sedation)? Note: we do know flouride
      ces                             varnish is covered by the medical plan.

153 Maternity     Contracts           What are Maternity Support Services as listed in the     Please refer to the Maternity Support Services billing                    X
    Support                           member handbook to be covered by FFS so we can           instructions for clarification on what services are
    Services                          ensure we are not covering them? We assume this          covered.
                                      includes childcare, transportation to appointment        http://hrsa.dshs.wa.gov/download/Billing_Instructions/M
                                      and child birth classes. Are there additional            SS-ICM/MSS-ICM_BI.pdf
                                      services, and if so, can we be provided the codes
                                      for each?
                                                                                                         35
                                                                                   All Plan Meeting - QMCO questions April 5, 2012
Q#      Group       SME         Page                         Question                          Response                                                  New Answer since last posting

154 2012 Guide Contracts               The following statement appears “A current EPSDT Yes.
     to Basic                          screening is required before medically necessary
    Health Plus                        non-covered services may be requested and
       and                             authorized. All non-covered services require prior
     Maternity                         authorization.” Does this mean the MCO may be
     Benefits                          responsible to pay for authorized non-covered
     Program                           services (i.e. more than 10 spinal manipulations or
      Page 15                          any other item on the non-covered list…and what
                                       about items from the FFS list)?

155    HIS and       Tribal            Can HCA provide a listing of providers associated       Please see the attached spreadsheet named FINAL                        X
      Tribal 638                       with Indian Health Services and Tribal 638 facilities   IHS CMS FACILITY. The list is inclusive of dental, MH
       Facilities                      to ensure the MCOs are able to appropriately            and CD facilites. As an FYI – IHS will be updating this
                                       identify these providers in their provider data         list next year. Tribes have to renegotiate their tribal
                                       management systems to ensure payment no less            compacts and contracts with IHS for the services they
                                       than payment to a par provider in the network?          will be providing under their 638 facility agreements.

156    Family       Contracts          Under the Healthy Options Program, are the MCO's Family planning is a benefit under the contract. The                          X
      Planning                         expected to administer the Family Planning          Family Planning Program is an HCA program separate
      Program                          Program as is in existance today?                   from the plans' contractual obligation. The plans are
                                                                                           expected to coordinate care with the Family Planning
                                                                                           Program.
157 Radiology  Contracts               Under the Basic Health program, information has      All radiology services other than out-patient x-ray and                   X
   Coinsurance                         been located to indicate 20% coinsurance for        ultrasound are subject to coinsurance and deductible.
                                       radiology except for OP x-ray and Ultrasound. Can
                                       HCA confirm what specific radiology services are
                                       subject to the 20% coinsurance and by outpatient x-
                                       ray and ultrasound is this all POS other than
                                       inpatient hospital?




                                                                                                         36
                                                                               All Plan Meeting - QMCO questions April 5, 2012
Q#    Group     SME         Page                         Question                          Response                                                     New Answer since last posting

158 Coinsurance Contracts          Documentation supports 20% coinsurance for OP           Coinsurance and would not apply to services that were                     X
      for OP                       hospital services for Basic Health. Does this apply     included as part of maternity care services for members
     Hospital                      to all OP non-emergent services except for x-ray        who are determined to be ineligible for medical
     Services                      and ultrasound as asked in question ID-94?              assistance. “The following maternity care services are
                                                                                           covered for members who are determined to be
                                                                                           ineligible for medical assistance through HCA. These
                                                                                           services are not subject to copays, coinsurance, or
                                                                                           deductibles: diagnosis of pregnancy; full prenatal care
                                                                                           after pregnancy is confirmed; delivery; postpartum care;
                                                                                           care for complications of pregnancy; preventive care;
                                                                                           physician services; hospital services; operating or other
                                                                                           special procedure rooms; radiology and laboratory
                                                                                           services; medications; anesthesia; normal newborn
                                                                                           care following birth, such as, but not limited to, nursery
                                                                                           services and pediatric exams; and termination of
                                                                                           pregnancy (including voluntary termination of
                                                                                           pregnancy).”

159    Home     Contracts          How are Home Health Nursing visist covered for all     The benefits for Healthy Options under the Contract are                    X
      Health                       programs?                                              any services that HCA provides in its fee-for-service
      Nursing                                                                             program that is not specifically excluded from the
       Visits                                                                             Contract. Please see billing instructions for home
                                                                                          health.
160 Coverage    Contracts          The member handbook for Basic Health and the            Coinsurance and would not apply to services that were                     X
    for Routine                    contract have conflicting information about            included as part of maternity care services for members
   Preventative                    coverage for routine preventative services. Are        who are determined to be ineligible for medical
      Services                     these services to be covered under any of the          assistance. “The following maternity care services are
                                   programs? And if so, which ones? Can HCA               covered for members who are determined to be
                                   provide the MCOs with a list of the routine            ineligible for medical assistance through HCA. These
                                   preventative services as defined by the state as well services are not subject to copays, coinsurance, or
                                   as the age restrictions and limitations? (specifically deductibles: diagnosis of pregnancy; full prenatal care
                                   interested in routine mammograms and vaccines)         after pregnancy is confirmed; delivery; postpartum care;
                                                                                          care for complications of pregnancy; preventive care;
                                                                                          physician services; hospital services; operating or other
                                                                                          special procedure rooms; radiology and laboratory
                                                                                          services; medications; anesthesia; normal newborn
                                                                                          care following birth, such as, but not limited to, nursery
                                                                                          services and pediatric exams; and termination of
                                                                                          pregnancy (including voluntary termination of
                                                                                          pregnancy).”

161    Take     Contracts          Are the MCOs expected to administer the Take            NO - The Take Charge program is administered by                           X
      Charge                       Charge Program as mentioned for the Healthy             HCA. These clients are not eligible for the Healthy
      Program                      Options, Basic Health and Basic Health Maternity        Options enrollment.
                                   programs?


                                                                                                     37
                                                                                  All Plan Meeting - QMCO questions April 5, 2012
Q#      Group      SME         Page                         Question                           Response                                                    New Answer since last posting

162     Out of     Contracts          The Basic Health member handbook indicates                The list of services NOT subject to the deductible and                  X
       Pocket                         deductible, coinsurance or out of pocket may apply       co-insurance is located on page 38 of the BH member
       Services                       to some services. Can HCA provide a list of all the      handbook Exhibit B-2.
                                      services these out of pocket dollars do apply to?

163 Blood Bank      Rates             What is coverage and reimbursement guidelines for        We have specific blood bank providers and specific                       X
      Services                        blood bank services? The blood bank manual               billing instructions for them. Link:
                                      would indicate these facilities will bill for services   http://hrsa.dshs.wa.gov/download/Billing_Instructions/Blo
                                      often performed in a facility or provider office. Can    od_Banks/Blood_Bank_BI.pdf
                                      HCA please provide clarity around the blood bank
                                      services and billing requirements?

164    Prenatal    Contracts          Healthy Options member handbook indicates                                                                                         X
       Genetic                        prenatal genetic counseling is covered FFS by the        Genetic counseling is identified by billing CPT code
      Counseling                      state. In the physician billing manual it states         96040 with diagnosis code V26.33
                                      genetic counseling is covered for adults and
                                      children using dxV26.33. Can HCA confirm how the
                                      state is identifying which genetic testing is carved
                                      out to the state?
165 Reduction       Rates             For CPT codes 19318 & 19300 - Only covered for           There are currently no diagnosis restriction for 19318                   X
    Mammoplas                         DX 611.1 & 611.9 (this is for reduction                  and 19300.
      ties /                          mammoplasties/mastectomy for Gynecomastia) .
    Mastectomy                        These CPT codes could be billed for covered
        for                           services with other dx (such as breast cancer). Can
   Gynecomast                         HCA please confirm the only dx for which these
         ia                           CPT codes are covered are 611.1 and 611.9?

166 Strabismus      Rates             One section of the Physician-Related Services/           Per Physician-Related Services Manual, strabismus                        X
      Surgery                         Healthcare Professional Services Medicaid Provider       surgery is covered with EPA for clients 18 years and
                                      Guides states that Strabismus Surgery is only            older and covered without authorization for clients 17
                                      covered for 18+ with dx 368.2 and CPT code               years and younger.
                                      67311. However, another section mentions the
                                      medical necessity for both 18+ and under 18. Can
                                      HCA confirm that the limit by dx will only be for 18+
                                      with no dx limit for under 18?

167 Transplants     Rates             Communication was sent stating pre-ex waiting            Medicaid does not have any pre-existing waiting periods                  X
                                      period does not apply effective 1/1/12, can HCA          for any services
                                      confirm if this also pertains to transplants?
168 First Steps     Rates             Are the First Steps services (child birth classes,       The services are the same as those for HO. First Steps                   X
     Services                         transportation to medial appointments and                is an HCA program separate from the Contract.
                                      childcare) provider under Basic Health Maternity the
                                      responsibility of the state or the MCOs? If the
                                      MCOs, can HCA provide the billing and
                                      reimbursement guidelines around these services?


                                                                                                        38
                                                                                  All Plan Meeting - QMCO questions April 5, 2012
 Q#       Group      SME         Page                        Question                         Response                                                   New Answer since last posting

 169    Newborn      Contracts          Can HCA confirm what benefit package a baby be        Basic Health does not cover children under age 19, any                  X
         Benefit                        added to if mom is covered under Basic Health or      other coverage the child may receive after the first
        Package                         Basic Health Maternity?                               month of coverage under the mother is dependent upon
                                                                                              what the family unit is eligible for and applies for.

 170 Maternity       Contracts          If a Basic Health Plus member under 19 years of      Basic Health Plus members have maternity benefits                        X
     Benefits                           age becomes pregnant, which benefit package will under the BH plus medical assistance program. No
                                        the state submit a benefit change to allow for at    change is required.
                                        least the 30 days of maternity benefits since there
                                        are no benefits for maternity for Basic Health Plus?
                                        If a member submits an application for Basic Health
                                        Plus and qualifies, will the member be transitioned
                                        to the Basic Health Maternity and if so, loose their
                                        Basic Health Plus benefits?

 171     Vision      Contracts          Basic Health Plus indicates vision services are      Basic Health does not cover vision and the following are                 X
        Coverage                        carved out and paid by the state. What protocol is   specifically excluded under item 17 of the member
                                        used by the state to determine what services the     handbook page 41, exhibit B-2, “Eyeglasses, contact
                                        state will pay for?                                  lenses (except the fi rst intraocular lens following
                                                                                             cataract surgery); routine eye examinations, including
                                        Can the state please confirm vision services are not eye refraction, except when provided as part of a
                                        covered for the Basic Health program and what        routine examination under “Preventive care.” Please
                                        services are defined as vision?                      see the billing instruction related to vision hardware at
                                                                                             http://hrsa.dshs.wa.gov/download/Billing_Instructions_W
                                        Can the state please confirm vision services are     ebpages/Vision_Care.html
                                        covered for the Basic Maternity program and define
                                        what services are/are not covered?
 172      Baby    Contracts             Please confirm our operating assumption that the     The ProviderOne system enrolls the baby in the same                      X
         Charge                         baby would be considered under the same benefit      plan as the Mom or others on the same case effective
        Reimburse                       package as the mother (Healthy Options or Basic      the first of the month following the date in which the
          ments                         Health) in order to allow us to split baby charges   newborn eligibility is reported.
                                        from mom to allow for correct processing and age
                                        appropriate edits to be applied.

                                        If mom and baby charges are indeed to be
                                        combined, how are baby charges reimbursed while
                                        inpatient after delivery?

173    Eligibility                      Please confirm that the member eligibility            Basic Health: Yes. HCA will provide a calendar with the                 X
                                        information being provided by the state will          key dates that are prior to the cutover.
                                        communicated using only a standard HIPAA 834
                                        file exchange.




                                                                                                        39
                                                                         All Plan Meeting - QMCO questions April 5, 2012
 Q#     Group   SME   Page                         Question                          Response                                                    New Answer since last posting

174   834                    Per Transitions meeting on 2/24, the State indicated    Medicaid: For Medicaid Programs, member eligibility
                             that the MCOs will be receiving daily 834 files. Will   information will be provided using the Standard HIPAA
                             HCA be providing the daily files Monday through         834 file. Managed Care organizations can also choose
                             Friday or will there be weekend files as well?          to utilize HIPAA 270/271 eligibility inquiry and response
                                                                                     transactions to inquire on member eligibility.
                                                                                                                  Basic Health: 834 files are
                                                                                     not delivered daily. There’s a monthly audit file and
                                                                                     weekly update files on the 7th, 14th and 3 working days
                                                                                     from the end of the month.

175   834                    Should the MCOs expect to see adds, changes,            Medicaid: MCOs should not expect to see adds,
                             terms, etc. on the Monthly file even though they will   changes and terminations on the monthly Audit file.
                             be sent with the INS03 of 030. For example, the         You may see end dates on the monthly Audit file as we
                             Monthly file will have provided a member end date       will pass a member’s end date if known.
                             that was not passed on a previous daily 834.                                               Basic Health: The
                                                                                     member status code will be sent with the INS04. Code
                                                                                     values used:
                                                                                     07=Termination of Benefits;
                                                                                     14=Voluntary Withdrawal;
                                                                                     20=Active;
                                                                                     41=Re-enrollment;
                                                                                     AI=No Reason Given or Ineligible, Not Enrolled or Not
                                                                                     Enrolled - Waiting

176   834                    Can HCA please provide the 834 file naming              Medicaid: The file naming convention is available within
                             convention? Will the MCOs be able to distinguish        the 834 Companion Guide available at
                             between the daily and monthly file based on the the     http://hrsa.dshs.wa.gov/dshshipaa/
                             file name?                                              File naming convention:
                                                                                     HIPAA.<MCO Program Specific
                                                                                     ID>.<datetimestamp>.834.O.out

                                                                                     Basic Health: The naming convention will be provided in
                                                                                     the companion guide. Yes, the filenames between the
                                                                                     monthly audit and weekly update will be different.

177   834                    Please confirm what HIPAA validation HCA is using Medicaid: All inbound and outbound HIPAA files are
                             for the 834 files.                                  validated to HIPAA Levels 1 and 2.
                                                                                                Basic Health: Inbound and outbound
                                                                                 HIPAA files are not validated.
178   834                    Will the 834 file contain a code identifying county Medicaid: Yes, the information is passed in Loop 2100A
                             code or region code?                                (Member Residence, City, State, Zip Code) element
                                                                                 N406. MCOs will receive the member’s ‘Rate Region
                                                                                 Code’ here. Basic Health: A county code is provided.




                                                                                               40
                                                                                     All Plan Meeting - QMCO questions April 5, 2012
 Q#       Group        SME         Page                        Question                          Response                                                   New Answer since last posting

179    834                                Will the MCOs receive a single member record per       Medicaid: 834s can include multiple transactions for the
                                          member on the 834 or multiple records per 834? If      same member. This is dependent upon the
                                          more than one will be sent, can HCA please provide     transactions that occur within the system, e.g. multiple
                                          what scenarios the MCOs should expect?                 change transactions for a single client within a file
                                                                                                 effective period.                          Basic Health:
                                                                                                 A single member record per member.
180    Eligibility                        Can HCA please communicate the length of the           Medicaid: The ID is 11 characters--9 alpha, 2 numberic.
                                          member's Medicaid ID and indicate if it is all
                                          numeric or alphanumeric?
 181     Eligibility   Contracts          Does HCA allow retro-enrollments? If yes, please   No, Medicaid does not allow retro enrollements.                             X
                                          indicate how far back.
 182     Eligiblity    Contracts          Do members sometimes receive more than one         No, members will not receive more than one medicaid                         X
                                          Medicaid ID? For example, the member enters the ID.
                                          Medicaid program, the member leaves the program,
                                          the member then returns but with a different
                                          coverage type (i.e. CHIP to adult Medicaid or
                                          Foster Care to standard Medicaid). If yes, can HCA
                                          indicate how frequent this occurs?

 183     Eligibility   Contracts          If members could at some point have more than          Members will not receive more than one medicaid ID                      X
                                          one Medicaid ID, could the member's effective date
                                          for one Medicaid ID overlap with the other?
184    834                                Will HCA provide family ties/links (i.e. case          Medicaid: Yes - this was dicussed during the IT
                                          number) for members on the 834 file? If so, please     Technical meeting. For Healthy Options programs
                                          indicate the length and if the number is all numeric   please use the 834 Companion Guide to determine the
                                          or alphanumeric?                                       loop/segment where this information is passed to the
                                                                                                 MCOs.
                                                                                                 Basic Health: Yes. The family ID ties family members
                                                                                                 together.
185    834                                For members unable to make medical decisions on        Medicaid: The case head of household is provided for
                                          their own (i.e. Foster Care members, members in        all clients in the 834 files, Please see the 834
                                          LTC, members under 18 years of age), will HCA be       Companion Guide for Loop and Segment information.
                                          including the consentor's (responsible party) name
                                          on the 834 file or on a supplemental file?

186    834                                Will the MCOs be expected to TERM BY ABSENCE Medicaid: This was discussed during the IT Technical
                                          members enrolled earlier though the daily 834 file, training on 3/9/12. A "term" transaction is sent to the
                                          but not present on the monthly 834 file?            MCO in the Update 834 files. The Audit file is sent
                                                                                              earlier in the month with a final Update files sent on the
                                                                                              last business day.                 Basic Health: Yes. No
                                                                                              834 means no enrollment.
187    834                                Will HCA provide a 5 or 9 byte zip code on the 834 Medicaid: The 9-digit member zip code will be passed
                                          files?                                              when known as well as when required by the Federal
                                                                                              TR3 guides. Basic Health: Both 5 and 9-digit (when
                                                                                              available) zip code.


                                                                                                           41
                                                                                  All Plan Meeting - QMCO questions April 5, 2012
 Q#      Group    SME         Page                         Question                           Response                                                    New Answer since last posting

188    834                           Please confirm how quickly the MCOs can expect to        Medicaid: Changes will be received within the week that
                                     receive changes made in the State's eligibility          they occur because update files are sent weekly.
                                     system in the 834 file. Will it be the next day or a     Depending on how you interpret this, there may be a lag
                                     lag of X days?                                           of up to a week depending on when the change occurs
                                                                                              and when the file is generated. Basic Health: We sent
                                                                                              the changes on the 7th, 14th and 3 working days from
                                                                                              end of month.
189    834                           Does the monthly 834 file represent the members          Medicaid: The 834 Audit file will include all members
                                     who will be active as of the first day of the next       who are eligible on the first day of the month that the
                                     month, or will it include members who are active at      834 is being generated for.
                                     the time the file was generated?                                               Basic Health: The same is true for
                                                                                              Basic Health.
190    834                           Is there a cut off date for enrollment for the           Medicaid: There are enrollment cut-off dates and this
                                     upcoming month? For example, members who                 variance in 834 Audit generation and cut-off are
                                     enroll after the 20th will not be effective until the    mitigated by the creation and delivery of the Last Day of
                                     month after the upcoming month (i.e. enrolls 2/22,       the Month 834 file. This file is intended to pick up any
                                     not active until 4/1).                                   manual adds that occur after cut-off which then
                                                                                              provides additional clients and gives the plans a full
                                                                                              picture of the next months’ eligible members.
                                                                                                 Basic Health: No specific cut-off date. Member could
                                                                                              enroll for next month of coverage until the Audit file
                                                                                              generated.
 191 Medicaid Contracts              Will HCA please provide the MCOs with a listing of       HCA will answer this in a future posting
      Provider                       recent years of history of Medicaid providers and
       Claims                        their claims activity?
       History
 192 Provider Contracts              Do the providers have be registered with the state        We are checking to see whether all MCO providers                        X
    Registration                     in order to be credentialed and par with the MCOs?       need to be recognized in our ProviderOne system as
     - Payment                       If the answer is yes, are non-par providers also         performing, servicing, prescribing or rendering
                                     required to be registered with the member’s state        providers. What we do know is that we are going to
                                     before the MCOs reimburse the provider for               need some basic information such as; NPI, DEA, SSN,
                                     services? If yes, please confirm our operating           DOB and WA professional license number. We are
                                     assumption that we are to deny those services to         looking at Form A from the OIC as a possible solution.
                                     the provider explaining the need for them to be          However, not all of the elements we need to know are
                                     registered with the member’s state to receive            on Form A. Stay tuned for an updated response to this
                                     payment (for emergent and non-emergent services).        question. It is a work in progress.

 193     Provider Contracts          If the provider is required to be registered with the     See the answer to the question above. If the care is                    X
       Registration                  members’ state before being paid for services, and       emergent or pre-authorized HCA will make some
             -                       the provider is not registered with the member’s         retroactive payment decisions. Unfortunately, there is
       Reprocess                     state at the time the services were performed, but       no “yes or no” answer that will address every scenario
        Previously                   later becomes registered with the state, is the MCO      and the final answer will be impacted by the solution the
         Denied                      able to reprocess previously denied claims for           question above.
          Claims                     payment and if so, for what time period after the
                                     provider is registered?


                                                                                                        42
                                                                                  All Plan Meeting - QMCO questions April 5, 2012
Q#      Group        SME         Page                        Question                          Response                                                   New Answer since last posting

194 Chiropractic      Rates             Please confirm our operating assumption that           Please see Osteopathic Manipulative Therapy under                       X
     Services                           chiropractic services are only covered for children    the Physician Billing guide, also Chiropractic Services
                                        under the age of 21. That benefit is further reduced   for Children
                                        to cover only Osteopathic Manipulative Therapy to a    http://hrsa.dshs.wa.gov/download/Billing_Instructions/Ch
                                        max of 10 per calendar year for CPT codes 98925-       iropractic_Services/Chiropractic_Services_BI.pdf
                                        98929 when performed by a DO. Any other
                                        chiropractic services are non-covered.

195 Biofeedback       Rates             Is Biofeedback covered? The member handbooks           CPT code 90911 is covered under FFS.                                    X
                                        indicate limited to plan requirements. Can HCA
                                        confirm what specific services are covered and can
                                        the codes be provided? Healthy Options Member
                                        Handbook, page 13. Basic Health Page 13.

196      Basic       Contracts          The link here                                          Basic Health offers coverage for legal dependents age                   X
         Heath                          (http://www.basichealth.hca.wa.gov/plus.shtml)         19-26. But does not cover members under age 19.
       Coverage                         indicates children not living in the home of the
      for Children                      covered member may not be eligible for Basic
                                        Health Plus but may be covered under Basic
                                        Health. However, the contract indicates Basic
                                        Health coverage is only for members 18 and over.
                                        Can HCA please clarify?
197 Administrati      Rates             Can HCA please confirm if exams for administrative     Examinations are only for medical issues.                               X
     ve Exams                           purposes covered under the Healthy Options             Administrative exams e.g. Sports physicals, camp
    for Healthy                         program? The Basic Health and Basic Health Plus        physicals, exams for disability determinations are not
      Options                           member handbooks clearly state these exams are         covered by Medicaid.
                                        not covered. The following are the diagnosis codes
                                        we are considering administrative exams: V70.3,
                                        V70.5, V70.6 and V70.7.




                                                                                                        43
                                                                                 All Plan Meeting - QMCO questions April 5, 2012
Q#     Group       SME        Page                         Question                          Response                                                   New Answer since last posting

198    Routine      Medical          Can HCA please confirm the below is an all-         Yes, the intent was for this to be inclusive unless the                     X
      Foot Care     Review           inclusive list of the routine foot care that is     client has an acute condition of the lower extremity;
      Diagnosis                      considered non-covered unless the member has an
                                     acute condition of the lower extremity?             Providers can submit requests for authorization to treat
                                                                                         conditions listed here if there is a clinical situation puts
                                     Non covered routine foot care diagnosis:            the need for treatment outside the definition of routine.
                                     (Reference Physicians Related Services, PG A5-A6)
                                     • Treatment of mycotic disease tinea pedis: ICD9-
                                     110.4
                                     • Removal of warts, corns and calluses- ICD9-700
                                     • Treatment of flat feet-ICD9-734
                                     • Treatment of high arches (cavus foot)-736.73
                                     • Onychomycosis- ICD9-110.1
                                     • Bunions and tailor’s bunion (hallux valgus) ICD9-
                                     735.0
                                     • Hallux malleus- ICD9-735.3
                                     • Equinus deformity of foot; acquired- ICD9-736.72
                                     • Cavovarus deformity; acquired-ICD9-736.75
                                     • Adult acquired flatfoot (metatarsus adductus or
                                     pes planus)- ICD9-754.53
                                     • Hallux limitus- ICD9-754.61

                                     Non Covered Foot Care Surgical Procedures:
                                     (Reference Physicians Related Services, PG A5-A6)
                                     • CPT 11719-Trimming of nails and other regular
                                     hygiene care
                                     • CPT 28290-Surgical correction of Hallux Valgus
199    Skilled       Rates           Can HCA confirm if there are any coverage limits  The contractor must coordinate with Aging and                                 X
      Nursing                        for Skilled Nursing Facilities?                   Disability Services Administration (ADSA) on skilled
      Facilities                                                                       nursing facility placement see section 15.14.2 of the
                                                                                       contract. Until the client’s eligibility status changes to
                                                                                       an “institutionalized” eligible client who is not eligible for
                                                                                       HOBD enrollment, the contractor is responsible for
                                                                                       services provided in the SNF. Once the eligibility status
                                                                                       of the client is changed, the client is disenrolled from
                                                                                       the MCO and ADSA continues to provide the services in
                                                                                       the SNF.
200 Dual Eligible Contracts          Can HCA confirm what percentage of the            None of the HO mediciad population is dually eligible                         X
                                     membership is dual eligible?                      with Medicare and Medicaid




                                                                                                       44
                                                                             All Plan Meeting - QMCO questions April 5, 2012
Q#   Group    SME          Page                        Question                          Response                                   New Answer since last posting

201 Addendum Contracts   pg 3     Based on the following question and 2/27 HCA           HCA will answer this in a future posting
    5 exhibit                     response, we have a follow up question:
    H(A)
    Section 1.6                   Original Question: Currently newborns identified as
    Retroactive                   SSI can be retroactively recouped and placed on
    Premium                       FFS. In the new RFP contract newborns identified
    Payments                      as SSI will remain on managed care and the MCO
    for Enrollee                  will receive a SSI premium prospectively the next
    Categorical                   month. Do we have the correct understanding of
    Changes                       how this process will work as it spans both
                                  contracts? Please take the following example:
                                  Baby is born 5/25/2012 and qualifies for SSI on
                                  7/10/2012 in HCA’s SDX system. Would May and
                                  June be retrorecouped so baby is FFS for those
                                  months, baby remains a Molina TANF Healthy
                                  Options member for July, and becomes a Molina
                                  SSI Healthy Options member prospectively in
                                  August?

                                  2/27 Response: No, the baby would not be
                                  retrorecouped and placed on FFS. The baby would
                                  be treated like any other baby born to a Healthy
                                  Options-enrolled mother and would be HO from
                                  date of birth, and would move to HOBD
                                  prospectively the first of the month following HCA's
                                  notification of HOBD eligiblity. The Healthy Options
                                  rates contemplate this arrangement.




                                                                                                   45
                                                                               All Plan Meeting - QMCO questions April 5, 2012
Q#    Group   SME           Page                         Question                           Response                                               New Answer since last posting

202 addendum Contracts    pg 112   Based on the following question and 2/27 HCA             HCA sent out a press release and list serve message                 X
    5 exhibit C                    response, we have a follow up response.                  announcing signed contracts and indicating providers
    13.2                                                                                    should work directly with MCOs. HCA will look into
    Transitional                   Question: Transitional care requires us to enter         sending additional list serve messages over the next
    Care                           facilities on a regular basis to see members. Most       several weeks.
                                   facilities have a set of requirements for anyone
                                   entering their hospital on a regular basis. Getting
                                   the clearance can take time and cooperation on the
                                   part of the facilities staff. Can HCA reach out to the
                                   facilities and assist the MCOs with this clearance?

                                   Answer: Our staffing is very limited, tell us what you
                                   might expect HCA do to assist the MCOs with this
                                   clearance.

                                   Follow up: It would be most helpful if HCA could
                                   send a communication to facilities advising them of
                                   the MCOs’ state contract requirement and to please
                                   allow MCOs to enter the facilities. So far three out
                                   of three facilities we have contacted want to set up
                                   face to face meetings with us to discuss. With the
                                   number of facilities we have, it will take quite some
                                   time if all of them want face to face meetings.



203           Rates                Could HCA give the MCOs a list of family planning        Please see the attached spreadsheet DOH fam plan srv                X
                                   clinics and contact information?
204           Contracts            Please confirm that because the contract requires        Yes
                                   additional subcontract provisions that include, but
                                   are also above, those required by statutes, that
                                   HCA is the ultimately authority for review and
                                   approval of our provider model agreements rather
                                   than OIC.
205           Communica            We understand that HCA will continue to produce          YES – you may want to refer to it as the New Member                 X
              tion                 and distribute a Healthy Options member                  Welcome packet instead of a “handbook”.
                                   handbook. If the plan would like to consolidate our
                                   initial member education materials that are required
                                   under §3.2 into a single resource document, can we
                                   refer to this as our (plan name) Member Handbook?

206           Contracts            If a provider is terminated for cause, please confirm This type of termination would be be handled on a case                 X
                                   that we are not required to allow members to          by case basis.
                                   continue seeing that provider for 60 days from the
                                   date we notify them of the provider’s termination
                                   (§5.15.2).

                                                                                                     46
                                                                                All Plan Meeting - QMCO questions April 5, 2012
 Q#       Group   SME         Page                        Question                           Response                                                   New Answer since last posting

 207              Contracts          Amerigroup uses Eliza, a vendor that provides           This is an acceptable alternative method, though the                    X
                                     phone-based, speech-enabled outreach, to                State will be asking for data from the MCO to confirm
                                     approximate the one-on-one conversation of a live       the success of this method in 1) reaching clients and in
                                     agent. We’ve achieved higher reach rates using          2)capturing screening data for risk screening purposes.
                                     Eliza than through live agents, and the vendor can
                                     contact virtually unlimited numbers of members
                                     simultaneously with consistent, structured
                                     information. We propose to use Eliza for new
                                     member initial health screenings and will provide
                                     the State with the list of optional questions for
                                     review and approval. Please confirm this is an
                                     acceptable method of complying with §13.5.1.5.

 208              Contracts          Please confirm that the plans will be responsible for HO/BH-yes, the plans are responsible for issuing plan                     X
                                     issuing plan-specific identification cards to both our specific identification
                                     new Healthy Options AND Basic Health members.

 209              Communica          Please identify who we should submit the following      You should submit anything that needs review and                        X
                  tion               to for review and approval:                             approval to hcamcprograms@hca.wa.gov
                                     o Marketing Materials and member education
                                     o Provider Model Agreements

 210              Communica           Can the State provide the health plan’s advance        Clients will be notified through ProviderOne generated                  X
                  tion               notice of any materials it intends to distribute to     client letters. We can send a copy of the letters to the
                                     members and/or providers regarding the Healthy          MCOs before they start getting distributed. All Provider
                                     Options/Basic Health program? It is important that      Specific notices will be through the Provider Listserv
                                     we have an opportunity to review the materials so       maintained by HCA. MCOs are encouraged to sign-up
                                     we can be prepared to directly address any              for the listserv at
                                     questions the recipients have when they call our        https://fortress.wa.gov/dshs/hrsalistsrvsignup/
                                     member/provider service lines.

 211              Communica          When will displaced Healthy Options members be          The HCA will be notifying displaced members by the                      X
                  tion               notified about their plan options?                      end of May.
212    Files                         Can you confirm when the plans will receive the first   Medicaid: Earliest possible date for file is 4-16-2012                  X
                                     enrollment files and what is expected of plans to do    (test) Production date is 5-17-2012
                                     with it? During the March 9th technology workgroup
                                     meeting there was mention this could come as early
                                     as April 4th.
 213              Contracts          Please confirm that the Basic Health open               The dates for Open Enrollment have not yet been                         X
                                     enrollment period will begin April 6th.                 announced, but it will not begin on April 6 as had been
                                                                                             originally discussed. The HCA will announce the dates
                                                                                             within the next week to 10 days.




                                                                                                      47
                                                                              All Plan Meeting - QMCO questions April 5, 2012
Q#    Group   SME         Page                         Question                           Response                                                      New Answer since last posting

214           Communica          Is there a template for the plan-developed Basic         There is no template, health plans have some flexibility                   X
              tion               Health Member Handbook or may we develop our             in creating their own handbook, as long as it contains all
                                 own? What about for Healthy Options if the plans         of the information included in the BH Member
                                 are allowed to develop their own?                        Handbook and has been approved by the HCA before
                                                                                          being made available to enrollees. Existing health
                                                                                          plans’ member handbooks are generally available on
                                                                                          their web sites and can be used as a guide.

215           Medical            Please confirm that lung, pancreas, small bowel          For Basic Health, lung, pancreas, small bowel ,and skin
              Review             and skin grafts are covered under Healthy Options.       grafts are not excluded and are covered as long as the
                                 Please confirm that they are NOT COVERED under           services meet the definition of “medical necessity” as
                                 Basic Health. Also will the state cover multiorgan       described in the COC. Multiple organ transplants may
                                 transplants?                                             be covered, if they meet the criteria on page 28 of the
                                                                                          COC and are also medically necessary. HO policy to be
                                                                                          discussed shortly
216           Contracts          Please confirm that both section 8.8 of the joint         That is correct – the template was a carryover from a                     X
                                 contract and line item #37 of the subcontract self-      previous contract and that correction got missed. We
                                 assessment state that home health providers              will make note of that and correct it for future use of the
                                 should reference §4724(b) Balance Budget Act of          self-assessment. For now please respond to the
                                 1997 rather than the current reference of §4708(d).      current version and make that correction yourself.

217           Communica          Are all HO enrollees receiving the handbook for           All Displaced Clients (clients losing their current health                X
              tion               July? If not, which clients will receive a handbook      plan) will receive a letter with an enrollment and
                                 and which clients will receive only an informational     information on which plan is available to them and
                                 letter and enrollment form?                              where to find the HO Medical Benefit Book.
218 FQHC//RHC Rates              Are foster care visits eligible for the FQHC/RHC         Yes, as long as the foster child is not on a program that                  X
                                 wrap or DCR or SPE payments?                             is state-funded only. Clients on state-funded programs
                                                                                          are not eligible.
219           Contracts           Please provide utilization data for foster kids.        Claims information for foster care clients is available to                 X
                                                                                          providers through the ProviderOne Portal eligibility
                                                                                          check (Benefit Inquiry). Navigation details and step by
                                                                                          step instructions are available in the ProviderOne Billing
                                                                                          and Resource Guide. You can use the link below to
                                                                                          access this information and instructions. See new
                                                                                          section 4, page 34 -- Review the Foster Care Client’s
                                                                                          Medical Records History.
                                                                                          http://hrsa.dshs.wa.gov/Download/ProviderOne_Billing_
                                                                                          and_Resource_Guide.html

220           Contracts          What is driving HCA decision to freeze assignment        HCA will answer this in a future posting
                                 in May and June?
221           Communica          When is the Basic Health open enrollment? Please         The HCA will provide the health plans with copies of                       X
              tion               send any HCA materials to the health plans in            member materials related to open enrollment and will
                                 advance of mailing them to members so we may             also provide assistance with talking points for use with
                                 prepare our call centers.                                enrollees or applicants .


                                                                                                    48
                                                                             All Plan Meeting - QMCO questions April 5, 2012
Q#    Group    SME         Page                        Question                          Response                                                   New Answer since last posting

222            Contracts          Please describe the funding flow for the $20 PMPM This question will be directed to our Health Home team                       X
                                  dedicated to Health Homes. Is it similar to the     for response. We will respond to this question on the
                                  Hospital Safety Net project? Are there any other    HCA Health Home website on or after April 12, 2012.
                                  requirements of the health plan in using the funds?

223 Contracting Network           New plans are permitted to continue to build their  This question seems to be connecting to different                          X
                                  networks after May 16, 2012 in counties where       subjects. We may need clarification from the plans on
                                  access was not met. May legacy plans expand their this inquiry.
                                  network if adequate or superior access is in place?  Contractors are always encouraged to build their
                                                                                      networks. There are no limitations on a plan, Legacy or
                                                                                      otherwise, building a larger provider network within their
                                                                                      contracted service area. However, “expanding a
                                                                                      service area” requires a process outlined in the
                                                                                      contract under section 2.2 Service Area Changes.


224 Contracting Network           When will HCA release the Network Access tool          The reporting tool was released March 14th, 2012                        X
                                  needed for reporting?
225            Contracts          Regarding Community Mental Health Center               HCA will answer this in a future posting
                                  reimbursements for services provided to members
                                  that do not meet the RSN access to care
                                  requirements: Can you confirm that we should not
                                  receive a separate bill for the professional side
                                  (e.g., psychologist, etc.) when a member receives
                                  outpatient mental health services at a CMHC?
                                  Also, which fee schedule should we use in paying
                                  CMHCs?
226 FQHC/RHC Rates                Are all of the FQHC encounter rates available and if   No, they are not available.                                             X
                                  so, could you direct us to where we can find them
                                  on HCA’s or DSHS’s websites?
227            Finance            3. The CAH percent of charge ratios located on the     Yes, this is accurate. These are smaller CAHs that                      X
                                  state website,                                         don’t do a large volume of inpatient services. Thus, one
                                  http://hrsa.dshs.wa.gov/hospitalpymt/InPatient/Rate    patient staying for a week, for example, can cause a
                                  Files/CahRates/CAH_Jan12_Final_121311v2.xlsx,          large fluctuation in the rate.
                                  have a few hospitals with rates well over 100%. Is
                                  this accurate? Specifically:
                                  HOSPITAL NAME INPATIENT OUTPATIENT
                                  Coulee Community 1184844185 168.994%
                                  69.827%
                                  Dayton General 1134128911 188.847% 59.167%
                                  Odessa Memorial 1073524690 784.032% 154.137%
                                  Snoqualmie Valley 1902846546 374.909% 96.996%




                                                                                                   49
                                                                                      All Plan Meeting - QMCO questions April 5, 2012
Q#     Group      SME              Page                         Question                           Response                                                      New Answer since last posting

228 Physician     Contracts   h.16        The Physician-Related Services/Healthcare                Yes. You would manage those situations as you would                        X
    Billing                               Professional Services Billing manual identifies that     with any non-par provider and you would reimburse
    Manual                                coverage of certain services including transplant        them at the current FFS rate. Alison to provide
                                          procedures, hysteroscopic sterilizations, and sleep      additional follow up. Alison will provide a list of Centers
                                          studies is limited to Agency-approved Centers of         of Excellence. Does this also apply to BH?
                                          Excellence. Are MCOs required to limit their
                                          coverage of these services to the Agency-approved
                                          CoEs as well?

                                          If the answer is yes, how are plans required to
                                          manage situations where an Agency-approved CoE
                                          is not contracted in the MCOs network? Please
                                          confirm that services would be reimbursed at the
                                          current FFS rate in this situation.


229 Contract      Contracts   28          For Basic Health enrollees, are residential chemical      Yes, intensive inpatient chemical dependency benefits                     X
    Exhibit B-2                           dependency benefits subject to an inpatient              are subject to the hospital in-patient deductible and co-
                                          deductible and co-insurance? The language in the         insurance. Less intensive services are subject to co-
                                          Exhibit identifies that they apply to "intensive         pays.
                                          inpatient services," but does not appear to specify
                                          applicability to other levels of inpatient/residential
                                          services.
230 Exhibit B-2   Contracts               For Basic Health enrollees, is partial hospitalization   Mental health and chemical dependency are separate.                        X
                                          covered as part of mental health treatment services,     Covered mental health services must meet the
                                          including chemical dependency services?                  standards described in RCW 70.47.200(2)(c).

                                          If so, what level of copayment/coinsurance applies?


231 Contract    Contracts     14          Exhibit A, section 3.1.14.1.4 states "contractor is  HCA will answer this in a future posting
    Ex A,                                 not responsible for coverage of any services when
    Sec.3.1.14.                           an enrollee is outside the United States of America
    1.4                                   and its territories and possessions." Please confirm
                                          that HCA's requirement to provide services to
                                          enrollees in British Columbia under certain
                                          circumstances as identified in WAC 182-501-0184
                                          is not applicable to MCOs.




                                                                                                            50
                                                                              All Plan Meeting - QMCO questions April 5, 2012
Q#     Group     SME         Page                        Question                          Response                                               New Answer since last posting

232 Final        Finance            The following question is regarding CPE                HCA has reviewed this request for change to the                     X
    HO/BH                           authorizations for HOBD and plan responsibility for contract, at this time HCA declines to make the
    Contract                        payment. During the RFP and contract finalization requested change.
    Section                         process we requested/suggested that health plans
    4.6.3.5                         be allowed to authorize CPE hospital stays because
    Inpatient                       we will be ultimately responsible if the inpatient
    CPE                             stays exceed our budgeted amount (contract
    Hospital                        section 4.6.3.5). It is our understanding under the
    Claims for                      MCS program (formerly Disability Lifeline), hospital
    HOBD                            facility charges are carved out and the responsibility
                                    of FFS, while the managed care plan is responsible
                                    for the professional services which is similar to
                                    HOBD CPE hospital coverage.

                                    A 3/20/2012 listserv email from HCA regarding the
                                    MCS program and this carve out describes that
                                    managed care is responsible for the authorization,
                                    even though FFS pays the hospital facility charges,
                                    and provides the process by which providers submit
                                    claims to HCA related to an authorization approved
                                    by the managed care plan. Since there is a
                                    process already in place for managed care, would it
                                    be possible for HCA to revisit our request to
                                    authorize services at CPE hospitals? Since
                                    managed care is ultimately “on the hook” for these
233 Final        Finance   pg 47    We have requested training related to trauma care      YES, WAC 182-531-2000 (physicians) and WAC 182-                     X
    HO/BH                           and want to give HCA an idea of the questions we       550-5450 (hospitals) will change to allow trauma
    Section                         have. WAC 182-550-5450 “Supplemental                   supplemental payments for managed care clients. The
    4.11                            Distributions to Approved Trauma Service Centers”      CR-101 for these WAC changes has been filed; it will
    Payment of                      clearly indicates MCOs should not pay professional     be published April 4, 2012 in WSR 12-07-074.
    Physician                       trauma rates. Will this WAC be changing?
    Services for
    Trauma                          Also, the Medicaid Provider Guide does not indicate
    Care                            how to pay the enhancement for trauma. It refers to
                                    the Trauma Care Fund on pages E.26 through
                                    E.29. It appears there are many complexities
                                    around payment for trauma, e.g. only some
                                    hospitals are eligible for trauma, physicians bill
                                    incorrectly, reconciliation of the Trauma Care Fund,
                                    and ISS scores.




                                                                                                    51
                                                                                All Plan Meeting - QMCO questions April 5, 2012
Q#    Group     SME           Page                         Question                         Response                                                   New Answer since last posting

234 Final       Contracts   pg 10    Will Basic Health cost sharing totals roll over from     For the period July - Dec 2012, BH members will be                    X
    Contract                         the previous health plan to the new health plan only credited for the year to date cost sharing and will start
    Exhibit B -                      if the client’s current plan will not be available after over in January 2013.
    BH                               of July 1st (Group Health and CUP)?
    Provisions
    Section 4.8
    Enrollee
    Cost
    Sharing

235             Contracts            Since HOBD clients may frequently become               Payments to physicians are based on the fee schedule                    X
                                     Medicare eligible, will the MCOs be informed when      amount multiplied by an enhancement percentage. The
                                     the client receives Medicare Part A and B?             current formula is base fee X 2.75. Not all procedures
                                                                                            receive the enhanced rate (e.g., labs are excluded). A
                                                                                            column will be added to the fee schedule showing the
                                                                                            applicable payment for an eligible procedure provided to
                                                                                            a qualified trauma case.

236             Contract             Since non-dual HOBD clients are in managed care,       Yes
                                     but duals are not, will a HOBD client who becomes
                                     Medicare eligible be dropped from HOBD back to
                                     FFS Medicaid and Medicare, as Healthy Options
                                     members are now?
237             Communication        Are all HO enrollees receiving the handbook for       Hospitals receive a supplemental payment after-the-                      X
                                     July? If not, which clients will receive a handbook   fact. HCA distributes the trauma supplemental
                                     and which clients will receive only an informational  payments to hospitals in five equal installments. Not all
                                     letter and enrollment form?                           hospitals qualify for the supplemental payments
                                                                                           because not all hospitals are equipped to care for
                                                                                           patients with major trauma. The criteria to qualify for
                                                                                           trauma supplemental payments and the distribution
                                                                                           method are described in WAC 182-550-5450.
                                                                                           Management of the Trauma Program is coordinated
                                                                                           with the Department of Health.
238             Contracts            PRISM Extract—Currently our access to PRISM           PRISM does not have population-based extract                             X
                                     only allows us to search at the individual level and  capability at this time, or sort capability by chronic
                                     there is no extract function available. It also       condition as listed in the contract. These changes will
                                     appears that there is not a function to sort based on be considered by HCA, and plans will be updated if
                                     chronic condition. Will a chronic condition flag be   such capacity is built
                                     added to PRISM? In order to most effectively flag
                                     our ESHCNs by using the PRISM risk score
                                     (section 13.5.1.1) it would be helpful to be able to
                                     access the PRISM data directly or through an
                                     extract function which could be automated. Is HCA
                                     building this functionality in PRISM? We would
                                     need to begin testing by early May in order to go
                                     live with the new process in July.

                                                                                                      52
                                                                              All Plan Meeting - QMCO questions April 5, 2012
 Q#      Group   SME         Page                        Question                         Response                                                  New Answer since last posting

 239             Contracts          A clear process and timeline for Contractor to        The discharge screening tool will be developed as part                 X
                                    collaborate with peer Medicaid managed care           of the Transitions Performance Improvement Project.
                                    organizations to develop the Screening Tools
                                    described section 13.7, will a similar process and
                                    timeline be created for the development of the
                                    Standardized Discharge Screening Tool described
                                    in section 13.2.1?
 240             Contracts          How and when should Plan submit their Initial       The MCOs are encouraged to send any and all                              X
                                    Health Assessment to HCA for approval (13.5.2)?     materials requiring HCA approval as soon as the
                                                                                        materials are ready for our review.
241    834                          Will ESHCNs (including kids) continue to be flagged There are no flags in the 834 for ESHCNs only for
                                    on our 834 file from the state.                     SCHIP ESHCN. If an enrollee provides a healthcare
                                                                                        rating on their enrollment it will be passed along to the
                                                                                        plans on the 834
 242             Contracts          The COC dentifies that there are no charges for     Yes, the same restriction applies to both mental health                  X
                                    inpatient hosptial services when readmitted for the and chemical dependency inpatient services.
                                    same condition within 90 days. Does this same
                                    restriction apply to mental health or chemical
                                    dependency inpatient services?
 243 Contracting Network            Can the plans have provisional credentialing        HCA can allow the MCOs to hold providers in a                            X
                                    through the state Medicaid id                       provisional credentialing status for a period of no more
                                                                                        than 120 calendar days.
                                                                                        To implement provisional credentialing the plan must do
                                                                                        the following:
                                                                                        1) Require a completed MCO provider application with
                                                                                        signed attestation statement.
                                                                                        2) Require plan to conduct the following review:
                                                                                        a. Check ProviderOne to determine if provider is
                                                                                        enrolled in Washington Medicaid.
                                                                                        b. Check Washington Department of Health to ensure
                                                                                        provider has a license in good standing with the State of
                                                                                        Washington.
                                                                                        c. If provider licensed in Oregon or Idaho, check
                                                                                        respective websites to assure license in good standing.
                                                                                        d. Check National Practitioner Data Bank for
                                                                                        malpractice and other actions against license.
                                                                                        3) The HCA will allow provisional credentialing process
                                                                                        as described above through December 31, 2012.
                                                                                        Beginning January 1, 2013, the NCQA requirement of
                                                                                        holding providers in a provisional status for no more
                                                                                        than 60 calendar days shall apply.


 244             Communica          Does the MCO have to distribute a hard copy of the No, the plans do not need to provide a hard copy of                       X
                 tion               plan provider directory?                           your provider directory to every enrollee, unless it is
                                                                                       specifically requested.

                                                                                                    53
                                                                                All Plan Meeting - QMCO questions April 5, 2012
Q#    Group     SME         Page                         Question                            Response                                                  New Answer since last posting

245 Exhibit B:  Contracts          Can HCA please clarify what is the annual review     For the period July - Dec 2012, BH members will be                          X
   Basic Health                    time frame for cost sharing? It seems below that the credited for the year to date cost sharing and will start
   4.8 Enrollee                    anniversary of the cost sharing is based on          over in January 2013.
       Cost                        calendar year not on our contract year.
     Sharing
                                   4.8 Enrollee Cost Sharing
                                   For the period July 1, 2012 through December 31,
                                   2012, an Enrollee who was enrolled before July 1,
                                   2012, will receive credit for all cost-sharing incurred
                                   for covered services incurred in calendar year 2012,
                                   if the health plan they were enrolled in before July
                                   1, 2012 is no longer available.


246 Maternity   Contracts          It appears that HCTC Basic Health members do not          An HCTC enrollee must apply for maternity benefits                     X
    Benefits                       need to provide notice of pregnancy, and can              through BH Plus. If the enrollee is denied for a reason
                                   remain covered under Basic Health. In this instance       for other than non-compliance, she will receive
                                   do they have member liability (eg; Deductible,            maternity benefits through HCTC BH. Member liability is
                                   Copay, Coinsurance and Out of Pocket) or is it            not waived during the pregnancy for all non-maternity
                                   waived for the pregnancy related services? Or, is         related servides.
                                   the member liability waived during the pregnancy
                                   for all non-maternity related services as well?

247 Maternity   Contracts          If a Basic Health member does not provide notice of       An HCTC enrollee must apply for maternity benefits                     X
    Benefits                       pregnancy and is limited to 30 days of maternity          through BH Plus. If the enrollee is denied for a reason
                                   coverage under this plan, do they have member             for other than non-compliance, she will receive
                                   liability (eg; Deductible, Copay, Coinsurance and         maternity benefits through HCTC BH. Member liability is
                                   Out of Pocket) for the pregnancy related services         not waived during the pregnancy for all non-maternity
                                   during those 30 days of coverage? Do they have            related servides.
                                   member liability for non-maternity related services
                                   during those 30 days of pregnancy coverage? At
                                   the end of 30 days, does the member retain their
                                   Basic Health plan coverage, minus the maternity
                                   benefits?




                                                                                                      54
                                                                                All Plan Meeting - QMCO questions April 5, 2012
Q#    Group     SME         Page                         Question                            Response                                                       New Answer since last posting

248 Maternity   Contracts          Are AI / AN members in Basic Health required to           It is in the patient best interest to notify us of pregnancy                X
    Benefits                       provide notification of pregnancy? If yes, and it is      (e.g., better benefit, etc). If they do not notify us, they
                                   not provided, does the member retain their Basic          can be held liable for any costs. See above.
                                   Health plan coverage, minus the maternity benefits
                                   after 30 days? Or, is there a different penalty for the
                                   AI / AN members? If yes, please provide details of
                                   that penalty. If required, and they provide
                                   notification of pregnancy, do they remain in the
                                   Basic Health Plan for the duration of the pregnancy
                                   since they have no member liability (eg; Deductible,
                                   Copay, Coinsurance and Out of Pocket) for any
                                   covered services? Or, are they moved to Basic
                                   Health Maternity?
249 Maternity   Contracts          If a child in the Basic Health Plus plan and becomes      The child will just stay in BH+. Bob to check if they are                   X
    Benefits                       pregnant, it appears that they remain in that plan. Is    required to provide notice.
                                   that member required to provide notification of
                                   pregnancy? If they are required to do so, is there
                                   any type of penalty, and if so what, if no notification
                                   is provided?
250 Maternity   Contracts          If a Basic Health member becomes pregnant and             They only can be on one program. They cannot be on                          X
    Benefits                       provides notification of pregnancy as required, do        both.
                                   those members continue to receive Basic Health
                                   benefits in addition to maternity benefits? If yes, is
                                   there member liability (eg; Deductible, Copay,
                                   Coinsurance and Out of Pocket) for the non-
                                   maternity benefits? Or, do they get Healthy Option
                                   benefits in addition to the maternity benefits?

251 Maternity   Contracts          Some pregnant members who do not qualify for          Members enrolled in the S-Medical (Matenity) program                            X
    Benefits                       Healthy Options or Basic Health are only eligible for receive the full scope Medicaid benefit package.
                                   the Basic Health Maternity plan. Do these members
                                   have coverage for non-maternity related services as
                                   well, or just the pregnancy related services? If non-
                                   maternity related services are covered, please
                                   verify what those covered services are, and if they
                                   are covered as Basic Health or Healthy Option
                                   benefits. Can they be considered Healthy Option
                                   members during the pregnancy, even though they
                                   do not have the financial need to qualify for that
                                   program?




                                                                                                      55
                                                                                 All Plan Meeting - QMCO questions April 5, 2012
 Q#      Group     SME         Page                        Question                          Response                                                      New Answer since last posting

 252 Maternity     Contracts          Does Healthy Options include all pregnant              Maternity benefits are received under HO or through S-                     X
     Benefits                         members in the state of WA with the exception of       Medical (Maternity) for BH Plus. A BH member who
                                      the Basic Health members who do not provide            does not apply for S-Medical within 30 days of
                                      notification of pregnancy and the HCTC Basic           confirmation of pregnancy may be responsible for
                                      Health members? Additionally, we did pose this         maternity costs. If the member is denied maternity for a
                                      question in regard to the exclusion of the members     reason other than non-compliance, her maternity
                                      that only qualify for Basic Health Maternity and the   services are covered under BH.
                                      AI / AN members in Basic Health in separate
                                      questions.
 253    Benefits   Contracts          Does Healthy Options include all the children          The HO and BH Plus benefit packages are identical. BH                      X
        Coverage                      considered to be in Basic Health Plus? If yes, do      Plus is intended to allow a BH family with a Medicaid
                                      some get Basic Health Plus benefits (the Basic         eligible child to be enrolled with the same health plan.
                                      Health benefits with some additional) and others get
                                      the Healthy Options benefits?
254    834                            How will members that are not eligible for the Basic   Basic Health: This will be addressed in Companion                          X
                                      Health or Healthy Options programs, but due to         Guide that goes out on 4/23/12. Tristan and Romeo
                                      pregnancy are eligible for the Basic Health            will meet to discuss this further.
                                      Maternity Program, be identified on the 834 file?

255    834                            How will pregnant members in the HCTC Basic            Basic Health: Tristan and Romeo will discuss how to                        X
                                      Health program, be identified on the 834 file?         identify this in the 834 file.
256    834                            How will pregnant members in the Basic Health          Basic Health: If BH is not notified of the pregnancy, we                   X
                                      program that do not provide notification of            will not know about it.
                                      pregnancy, and only have 30 days of maternity
                                      benefits, be identified on the 834 file?
257    834                            How will pregnant members in AI / AN Basic Health      Basic Health: This is similar to #255. Need to specific                    X
                                      program be identified on the 834 file? As they have    identifier, and it will be addressed in the Companion
                                      member liability waived (eg; No Ded, Copay, Coins,     Guide.
                                      OOP) in Basic Health do they remain in Basic
                                      Health or are they moved to the Healthy Options
                                      834 file?
258    834                            How will AI / AN members be identified on the 834      Basic Health: This is similar to #255 and #257. Need                       X
                                      file?                                                  to specific identifier, and it will be addressed in the
                                                                                             Companion Guide.
259    834                            How will AI / AN family members that can join the      Basic Health: This is Eligibility determination and it will                X
                                      program regardless of race when approved by the        remain outside of the BH system. Will not be provided
                                      Tribal Council, be identified on the 834 file? This    in the 834 File.
                                      could not be denoted by race in this instance.




                                                                                                       56
                                                                                  All Plan Meeting - QMCO questions April 5, 2012
 Q#     Group       SME         Page                        Question                          Response                                                  New Answer since last posting

 260 Exhibit A -    Contracts          Section 2.9.2 states "If the newborn does not          This question has previously been answered.                            X
       Healthy                         receive a separate client identifier from the Health                                               No you
       Options                         Care Authority the newborn enrollment will be only     would not receive the newborn with the mother's id.
     Provisions                        available through the end of the month in which the
        2.9.2                          first 21 Days of life occur"
      Newborns
                                       Does this mean that we would receive the newborn
                                       on the 834 with the mother's Medicaid ID?

261 Subsidized                         Can HCA please clarify how the MCOs will be able       Basic Health: This information will be provided in the                 X
    Members                            to identify member's who are Subsidized?               Companion Guide.
 262 Healthy        Contracts          Can HCA please clarify what the cut off for age is?    9/1/2012                                                               X
      Options                          For example if a member turn 19 on August 5th, is
                                       the member consider 19 on August 1st of Sept 1?

263   Healthy                          Can HCA please clarify what the Rate CoHort is         Medicaid: Currently working on Rate CoHorts now. It is                 X
      Options                          and when MCOs will get the details on the              changing. Andree will share information once it is
                                       combinations of what could be sent (i.e. data          available. Rate CoHort links to program, age bracket,
                                       dictionary)?                                           gender and by region.
264   Healthy                          On the RAC document - there are columns for RAC        Medicaid: RAC spreadsheet has formatting issues.                       X
      Options                          start date and end date, but the values in the rows    RAC information will be in the 834.
                                       for those columns are not dates? What do those
                                       stand for? Are the columns miss labeled?

265   Error Codes                      Is there a listing available of current Encounter      Yes, these codes are listed in the Encounter Data
                                       reject/error codes?                                    Reporting guide
266   837                              Is there an updated 837 Healthcare Claim               Medicaid: All Guides are on website. Shows what was                    X
                                       Technical Specification document? [the current         updated. API information is needed/updates are
                                       version is dated 12/17/2010] (i.e. the 837             needed. Andree will provide clarification.
                                       Encounter Data Companion Guide was updated on
                                       2/27/2012)
267   ETRR                             Where can we obtain a copy of the file layout for      Medicaid: Encounter Reporting Guide (January, 2012).                   X
                                       the Encounter Transaction Results Report (ETRR)?

268   Encounter                        Can HCA provide what the Production encounter          Medicaid: Contract states 2 months (60 days) - but can                 X
      Submission                       submission dates are going to be – i.e. weekly?        report daily, weekly or monthly. It is up to each plan.
      Dates                            monthly?                                               Additional Question: Can health plans share their
                                                                                              schedule to HCA? Answer: Yes
269   Response                         What is the timeline/turn-around time for Response     Medicaid: It is dependent on when it is submitted to                   X
      Files                            files for the encounter submissions?                   HCA. Example: submitted on Tuesday, could be
                                                                                              available by Friday. Need to wait for 2 cycles from
                                                                                              when it is submitted. Todd will provide additional
                                                                                              information at the Encounter Training.
270   HIPPA                            Is HCA using a HIPAA level 5 compliance level?          Medicaid: Level 1 and Level 2 on the 834.                             X
      Compliance


                                                                                                        57
                                                                                     All Plan Meeting - QMCO questions April 5, 2012
 Q#       Group        SME      Page                          Question                            Response                                                    New Answer since last posting

271    Compliance                      Does HCA have their own RAMP                               Medicaid: No. MCO's will test their own data and more                    X
       Software                        manager/encounter file compliance check software           information will be addressed in Encounter Training.
                                       we are to use?
272    Provider                        Does HCA require the providers submitted on the            Medicaid: No. This will be addressed in Encounter
       Match                           encounter file to match the State’s ProviderOne            Training. HCA will update # 16 needs to be updated in
                                       database via billing or rendering provider NPI?            the guide.

273    RSN                             How do we identify RSN vs. MCO encounters?                 Medicaid: No. RSN's are separate from MCO, but will                      X
       Encounters                      Does RSN apply to us or are we strictly MCO                coordinate. Same companion guide.
                                       coverage?
274    837                             In the 837 Companion Guide and the 837 Technical           Medicaid: Yes. Todd will provide additional information                  X
       Required                        Specification guide, they do not designate Required        at the Encounter Training.
       Fields                          vs. Situational fields – are we to follow the standard
                                       v5010 837 Implementation Guide requirements?

275    Multiple                        Does HCA accept paid, denied and voided claims             Medicaid: Todd will provide additional information at                    X
       837                             all in one 837 file or must they be submitted in           the Encounter Training.
       Iterations                      separate file iterations?
276    Zip Code                        Is there a default value for the zip + 4 if the provider   Medicaid: not certain (not always has the 4 digits) defer                X
                                       only has the root 5 digit zip code? (i.e. can we           to Training.
                                       default the last 4 to ‘9999’?)                                    Basic Health: If it is blank in the Basic Health
                                                                                                  system, it stays blank, do not force
 277 Newborns Contracts                Will HCA reject encounters for newborns if their           HCA will answer this in a future posting
                                       weight in grams is not populated on the encounter
                                       submission?
278    Language                        In the Enrollment and Payment Transactions                 HCA will answer this in a future posting
       Codes                           meeting, it was indicated that the language code in
                                       the 834 would be ISO 639. Can HCA clarify if the
                                       834 will contain the ISO 639-1 or 639-2?

                                       Also, can you specify if you have a sub-set of
                                       language values available in your system (for
                                       example in 639-2 there are 545 possible
                                       languages)?

 279     FQHC           Rates          Will a nonparticipating FQHC bill a T1015? Who             FQHC - We do not recognize Par/Non-par. This is up to                    X
        Provider                       and what determines the list of the non-participating      the plan. Par/Non par means they are contracted with
         Guide -                       FQHCs? Are they non-participating with the state or        you or non contracted with you. They will bill as per the
       Participating                   with the MCO?                                              FQHC Billing Instructions.
        FQHC vs.
          Non-
       Participating
         DHHS
         FQHC
        Page A.1


                                                                                                           58
                                                                              All Plan Meeting - QMCO questions April 5, 2012
Q#     Group      SME      Page                         Question                          Response                                                    New Answer since last posting

280    FQHC        Rates          Could a dental encounter include treatment for          Yes, as long as it is medically necessary. HO - What is                  X
      Provider                    accidental injury to sound natural teeth or jaw?        excluded in the contract are services provided by a
       Guide -                                                                            dentail provider type for a "D" dental code. You may pay
       Dental                                                                             for a dental code by a non-dental provider. BH - If there
      Services                                                                            was an injury to sound teeth, this may be covered. BH
      Page C.9                                                                            does not cover dental services.
281    FQHC        Rates          Will the Medical Mental Health for members ages         No.                                                                      X
      Provider                    18 and under require the ‘HE’ modifier?
       Guide -
       Dental
      Services
      Page C.7
282    FQHC        Rates          When the individual provider’s NPI is billed in box     Mlutiple rendering providers would not be billed on the                  X
      Provider                    24J, how can they bill multiple encounters on 1         same claim form.
       Guide                      form?
283    FQHC        Rates          If the services paid FFS during an encounter are        You reimburse at your schedule and the encounter rate                    X
      Provider                    greater than the encounter rate itself, do we pay       is irrelevant.
       Guide                      total FFS amount due or up to the encounter rate?

                                  EXAMPLE: T1015 = $150; office visit = $100 +
                                  vaccination = $80

                                  Would we pay $100 for the office and $80 for the
                                  vaccine or would we only pay up to the $150?

284    FQHC        Rates          Is it possible for there to be a hospital based         No. Instructions are in there for Medicare crossover                     X
      Provider                    FQHC? If no, why are there UB billing instructions      claims.
       Guide                      the manual?
285     RHC        Rates          Can HCA please provide clarity on the wrap              It is based on the monthly rosters that the plans provide                X
      Provider                    payment to the RHC when they will only be billing a     - PMPM. When RHC billed HO, they do not bill
       Guide                      T1015 for true encounters?                              CPT/HCPCS, they bill encounters. When they bill the
                                                                                          health plans, they will be billing CPT/HCPCS
286 Physician-     Rates          Can HCA please provide a list of V codes that are       FFS - ICD-9-CM is followed or any rule outlined in the                   X
     Related                      not to be billed as primary?                            billing instructions.
    Services/He
     althcare
   Professional
     Services
     Provider
      Guide -
     Page A.2




                                                                                                    59
                                                                             All Plan Meeting - QMCO questions April 5, 2012
Q#    Group       SME      Page                        Question                          Response                                                        New Answer since last posting

287 Physician-     Rates          Can HCA please confirm if preventative medicine is Preventative is covered to the extent that it is covered in                      X
     Related                      not covered for members over 21? (Healthy Options the billing instructions. BH - preventative services
    Services/He                   handbook pg 14)                                    covered and are in Schedule A of the BH Member
     althcare                                                                        Handbook.
   Professional
     Services
     Provider
      Guide -
     Page A.5

288 Physician-     Rates          Smoking Cessation is covered for Healthy Options       Health plans may offer member smoking cessation. HO                          X
     Related                      but not Basic Health, are we responsible for           provides specific codes for this in the billing instructions.
    Services/He                   covering this benefit for all members? And if so are
     althcare                     there any limitations? Are there specific codes that
   Professional                   can be billed?
     Services
     Provider
      Guide -
     Smoking
     Cessation
     Page B.9

289 Physician- Contracts          Are the MCOs responsible for covering telehealth       See attached document. It is covered and the document                Attached Documents
      Related                     for Basic Health/Healthy Options?                      outlines the HO policy. BH is still reviewing the contract
    Services/He                                                                          regarding this policy at this time.
      althcare
   Professional
      Services
      Provider
       Guide -
     Telehealth
     Page B.24

290 Physician-     Rates          What are HCA's requirements for the QW Modifier        There is currently work being done to recognize it.                          X
     Related                      for CLIA requirements?
    Services/He
     althcare
   Professional
     Services
     Provider
      Guide




                                                                                                   60
                                                                            All Plan Meeting - QMCO questions April 5, 2012
Q#    Group       SME      Page                        Question                         Response                                                 New Answer since last posting

291 Physician-     Rates          Is it ok for MCOs to deny for LC12? Would this be     Currently TENS are a non-covered item listed on the                   X
      Related                     covered in a home health setting?                     Non-Covered WAC 182-543-6000(11).
    Services/He
      althcare                                                                          We are following the HTA decision that these are not
   Professional                                                                         medically necessary items. This information is located
      Services                                                                          at: http://www.hta.hca.wa.gov/tens.html.
      Provider
       Guide -
       TENS
       Device
     Page E.13

292 Physician-     Rates          The manual gives 6 CPT codes that can be covered HCA will answer this in a future posting
      Related                     when medically necessary and ONLY for Cancer
    Services/He                   Pain and Spasticity? What DX codes are used to
      althcare                    determine Cancer Pain and Spasticity?
   Professional
      Services
      Provider
       Guide -
    Implantable
      Infusion
     Pumps or
    Implantable
        Drug
      Delivery
     Systems
       (IDDS)
     Page E.14

293 Physician-     Rates          Should the MCOs limit the T1023 with HI modifier to HCA will answer this in a future posting
     Related                      the ABD member population, or can it be billed for
    Services/He                   other members?
     althcare
   Professional
     Services
     Provider
      Guide -
       DDD
     Physical
     Page F.2




                                                                                                  61
                                                                             All Plan Meeting - QMCO questions April 5, 2012
Q#      Group      SME      Page                        Question                         Response                                                 New Answer since last posting

294 Physician- Contracts           Can HCA please confirm abortion services covered      HCA will answer this in a future posting
     Related                       under the MCO? If yes, do you require a consent
    Services/He                    form for abortion services? If yes, where can the
     althcare                      MCOs locate the form?
   Professional
     Services
     Provider
      Guide -
     Abortions

295 Physician- Contracts           For Basic Health, is family planning considered       FP is not considered preventative, so copays would
     Related                       preventative and copays would not apply? If there     apply. We do not have a list of services that are not
    Services/He                    are services that are not considered preventative,    considered preventative. The BH COC outlines
     althcare                      can we get a list of these services?                  covered services.
   Professional
     Services
     Provider
      Guide -
      Family
     Planning

296    BR - By      Rates          What is the state's default rate used to price        The rate for BR codes varies by service (as defined by                X
        Report                     procedures denoted as "BR" for billed charges         CPT codes) as follows: Surgical procedures -- 45%;
      Procedures                   under $1100.00? What is the state's default rate      Labs -- 40%; Medicine -- 50%; Radiology -- 45%. For
                                   used to price procedures denoted as "BR" for billed   charges $1,100 and over, providers are required to
                                   charges of $1100.00 or greater? Does the default      submit documentation. The rate for BR codes for
                                   rate vary by fee schedule? If so, please advise the   supplies (DME) is based on a percentage of invoice or
                                   percentage for each. Or, if no default rates have     MSRP.
                                   been established, what methodology is used to
                                   determine reimbursement?

297 Anesthesia      Rates          Per state guidelines an anesthesia provider may       No. Modifier AD pays 50%.                                             X
    Supervision                    direct no more than four anesthesia services
                                   concurrently. In the Anesthesia Modifiers section of
                                   the "Physician Related Services Manual "it lists
                                   Modifier "AD" which is "Medical supervision by a
                                   physician for more than four concurrent anesthesia
                                   services." There is no pricing directive included for
                                   this modifier in the manual. Due to the verbiage that
                                   an anesthesia provider cannot direct more than four
                                   anesthesia services concurrently, and this modifier
                                   is for more than four, was the state denying
                                   anesthesia procedure codes appended with
                                   Modifier AD? If not, how should procedure codes be
                                   paid that include this modifier?


                                                                                                   62
                                                                                All Plan Meeting - QMCO questions April 5, 2012
Q#      Group       SME      Page                         Question                           Response                                                  New Answer since last posting

298    Assistant     Rates          The state indicates that Assistant Surgeon               Modifier AS is set up to pay 20%.
       Surgeon                      Modifiers 80, 81 & 82 are paid at 20% of the
       Modifiers                    maximum allowance. Modifier AS is listed in the
                                    CPT / HCPCS Modifiers section of the "Physician
                                    Related Services Manual", but there is no pricing
                                    directive included for this modifier. Does the state
                                    reimburse for Modifier AS? If so, what is the
                                    reimbursement percentage? If not, should
                                    procedure codes appended with Modifier AS be
                                    denied?
299      Fee         Rates          It appears that some procedure codes allowed on          We take information directly from CMS. The CMS file                    X
      Schedule;                     the fee schedules as global, technical and               did not have relative values assigned to 74420 TC and
         Prof,                      professional, only include a rate for the professional   74420 global, so these codes were set as B.R. If one is
       Technical                    component appended with Modifier 26. The global          not listed, there is no separate payment. Codes can be
      and Global                    procedure with no modifier and the technical             defined as global and do not need 26/TC.
         Rates                      procedure with Modifier TC are listed as "BR". An
                                    example of this is CPT 74420 on the 2012
                                    "Physician-Related Services/ Professional and
                                    Emergent Oral Healthcare Services" fee schedule.
                                    Is there a reason that state did not include fees for
                                    the global and technical components for this or
                                    other codes? What percentage of the global
                                    allowable does the state consider the professional
                                    component to be (eg; 20% of global and technical is
                                    80%, etc)?

300     EPSDT -      Rates          In the EPSDT Manual in the section regarding the         For immunizations that are free from the DOH, the plan                 X
      Immunizatio                   "Free from DOH" immunizations there is reference         pays the administration fee. Providers must bill SL
        ns "Free                    on two of the CPT Codes (90680, 90698) that these        modifier with the vaccine code to be reimbursed for
       from DOH"                    are "Covered only if free from DOH for children".        administration.
                                    The same verbiage is on the "Injectable Drug Fee
                                    Schedule". How would we determine if these
                                    immunizations are free from DOH?




                                                                                                      63
                                                                                All Plan Meeting - QMCO questions April 5, 2012
Q#      Group       SME      Page                         Question                           Response                                                     New Answer since last posting

301    Facility      Rates          Reviewing the state's Provider Guides it does not        Question 1: The Inpatient Hospital Services Provider                      X
      Admission                     appear that there is any criteria based on hours or      Guide states that a change in admission status may be
        Status                      days in regard to requiring a change in admission        made “prior to, or on the next business day following,
       Change                       status. For example, if a member is in Outpatient        discharge” - Page E.3, Inpatient Hospital Services
       Criteria -                   Observation, there no time limitation as to when this    Provider Guide; link is
      Outpatient                    becomes an Inpatient Admission (eg; 24 hours). Do        http://hrsa.dshs.wa.gov/download/Billing_Instructions/Inp
      Observation                   you allow a patient to be in Outpatient Observation      atient_Hospital/Inpatient_Hospital_BI.pdf. Question
                                    for an unlimited period of time? If not, do you have     2: Do you allow a patient to be in Outpatient
                                    a specific limitation as to how many hours or days a     Observation for an unlimited period of time? The
                                    member can be in this admission status before it         Medicare Claims Processing Manual, Chapter 4,
                                    becomes an Inpatient Admission?                          section 290, has guidelines for the length of time a
                                                                                             patient may be under active observation. We adhere to
                                                                                             those guidelines. “In only rare and exceptional cases
                                                                                             do reasonable and necessary outpatient observation
                                                                                             services span more than 48 hours. In the majority of
                                                                                             cases, the decision whether to discharge a patient from
                                                                                             the hospital following resolution of the reason for the
                                                                                             observation care or to admit the patient as an inpatient
                                                                                             can be made in less than 48 hours, usually in less than
                                                                                             24 hours.” Question 3: Do you have a specific
                                                                                             limitation as to how many hours or days a member can
                                                                                             be in this admission status before it becomes an
302      17P         Rates          In the "Physician Related Services Manual" the           Effective April 2012, providers are instructed to bill 17P                X
       HCPCS                        direction is to bill a 17P injection using HCPCS         with J3490. The Physician Related Services Manual
      Procedure                     J1725. Reviewing the "Injectable Drug Fee                has been updated.
        Code                        Schedule" effective 01/01/2012 it indicates that
                                    HCPCS J1725's allowable is a # sign, as though it
                                    is not a covered procedure. Should this injection be
                                    billed with a different procedure code or will the fee
                                    schedule be updated to reflect this is a covered
                                    procedure code?
303    Multiple      Rates          If an endoscopy procedure and an open procedure          If procedures are subject to the Multiple Procedure                       X
       Surgeries                    are both billed during the same operative session,       payment reduction rule, then payment will be reduced
                                    do both procedures get paid at 100% of the               (multiple procedure indicator comes from CMS). We
                                    allowable?                                               follow CMS.
304 Anesthesia       Rates          Per the "Physician Related Services Manual" the          Dental anesthesia providers.                                              X
     Provider                       state pays providers for covered anesthesia
      Types                         services performed by; anesthesiologists, CRNAs
                                    or other providers who have a contract to provide
                                    anesthesia services. What other provider
                                    specialties would be allowed to perform anesthesia
                                    services?
305 Anesthesia       Rates          There is no mention of Anesthesia "Physical Status       We do recognize them, but there is no payment                             X
     Physical                       Modifiers" in the "Physician Related Services            differential for them.
      Status                        Manual"; P1 - P6. Does the state recognize these
     Modifiers                      modifiers? Does the state allow additional units for
                                    these modifiers?
                                                                                                      64
                                                                                           All Plan Meeting - QMCO questions April 5, 2012
 Q#      Group       SME           Page                              Question                          Response                                                 New Answer since last posting

306   IT Question                              Encounters – HOBD and HOFC: MCOs will be             Medicaid: Same as today. Andree will confirm with                        X
      - Medicaid                               receiving 2 new 834 enrollment files for the Healthy Todd. Separate Suffix for Encounter. Will need to
                                               Options Blind Disabled (HOBD) and Healthy            supply Suffixes earlier / before training
                                               Options Foster Care (HOFC) members, and new
                                               MCO ProviderOne IDs will be assigned. Currently
                                               encounters are submitted with a program specific
                                               MCO ProviderOne ID i.e. 105010201 for Healthy
                                               Options. Will MCOs be required to submit separate
                                               encounter files with the new MCO ProviderOne IDs
                                               for HOBD and HOFC?

307   IT Question                              Date of first HOBD/HOFC file: In the 3/16 technical Medicaid: Can not confirm until testing is complete                       X
      - Medicaid                               meeting it was discussed that as soon as changes (need plan feedback regarding testing issues). Hoping
                                               begin to occur for HOBD and HOFC members,           for June 25th for production date.
                                               transaction records will be created in ProviderOne.
                                               Can you please confirm when the MCOs will
                                               receive the first 834 enrollment files for HOBD and
                                               HOFC? Will it be the 6/25/2012 Audit/Update files?

308   IT Question                              Effective date of assignments and enrollee choice: Medicaid: Effective date is 7-1-2012. Cutoff is 10 days                    X
      - Medicaid                               Health Care Authority may be sending notices as         prior (18th) for 7-1-2012. Clients can make changes up
                                               early as April 2012 to inform displaced clients which to 6-28-2012 to be effective 7-1-2012.
                                               MCO they have been assigned to. As the
                                               assignment changes occur in ProviderOne for the
                                               displaced clients, will MCOs receive the member
                                               enrollment effective first of the following month after
                                               being assigned, or would the members have a
                                               future effective date of 7/1/2012?

 309 Final           Contracts   pg 2 pg       Exhibit A of the final contract includes 365 days to    HCA will answer this in a future posting
     Contract                    36            reconcile newborn premium, and the main contract
     Exhibit A                   respectivel   includes 60 days to reconcile the enrollment file. It
     Section                     y             has been confirmed that MCOs must submit all
     1.1.4                                     Premium Adjustment Request Forms (PARFs)
                                               within 60 days with exception of newborn
                                               premiums. What is the time requirement for
      Main                                     Delivery Case Rate (DCR) PARF submissions? It
      Contract                                 does not appear to be specified in the contract.
      Section
      4.1.2 Rates
      & Premium
      Reconciliati
      on




                                                                                                                 65
                                                                                     All Plan Meeting - QMCO questions April 5, 2012
 Q#      Group       SME           Page                         Question                         Response                                                  New Answer since last posting

310   IT Question                          BH Number of Transactions: As Basic Health            Basic Health: One Transaction Per member                               X
      – Basic                              members will remain in the legacy system, can we
      Health                               expect to see only one transaction per member on
                                           the 834 enrollment file? Currently for the
                                           ProviderOne Medicaid 834 enrollment files, we can
                                           receive multiple transactions for a member record,
                                           showing the history that occurred in the
                                           ProviderOne system
  311 Section     Contracts      Page 93   Can HCA please clarify what constitutes a             CMS would be the one to determine and define
      11.7.9.2                             “significant” business transaction, or should MCOs    "signficant" business transaction.
      Program                              make this determination ourselves?
      Integrity
      Reporting-
      Significant
      Business
      Transaction

  312 Incentive      Contracts             Are there any restrictions/limits to the amount of    We cannot give cash, and the gift cards given to
      Restrictions                         incentives (monetary value) a member can receive      enrollees need to be about $5-$10. Some health plans
      and Limits                           in one year? If so, what is the amount?               give carseats, as an example. We do not have actual
                                                                                                 rules.
 313 Clarification   Contracts             The contract states that the contractor shall         If a request is made on Friday, approval would come on                 X
     on Business                           approve or deny all requests for non-formulary        Monday. Saturday and Sundays are not business days.
     Days                                  drugs by the business day following the request.
                                           Need clarification on Saturday hours. Does a Friday
                                           request have to be concluded on Saturday or
                                           Monday?
 314 Replacement                           Please confirm that plans are responsible for         Gail will discuss these issues at the 04.13.12 All Plan                X
     Parts                                 covering replacement parts for cochlear implants      Mtg
     Coverage                              and bone anchored hearing aids however that the
                                           implantation and initial device are covered under
                    Rates                  Fee-For-Service.
  315 Substance     Rates                  Can the State provide a list of the specific          HCA will answer this in a future posting
      Abuse &                              outpatient substance abuse and detox services that
      Detox                                are provided by the Community Mental Health
      Services List                        Centers?
316 State                                  Where can we get a listing of the state county        Medicaid: Andree will confirm with Todd re: the 2 digit                X
      County                               codes and cohorts that will be received on the 834    county code. CoHort is in progress
      Codes                                enrollment files?
317 ProviderOne                            On the ProviderOne web portal, there is an option     Medicaid: When you log on to P1 providers it shows                     X
       Web Portal                          for accessing and printing a provider listing. Does   providers that have a contract with Medicaid.
                                           this list include all providers registered with WA
                                           Medicaid, or is this a subset relevant only to the
                                           MCO who is logged into the portal?



                                                                                                           66
                                                                                     All Plan Meeting - QMCO questions April 5, 2012
Q#     Group       SME         Page                          Question                            Response                                                    New Answer since last posting

318 Coordinating Contracts            State Q&A #82 indicates that existing MCOs will     HCA is still working on this process. Bob to clarify cost
    with Existing                     share YTD deductible and out of pocket costs to the sharing.
    MCO                               enrollee’s new health plan once his or her
                                      enrollment with the new plan is confirmed. Is there
                                      more detail available regarding how to coordinate
                                      with the exiting MCO and the format in which this
                                      information will be shared?

319 HO             Contracts          We would appreciate more detail on specific           Health plans need to refer to the Billing Instructions.                       X
    Behavioral                        services covered under HO. For example, is
    Health                            neuropsychological testing included in the benefit
    Services                          related to psychological testing? What other specific
                                      services are covered under “treatment” for
                                      members not meeting RSN access standards?

320 HO             Contracts          For enrollees not meeting RSN access standards,            Plans need to review the Billing Instructions
    Behavioral                        are all BH diagnoses covered, including V-codes?
    Health
    Benefits
321 Basic Health   Contracts          What is the difference in benefits between Basic           The BH+ benefit and the HO benefit are the same.                         X
    Behavioral                        Health and Basic Health Plus? Can Basic Health or
    Health                            Basic Health Plus members obtain their care
    Benefits -                        through the RSN’s as can the HO members?
    Benefits for
    Basic Health
    & Basic
    Health Plus


322 Basic Health Contracts            Chemical dependency – What specific services are           BH specific services are listed in the Member Handbook
    Behavioral                        included in the CD benefit (e.g. ambulatory                on pg. 28. As to the point of service restrictions, there
    Health                            detoxification, intensive outpatient treatment, partial    are none that we are aware of. Out of network services
    Benefits -                        hospitalization, methadone maintenance, traditional        can be done as long as the member is not being
    Chemical                          outpatient)?                                               balance billed.
    Dependency                        o Are there any Place of Service (POS) restrictions for
                                      these services?
                                      o Does “health plan-contracting approved treatment
                                      program” allow for any out of network services?




                                                                                                           67
                                                                                       All Plan Meeting - QMCO questions April 5, 2012
Q#     Group       SME         Page                           Question                             Response                                                    New Answer since last posting

323 Basic Health   Contracts          Mental Health –                                              BH specific services are listed in the Member Handbook
    Behavioral                        o IP – Is psychiatric residential treatment a covered        on pg. 28. As to the point of service restrictions, there
    Health                            benefit?                                                     are none that we are aware of. Out of network services
    Benefits -                        *Same question as above regarding out of network             can be done as long as the member is not being
    Mental                            facilities                                                   balance billed. Bob to provide additional follow up
    Health                            o OP – What specific services are covered under
                                      the outpatient benefit?

324 CTA Place of Rates                The Physician-Related Services/Healthcare                    Please review the billing instructions                                   X
    Service                           Professional Services billing guide (page E-13)
    Requirement                       identifies that Computed Tomography Angiography
    s                                 (CTA) is covered when the medical necessity
                                      criteria are met. However, it also restricts CPT code
                                      75574 to POS 21, 22, 23. Are MCOs required to
                                      restrict coverage of this service to these POS as
                                      well?
325 Basic Health   Contracts          Beyond the Certificate of Coverage, please identify          Covered Benefits are only outlined in the COC for BH.                    X
    Benefit                           the best source of information regarding Basic               BH does not set fees, the managed care plans do, so
    Coverage                          Health covered benefits and limitations. We have             we do not have a fee schedule.
                                      found several sources for Healthy Options (i.e. fee
                                      schedule) but have not found a corresponding one
                                      for Basic Health.
326 Provider    Contracts             1) Provider Contracting – We would like the                  Updates have been scheduled.                                             X
    Contracting                       opportunity to provide you an update on our
                                      network development efforts. We would also like to
                                      discuss difficulties we have encountered with some
                                      provider groups and potential assistance from HCA.

327 Assignment Contracts              What is the process for new members being                    Only to HO - everyone who is a new enrollee will be                      X
                                      enrolled in managed care. Will they be initially auto-       auto-assigned, but this process includes a choice. BH -
                                      assigned into a health plan and provided an                  for existing plans, members will stay with that plan
                                      opportunity to change OR will they have an initial           unless they choose another health plan. For those
                                      choice period and if they don’t self-select, be auto-        plans that are no longer available, members will be
                                      assigned? This question pertains to both new                 assigned and would still have the opporutnity to change
                                      populations (i.e. SSI) as well as new members after          their health plan during Open Enrollment.
                                      go-live (Healthy Options, Basic Health).

328 Assignment Contracts              Will the new SSI population be auto-assigned equally         The assignment percentages will be the same across                       X
                                      across all operating plans in a service area or will the     the entire HO population
                                      State be assigning a higher percentage to new plans?

329 Assignment Contracts              Has there been a final decision made on whether or not       That population is not included.                                         X
                                      the previous GAU population will still be included in the
                                      program?



                                                                                                             68
                                                                                 All Plan Meeting - QMCO questions April 5, 2012
 Q#     Group    SME         Page                          Question                           Response                                                  New Answer since last posting

 330 Marketing   Communica          Please confirm who we should submit member                You can submit materials for review to                                 X
                 tion               communications and marketing material to for HCA          hcamcprograms@hca.wa.gov
                                    review and approval.
 331 Communicat Communica           Please confirm that provider communication (i.e           This is correct.
     ion        tion                Manual, newsletter, blast faxes, etc.) does not require
                                    HCA approval as it is focused more on plan-specific
                                    operational processes and procedures.
 332 Care        Contracts          Will the state be providing any copies of any existing We do not have this information. Care management                          X
     Coordinatio                    approved care plans for members newly enrolled in our  will need to work with the people who also provide the
     n                              plan?                                                  care to these individuals to develop an appropriate care
                                                                                           plan.
 333 Prism       Contracts          Do the existing plans have an automated process to     PRISM itself is able to sort members by their risk                        X
                                    interface with the PRISM system to identify members    scores. PRISM carries all RSN data, and the health
                                    with scores above 1.5 and/or determine those members plans would be able to know who is receiving RSN
                                    receiving RSN services because they meet RSN access to services.
                                    care standards?
334   Barcodes                      WA currently has the capability of printing a bar      Medicaid: This is up to each plan on how they are                         X
                                    coded sheet for provider that would like to submit     required to process claims.
                                    attachments related to the claim submission (Pg 14
                                    Provider One billing and Resource guide). Please
                                    confirm this is a State process and that we can
                                    develop our own process for requesting/receiving
                                    this information from our providers.

335   NDC                           We would like to discuss NDC reporting and the       Medicaid: Todd will discuss this in Encounter Training.                     X
                                    appropriate fields to use for reporting.
336   Taxonomy                      Appendix L – (Taxonomy Code Reporting) The           Medicaid: Todd will discuss this in Encounter Training.                     X
                                    Appendix speaks to a validation of the taxonomy
                                    code to the ProviderOne provider file. Is this level
                                    of validation on an inbound claims required for
                                    health plans?
 338 FQHC/RHC Rates                 Can you confirm timing of the FQHC montly roster? Plans must post each month's file to the website by the                        X
                                                                                         15th of the month
 339 FQHC/RHC Rates                 Can you provide a sample layout of the FQHC          Document to be sent                                                         X
                                    report, with file layout specifications?
 340 FQHC/RHC Rates                 Can you identify FQHC file naming conventions?       Document to be sent                                                         X

 341 FQHC/RHC Rates                 Are the Plans required to submit monthly payment          It would be up to each health plan to review with their                X
                                    detail to FQHC and RHCs?                                  contractors
 342 FQHC/RHC Rates                 Can you explain what and how the monthly payments         The plans submit the roster to HCA and the monthly                     X
                                    are made to the FQHCs and RHCs                            wrap payment is included in the RA for the FQHC/RHC.

 343 FQHC/RHC Rates                 Please confirm payment timing of the states          If loaded on the 15th, clinics should expect it on the 3rd                  X
                                    supplemental payments to the FQs and RHCs? Does that to 4th week of the month
                                    reflect any change to the FQs and RHC?


                                                                                                       69
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 Q#      Group       SME   Page                          Question                          Response                                                    New Answer since last posting

 344 FQHC/RHC Rates               Are there any known unique services that WA              Not that HCA is aware of, except the DCR                                 X
                                  recognizes as eligible for supplemental payments that
                                  don't exist nationally?
345   Operations/                 COB follow up.                                           Medicaid: Need information on when / how the plans                       X
      Eligibility/                                                                         will determine cost sharing data: Historical Data (client
      Benefits                                                                             RX information) - PRISM and Transitioanl Data (is client
                                                                                           in hospital /needs transportation), Prior Authorizations.

346   834                         Health Plans had issues with how they get                HCA will answer this in a future posting
                                  information in Files. How they determine clients by
                                  family or by individual. How to determine a specific
                                  type: Plus / Y50 and new plans need to know how
                                  to read Files
347   834                         #255 Can we identify HCTC only and HCTC                  HCA will answer this in a future posting
                                  pregnancy on 834
348   834                         Is there a guide to the codes for reading the            HCA will answer this in a future posting
                                  Companion Guide / Proprietary File
349   Operations/                 When does the first 30 days of pregnancy start?          HCA will answer this in a future posting
      Eligibility/
      Benefits

350   834                         Will term dates be on audit file?                        Basic Health: Due to HIPPA, will not have term dates on                  X
                                                                                           audit file (Shane / Romeo)
351   834                         How will restricted/protected addresses work             Medicaid: Use address in 834. Andree will follow up in
                                                                                           Test, AREP screen.
352   834                         What happens if they are not on the audit file?          Medicaid/Basic Health: Yes. Term if not on audit file.                   X

353   834                         Will assignments be automatically changed?               Medicaid: No. Assignment to client responding. It will                   X
                                                                                           stay the same until the client makes a change.
354   834                         #151 - Newborns given own ID?                            Basic Health: Yes.                                                       X
355   834                         Will Plans see Transaction code 025 / reinstate          Medicaid: Not very often, should be code 021, treat as                   X
                                  code                                                     “add” record, Should not see Void Transaction on 834.

356   834                         What is the term date on 834? First date of new          Medicaid: It is the last day of the month                                X
                                  month or last day of the month?
357   834                         Will Plans see the same, duplicate members in two        Medicaid: Yes, but rarely. Plans needs a process for                     X
                                  different files?                                         newborns (it depends on when the newborn is reported).

358   837                         PRC - Encounter data?                                    Medicaid: Andree will follow up on PRC Training.                         X
359   834                         Can you determine file type (weekly updates vs.          Medicaid: No. They have to be opened audit and or                        X
                                  monthly audit) without opening them?                     update file to verify what type it is.
360                               Rate CoHort                                              HCA will answer this in a future posting                                 X
361   837                         BH- Do we need encounter file?                           Basic Health: Not 837. Posts to site, use outside                        X
                                                                                           source (Milliman). Romeo will need to ask Kathy Ott
                                                                                           regarding 837 and the file format.


                                                                                                     70
                                                                              All Plan Meeting - QMCO questions April 5, 2012
 Q#       Group      SME   Page                         Question                          Response                                                New Answer since last posting

362   837                         What is the Proprietary format for BH                   Basic Health: Romeo will find out, was not from IT.                  X
                                                                                          HCA / Molina has contract with out side vendor -
                                                                                          Milliman
363                               Can financial Reporting be addressed, not in            HCA will answer this in a future posting                             X
                                  HIPPA?
364   Operations/                 Does a newborn baby have coverage under the             Medicaid: No. The newborn baby has its own ID. Do                    X
      Eligibility/                mom's ID?                                               not set up temporary information, add when the
      Benefits                                                                            information shows on 834. Under contract, plans cover
                                                                                          baby for first 21 days. Plans will need to report
                                                                                          newborns that are added and they do not receive
                                                                                          payment for.
365                               Can MCO's get the Member Portal Language?               HCA will answer this in a future posting                             X
366   Operations/                 Can MCO's get Diagnostic Codes for Womens               HCA follows ICD-9-CM guidelines
      Eligibility/                Services?
      Benefits

367   Operations/                 What happens when client is both BH and HO              Medicaid: Plans need to report dual enrollment, term                 X
      Eligibility/                active?                                                 HO (retro changes show on weekly reports).
      Benefits                                                                                         Basic Health: We have a monthly match
                                                                                          process with Medicaid that disenrolls dually enrolled
                                                                                          members from BH coverage.
368   834                         Test file date: Is there an estimated date that the     Medicaid: Hopefully as early as 4/16/12.                             X
                                  834 HOBD and HOFC test files will be available?

369   ?                           Rate cohorts date: When will the revised rate cohort Medicaid: It is in the process of being updated now.                    X
                                  mapping be available?
370   ?                           On various reports submitted to HCA (excluding       HCA will answer this in a future posting
                                  encounters) can HOBD and HOFC be lumped in
                                  with Medicaid HO/CHIP/BH+? Or do HOBD and
                                  HOFC need to be reported separately?
371   ?                           How soon can MCOs receive additional accesses to HCA has future trainings scheduled for this.                                X
                                  PRISM?




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                     142
MCO P1 ID FQHC/RHC NPI Client P1 ID   Client Last Name   Client DOB Gender Start Date End Date
Reverse Payment
                                                       Cove
                         RAC               Progr Progr rage       Federally
NEW or                   Start     RAC End am    am    Grou       Qualified
Existing   Program       Date      Date    Code Type p      Age   Code


                                                                   Blind or Disabled CNP and
           Blind/Disab
New        NonDual
Existing   WMIP            25477     401768 GA   B    G02
           Blind/Disab
New        NonDual
Existing   WMIP            25477     401768 GA   D    G02
           Blind/Disab
New        NonDual
Existing   WMIP            25477     401768 MA   B    S01
           Blind/Disab
New        NonDual
Existing   WMIP            25477     401768 MA   B    S01
           Blind/Disab
New        NonDual
Existing   WMIP            25477     401768 MA   D    S01
           Blind/Disab
New        NonDual
Existing   WMIP            25477     401768 MA   D    S01
           Blind/Disab
New        NonDual
Existing   WMIP            25477     401768 MA   N    S01
           Blind/Disab
New        NonDual
Existing   WMIP            25477     401768 MA   O    S01
           Blind/Disab
New        NonDual
Existing   WMIP            25477     401768 MA   B    S02
           Blind/Disab
New        NonDual
Existing   WMIP            25477     401768 MA   D    S02
           Blind/Disab
New        NonDual
Existing   WMIP            25477     401768 MA   B    S02
           Blind/Disab
New        NonDual
Existing   WMIP            25477     401768 MA   D    S02
           Blind/Disab
New        NonDual
Existing   WMIP          25477   401768 MA   B    S08
           Blind/Disab
New        NonDual
Existing   WMIP          25477   401768 GA   X    G02




                                                                    Foster Care
                                                         excludes those with Juv
New
Optional   Foster Care                 MA        1 D01

New
Optional   Foster Care                 MA        2 D01

New
Optional   Foster Care                 MA        3 D01

New
Optional   Foster Care                 MA        4 D01

New
Optional   Foster Care                 MA        1 D02

New
Optional   Foster Care                 MA        2 D02

New
Optional   Foster Care                 MA        3 D02

New
Optional   Foster Care                 MA        4 D02




                                                            Healthy Options/PC
           HO
New        PCCM                        MA    P    F03

           HO
New        PCCM                        MA    R    F03

           HO
Existing   PCCM                        AF        9 F01
           HO
Existing   PCCM       AF   P   F01

           HO
Existing   PCCM       AF   R   F01

           HO
Existing   PCCM       AF   R   F01

           HO
Existing   PCCM       AF   F   F01

           HO
Existing   PCCM       AF   F   F01

           HO
Existing   PCCM       MA   P   F02

           HO
Existing   PCCM       MA   G   F02

           HO
Existing   PCCM       MA   R   F02

           HO
Existing   PCCM       MA   P   F04

           HO
Existing   PCCM       MA   R   F04

           HO
Existing   PCCM-BHP   MA   R   F05

           HO
Existing   PCCM-BHP   MA   R   F06   <1

           HO                        >=6&
Existing   PCCM-BHP   MA   R   F06   < 19

           HO                        >=1&
Existing   PCCM-BHP   MA   R   F06   <6

           HO                        >=1&
Existing   PCCM-BHP   MA   R   F06   <6

           HO                        >=1&
Existing   PCCM-BHP   MA   R   F06   <6

           HO
Existing   PCCM-BHP   MA   R   F06   <1
           HO                                       >=6&
Existing   PCCM-BHP                 MA    R   F06   < 19

           HO                                       >=6&
Existing   PCCM-BHP                 MA    R   F06   < 19

           HO
Existing   PCCM       25477   401768 MA   R   F10

           HO
Existing   PCCM       25477   401768 MA   P   F10

           HO
Existing   PCCM       25477   401768 GA   R   G01          FQ

           HO
Existing   PCCM-BHP   25477   401768 MA   P   P02

           HO
Existing   PCCM-BHP   25477   401768 MA   P   P02

           HO
Existing   PCCM-BHP   25477   401768 MA   P   P02

           HO
Existing   PCCM-BHP   25477   401768 MA   P   P02


                                                                CHIP

Existing   CHIP       25477   401768 MA   R   F07


Existing   CHIP       39814   401768 MA   R   F07
                            F07             Income                        Living    Disability
       Citizenship          Premium         Qualification   Pickle Pass   Arrangeme Approval
       Code          FPL%   Tier (1 or 2)   Standard Code   Along Ind     nt        Code


lind or Disabled CNP and MNP non dual




                                                            Y


                                                            Y


                                                            Not Y


                                                            Not Y
           Foster Care
excludes those with Juvenile Rehab




   Healthy Options/PCCM/BHP
<= 185%
FPL

< = 100%
FPL

< = 133%
FPL

> 133%
FPL

> 133%
FPL

> 185%
FPL
 > 100%
 FPL

 > 100%
 FPL




CHIP

          1, 3


          2, 4
           RAC
Program    Code 4
Class Code Bytes    RAC Description (Short) (100 char)




                   General Assistance cash with Categorically Needy SSI
              1044 related Medicaid


              1044 General Assistance cash with CN SSI related Medicaid

                    Categorically Needy Medicaid Blind/Disabled; SSI cash
              1105 eligible

                   Categorically Needy Medicaid Blind/Disabled; SSI cash
              1105 eligible

                    Categorically Needy Medicaid Blind/Disabled; SSI cash
              1105 eligible

                   Categorically Needy Medicaid Blind/Disabled; SSI cash
              1105 eligible

                   Categorically Needy Blind/Disabled; SSI cash eligible; with
              1107 AREQ cash;

                    Categorically Needy Blind/Disabled; SSI cash eligible; with
              1107 AREQ cash;

                   Categorically Needy Blind/Disabled; =< SSI CNIL; Income
              1110 disregards

                    Categorically Needy Blind/Disabled; =< SSI CNIL; Income
              1110 disregards

                   Categorically Needy Blind/Disabled; SSI related; income =<
              1111 SSI CNIL

                   Categorically Needy Blind/Disabled; SSI related; income =<
              1111 SSI CNIL
     Categorically Needy Health Care for Workers with
1121 Disabilities (HWD); basic group


1045 General Assistance cash with CN SSI related Medicaid




     Categorically Needy with SSI cash; Title IV-E Federal Foster
1014 Care

      Categorically Needy with SSI cash; Non IV-E State Foster
1015 Care

     Categorically Needy with SSI cash; Title IV-E Federal
1016 Adoption Support

      Categorically Needy with SSI cash; Non IV-E State Adoption
1017 Support


1019 Categorically Needy Title IV-E Federal Foster Care


1020 Categorically Needy Non IV-E State Foster Care


1021 Categorically Needy Title IV-E Federal Adoption Support


1022 Categorically Needy Non IV-E State Adoption Support




      Categorically Needy 4 mo extended TANF/Family
1027 Medicaid; adult or child;

     Categorically Needy 4 mo extended TANF/Family
1027 Medicaid; adult or child;

      Categorically Needy Medicaid adult or child with TANF
1024 cash;
     Categorically Needy Medicaid adult or child with TANF
1024 cash;

      Categorically Needy Medicaid adult or child with TANF
1024 cash;

     Categorically Needy Medicaid adult or child with TANF
1024 cash;

     Categorically Needy Medicaid adult or child with TANF
1024 cash;

      Categorically Needy Medicaid adult or child with TANF
1024 cash;

     Categorically Needy 12 mo extended TANF/Family
1026 Medicaid; adult or child;

      Categorically Needy 12 mo extended TANF/Family
1026 Medicaid; adult or child;

     Categorically Needy 12 mo extended TANF/Family
1026 Medicaid; adult or child;

     Categorically Needy TANF related/Family Medicaid; adult
1028 or child

      Categorically Needy TANF related/Family Medicaid; adult
1028 or child


1029 Categorically Needy Newborn Medical birth to one year

      Categorically Needy Children's Medicaid/age under 19;
1030 Mandatory

     Categorically Needy Children's Medicaid/age under 19;
1030 Mandatory

     Categorically Needy Children's Medicaid/age under 19;
1030 Mandatory

      Categorically Needy Children's Medicaid/age under 19;
1031 optional

     Categorically Needy Children's Medicaid/age under 19;
1031 optional

      Categorically Needy Children's Medicaid/age under 19;
1031 optional
     Categorically Needy Children's Medicaid/age under 19;
1031 optional

      Categorically Needy Children's Medicaid/age under 19;
1031 optional

     Categorically Needy TANF related Family Medicaid; adult
1038 or child

     Categorically Needy TANF related Family Medicaid; adult
1038 or child

      General Assistance cash with Categorically Needy; child <
1042 19; Federally Qualified


1095 Pregnancy Categorically Needy


1095 Pregnancy Categorically Needy


1095 Pregnancy Categorically Needy


1095 Pregnancy Categorically Needy




     Children's Health Insurance Program (CHIP) Children under
1032 19; premium payment program

      Children's Health Insurance Program (CHIP) Children under
1140 19; >250%FPL; premium payment program
                                                     Progr       Med BSP        Related BSP/Scope
                                                     am    Match Elig Code 15   of Care (Short desc
RAC Description (Long 500 bytes)                     Code Code Code bytes       100 bytes)




General Assistance cash; Categorically Needy                                    Categorically Needy
Medicaid; person is SSI related (blind or disabled) B     U         0 CNP       Program

General Assistance cash; Categorically Needy                                    Categorically Needy
Medicaid; person is SSI related (blind or disabled) P     U         0 CNP       Program

Categorically Needy Medicaid for person Blind or                                Categorically Needy
Disabled and SSI cash eligible                   B        C         0 CNP       Program

Categorically Needy Medicaid for person Blind or                                Categorically Needy
Disabled and SSI cash eligible                   B             2    0 CNP       Program

Categorically Needy Medicaid for person Blind or                                Categorically Needy
Disabled and SSI cash eligible                   P             2    0 CNP       Program

Categorically Needy Medicaid for person Blind or                                Categorically Needy
Disabled and SSI cash eligible                       P    C         0 CNP       Program
Categorically Needy Medicaid for person Blind or
Disabled; SSI cash eligible and receiving an                                    Categorically Needy
Additional Requirement payment                       B         1    0 CNP       Program
Categorically Needy Medicaid for person Blind or
Disabled; SSI cash eligible and receiving an                                    Categorically Needy
Additional Requirement payment                       P         1    0 CNP       Program
Categorically Needy SSI related Medicaid for
person Blind/Disabled; eligible for Disabled Adult                              Categorically Needy
Child, Divorced Surviving Spouse/Widowed             B    S         0 CNP       Program
Categorically Needy SSI related Medicaid for
person Blind/Disabled; eligible for Disabled Adult                              Categorically Needy
Child, Divorced Surviving Spouse/Widowed             P    S         0 CNP       Program
Categorically Needy Medicaid for person Blind or
Disabled; SSI related with income under the SSI                                 Categorically Needy
income level                                         B    C         0 CNP       Program
Categorically Needy Medicaid for person Blind or
Disabled; SSI related with income under the SSI                                 Categorically Needy
income level                                         P    C         0 CNP       Program
Categorically Needy SSI related Health Care for
Workers with Disabilities (HWD); premium                               Categorically Needy
program; basic group                               B   X       0 CNP   Program
General Assistance cash; Categorically Needy
Medicaid; person has Presumptive SSI;                                  Categorically Needy
application pending with Social Security (blind or X   U       0 CNP   Program




Categorically Needy Medicaid; receives SSI cash;                       Categorically Needy
Title IV-E Federal Foster Care                   D     Q       0 CNP   Program

Categorically Needy Medicaid; receives SSI cash;                       Categorically Needy
Non IV-E State Foster Care;                      D     M       0 CNP   Program

Categorically Needy Medicaid; receives SSI cash;                       Categorically Needy
Title IV-E Federal Adoption Support              D     V       0 CNP   Program

Categorically Needy Medicaid; receives SSI cash;                       Categorically Needy
Non IV-E State Adoption Support                  D     Y       0 CNP   Program

Categorically Needy Medicaid; Title IV-E Federal                       Categorically Needy
Foster Care                                      D     I       0 CNP   Program

Categorically Needy Medicaid; Non IV-E State                           Categorically Needy
Foster Care                                       D    E       0 CNP   Program

Categorically Needy Medicaid; Title IV-E Federal                       Categorically Needy
Adoption Support                                 D     O       0 CNP   Program

Categorically Needy Medicaid; Non IV-E State                           Categorically Needy
Adoption Support                                  D    T       0 CNP   Program




Categorically Needy 4 month extended
TANF/Family Medicaid; adult or child; over                             Categorically Needy
income for TANF cash due to child support        C     S       0 CNP   Program
Categorically Needy 4 month extended
TANF/Family Medicaid; adult or child; over                             Categorically Needy
income for TANF cash due to child support        C     S       0 CNP   Program
Categorically Needy Medicaid adult or child in
TANF cash assistance unit; combined categories:                        Categorically Needy
pregnant; HOH child relinquished/no other child; C         1   0 CNP   Program
Categorically Needy Medicaid adult or child in
TANF cash assistance unit; combined categories:                        Categorically Needy
pregnant; HOH child relinquished/no other child;   C       1   0 CNP   Program
Categorically Needy Medicaid adult or child in
TANF cash assistance unit; combined categories:                        Categorically Needy
pregnant; HOH child relinquished/no other child;   C       1   0 CNP   Program
Categorically Needy Medicaid adult or child in
TANF cash assistance unit; combined categories:                        Categorically Needy
pregnant; HOH child relinquished/no other child;   C       2   0 CNP   Program
Categorically Needy Medicaid adult or child in
TANF cash assistance unit; combined categories:                        Categorically Needy
pregnant; HOH child relinquished/no other child;   C       1   0 CNP   Program
Categorically Needy Medicaid adult or child in
TANF cash assistance unit; combined categories:                        Categorically Needy
pregnant; HOH child relinquished/no other child;   C       2   0 CNP   Program
Categorically Needy 12 month extended
TANF/Family Medicaid; adult or child; over                             Categorically Needy
income for TANF cash                               C   S       0 CNP   Program
Categorically Needy 12 month extended
TANF/Family Medicaid; adult or child; over                             Categorically Needy
income for TANF cash                               C   S       0 CNP   Program
Categorically Needy 12 month extended
TANF/Family Medicaid; adult or child; over                             Categorically Needy
income for TANF cash                               C   S       0 CNP   Program
Categorically Needy TANF related/Family
Medicaid; adult or child; combined categories:                         Categorically Needy
pregnant/no other child; adult with at least one   C   C       0 CNP   Program
Categorically Needy TANF related/Family
Medicaid; adult or child; combined categories:                         Categorically Needy
pregnant/no other child; adult with at least one   C   C       0 CNP   Program
Categorically Needy Medicaid; infants from birth
through the end of the month of their first                            Categorically Needy
birthday.                                          H   C       0 CNP   Program
Categorically Needy Medicaid; combined
categories of mandatory children: <1 yr &                              Categorically Needy
income =<185% FPL; =>1 <6 & income =<133%          H   S       0 CNP   Program
Categorically Needy Medicaid; combined
categories of mandatory children: <1 yr &                              Categorically Needy
income =<185% FPL; =>1 <6 & income =<133%          H   S       0 CNP   Program
Categorically Needy Medicaid; combined
categories of mandatory children: <1 yr &                              Categorically Needy
income =<185% FPL; =>1 <6 & income =<133%          H   T       0 CNP   Program
Categorically Needy Medicaid; combined
categories of optional children: <1                                    Categorically Needy
income>185% & =<200%FPL; =>1 <6                    H   M       0 CNP   Program
Categorically Needy Medicaid; combined
categories of optional children: <1                                    Categorically Needy
income>185% & =<200%FPL; =>1 <6                    H   Q       0 CNP   Program
Categorically Needy Medicaid; combined
categories of optional children: <1                                    Categorically Needy
income>185% & =<200%FPL; =>1 <6                    H   Q       0 CNP   Program
Categorically NeedyN Medicaid; combined
categories of optional children: <1                                   Categorically Needy
income>185% & =<200%FPL; =>1 <6                   H   M       0 CNP   Program
Categorically Needy Medicaid; combined
categories of optional children: <1                                   Categorically Needy
income>185% & =<200%FPL; =>1 <6                   H   Q       0 CNP   Program
Categorically Needy Medicaid Family related
adult or child; prerequisite of one month TANF                        Categorically Needy
or Family Related Medicaid eligibility; Program   C   C       0 CNP   Program
Categorically Needy Medicaid Family related
adult or child; prerequisite of one month TANF                        Categorically Needy
or Family Related Medicaid eligibility; Program   C   C       0 CNP   Program
General Assistance cash; Categorically Needy;
person related to CN Medicaid due to age < 19                         Categorically Needy
yrs. Not SSI related.)                            U   H       0 CNP   Program

Categorically Needy Pregnancy Medicaid;                               Categorically Needy
Income =<185% FPL                                 S   C       0 CNP   Program

Categorically Needy Pregnancy Medicaid;                               Categorically Needy
Income =<185% FPL                                 S   T       0 CNP   Program

Categorically Needy Pregnancy Medicaid;                               Categorically Needy
Income =<185% FPL                                 S   C   T    CNP    Program

Categorically Needy Pregnancy Medicaid;                               Categorically Needy
Income =<185% FPL                                 S   T   T    CNP    Program



Children's Health Insurance Program (CHIP)
Children under 19; Family income >200%FPL &<=                         Categorically Needy
250%FPL; monthly premium payment is required; N       S       0 CNP   Program
Children's Health Insurance Program (CHIP)
Children under 19; Family income >250%FPL &<=                         Categorically Needy
300%FPL; monthly premium payment is required; N       M       0 CNP   Program
                                                                         Restrictiv
Related BSP scope of                                                     e          Buy-In
care (long desc 4000            Fund      RAC                            Benefits Elig
bytes)                 Status   Source    Category   MAS       BOE       Flag       Code




Categorically Needy
Program                Valid    FEDERAL   MEDICAL          4         2           1W

Categorically Needy
Program                Valid    FEDERAL   MEDICAL          4         2           1W

Categorically Needy
Program                Valid    FEDERAL   MEDICAL          1         2           1W

Categorically Needy
Program                Valid    FEDERAL   MEDICAL          1         2           1W

Categorically Needy
Program                Valid    FEDERAL   MEDICAL          1         2           1W

Categorically Needy
Program                Valid    FEDERAL   MEDICAL          1         2           1W

Categorically Needy
Program                Valid    FEDERAL   MEDICAL          1         2           1W

Categorically Needy
Program                Valid    FEDERAL   MEDICAL          1         2           1W

Categorically Needy
Program                Valid    FEDERAL   MEDICAL          4         2           1M

Categorically Needy
Program                Valid    FEDERAL   MEDICAL          4         2           1M

Categorically Needy
Program                Valid    FEDERAL   MEDICAL          1         2           1M

Categorically Needy
Program                Valid    FEDERAL   MEDICAL          1         2           1M
Categorically Needy
Program               Valid   FEDERAL   MEDICAL   4          2   1M

Categorically Needy
Program               Valid   FEDERAL   MEDICAL   1          2   1W




Categorically Needy
Program               Valid   FEDERAL   MEDICAL   1          2   1W

Categorically Needy
Program               Valid   FEDERAL   MEDICAL   1          2   1W

Categorically Needy
Program               Valid   FEDERAL   MEDICAL   1          2   1W

Categorically Needy
Program               Valid   FEDERAL   MEDICAL   1          2   1W

Categorically Needy
Program               Valid   FEDERAL   MEDICAL   4          8   1M

Categorically Needy
Program               Valid   FEDERAL   MEDICAL   4          8   1M

Categorically Needy
Program               Valid   FEDERAL   MEDICAL   4          8   1M

Categorically Needy
Program               Valid   FEDERAL   MEDICAL   4          8   1M




                                                    4 if
Categorically Needy                                 client
Program               Valid   FEDERAL   MEDICAL   4 age <        1M
                                                    4 if
Categorically Needy                                 client
Program               Valid   FEDERAL   MEDICAL   4 age <        1M
                                                    4 if
Categorically Needy                                 client
Program               Valid   FEDERAL   MEDICAL   1 age <        1W
                                                      4 if
Categorically Needy                                   client
Program               Valid   FEDERAL   MEDICAL   1   age <        1W
                                                      4 if
Categorically Needy                                   client
Program               Valid   FEDERAL   MEDICAL   1   age <        1W
                                                      4 if
Categorically Needy                                   client
Program               Valid   FEDERAL   MEDICAL   1   age <        1W
                                                      4 if
Categorically Needy                                   client
Program               Valid   FEDERAL   MEDICAL   1   age <        1W
                                                      4 if
Categorically Needy                                   client
Program               Valid   FEDERAL   MEDICAL   1   age <        1W
                                                      4 if
Categorically Needy                                   client
Program               Valid   FEDERAL   MEDICAL   4   age <        1M
                                                      4 if
Categorically Needy                                   client
Program               Valid   FEDERAL   MEDICAL   4   age <        1M
                                                      4 if
Categorically Needy                                   client
Program               Valid   FEDERAL   MEDICAL   4   age <        1M
                                                      4 if
Categorically Needy                                   client
Program               Valid   FEDERAL   MEDICAL   4   age <        1M
                                                      4 if
Categorically Needy                                   client
Program               Valid   FEDERAL   MEDICAL   4   age <        1M

Categorically Needy
Program               Valid   FEDERAL   MEDICAL   4            4   1M

Categorically Needy
Program               Valid   FEDERAL   MEDICAL   3            4   1M

Categorically Needy
Program               Valid   FEDERAL   MEDICAL   3            4   1M

Categorically Needy
Program               Valid   FEDERAL   MEDICAL   3            4   1M

Categorically Needy
Program               Valid   FEDERAL   MEDICAL   3            4   1M

Categorically Needy
Program               Valid   FEDERAL   MEDICAL   3            4   1M

Categorically Needy
Program               Valid   FEDERAL   MEDICAL   3            4   1M
Categorically Needy
Program               Valid   FEDERAL    MEDICAL   3   4   1M

Categorically Needy
Program               Valid   FEDERAL    MEDICAL   3   4   1M

Categorically Needy
Program               Valid   FEDERAL    MEDICAL   4   4   1M

Categorically Needy
Program               Valid   FEDERAL    MEDICAL   4   4   1M

Categorically Needy
Program               Valid   FEDERAL    MEDICAL   1   4   1W

Categorically Needy
Program               Valid   FEDERAL    MEDICAL   3   5   1M

Categorically Needy
Program               Valid   FEDERAL    MEDICAL   3   5   1M

Categorically Needy
Program               Valid   FEDERAL    MEDICAL   3   5   1M

Categorically Needy
Program               Valid   FEDERAL    MEDICAL   3   5   1M




Categorically Needy
Program               Valid   TITLE-21   MEDICAL   0   0   0M

Categorically Needy
Program               Valid   TITLE-21   MEDICAL   0   0   0M
RSN
Capitatio    RSN
n Y/N-       Capita    RSN
Legacy       tion      Capitat
prior to     Y/N-      ion
12/09        effecti   Y/N-
calc for     ve        P1 Go-
1/2010       1/1/201   Livest
monthly      0 to      atus
capitation   P1 Go     0,2,4,8




Y            Y         Y


Y            Y         Y


Y            Y         Y


Y            Y         Y


Y            Y         Y


Y            Y         Y


Y            Y         Y


Y            Y         Y


Y            Y         Y


Y            Y         Y


Y            Y         Y


Y            Y         Y
Y   Y   Y


Y   Y   Y




Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y




Y   Y   Y


Y   Y   Y


Y   Y   Y
Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y
Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y


Y   Y   Y




Y   Y   Y


Y   Y   Y
       Medical Assistance Households by Primary Language - 03/13/12
Code Count             Language    % of total
  AE          26 Armenian             0.004%
  AL          37 Albanian             0.006%
 AM         456 Amharic               0.075%
  AR        680 Arabic                0.112%
  BK           2 Bikol                0.000%
  BL          27 Bulgarian            0.004%
  BN          18 Bengali              0.003%
  BR          52 Braille              0.009%
  BS        264 Burmese               0.044%
  CA       1589 Cambodian             0.262%
  CB           3 Cebuano              0.000%
  CC           2 Chiu Chow            0.000%
  CH       3783 Chinese               0.624%
 CM            5 Cham                 0.001%
  CR           5 Chamorro             0.001%
  CZ           5 Czech                0.001%
  DA           4 Dari                 0.001%
  DN           1 Danish               0.000%
  EN    513463 English               84.632%
  FA        462 Farsi                 0.076%
  FC          11 French Creole        0.002%
    FI         3 Finnish              0.000%
    FJ         2 Fijian               0.000%
  FR          72 French               0.012%
  GE           4 German               0.001%
   GJ         16 Gujarati             0.003%
  GR           8 Greek                0.001%
  HC           9 Haitian-Creole       0.001%
  HE           7 Hebrew               0.001%
   HI       134 Hindi                 0.022%
  HK           1 Hakka                0.000%
 HM         105 Hmong                 0.017%
  HU          14 Hungarian            0.002%
   IB          4 Ibo                  0.001%
    IL      118 Ilocano               0.019%
   IN         25 Indonesian           0.004%
   IO          7 Ilongo               0.001%
    IT         6 Italian              0.001%
   JA         49 Japanese             0.008%
 KM            3 Kmhmu                0.000%
  KO       3020 Korean                0.498%
  KY           1 Kikuyu               0.000%
  LA        526 Laotian               0.087%
   LP       582 Large Print           0.096%
 MC            2 Macedonian           0.000%
  MI        51   Mien               0.008%
  ML         1   Malaysian          0.000%
 MM          6   Malayalam          0.001%
 OM        103   Oromo              0.017%
  OT       492   Other Language     0.081%
  PA        10   Pashto             0.002%
  PE        22   Persian            0.004%
  PG        56   Portuguese         0.009%
   PJ      664   Punjabi            0.109%
  PO        41   Polish             0.007%
  PU         2   Puyallup           0.000%
  RO       206   Romanian           0.034%
  RU      9062   Russian            1.494%
  SA       131   Samoan             0.022%
  SC       312   Serbo-Croatian     0.051%
  SD         5   Sudanese           0.001%
  SH         1   Salish             0.000%
   SI       53   Swahili            0.009%
   SL      413   American Sign      0.068%
 SM       1286   Somali             0.212%
  SN         2   Shona              0.000%
  SP     58813   Spanish            9.694%
  SV         3   Slovak             0.000%
  TA       793   Tagalog            0.131%
  TB         8   Tibetan            0.001%
  TH        88   Thai               0.015%
   TI      264   Tigrigna           0.044%
  TK        23   Turkish            0.004%
 TM          6   Tamil              0.001%
  TN        13   Tongan             0.002%
  TR        29   Trukese            0.005%
  UK       484   Ukrainian          0.080%
  UR        55   Urdu               0.009%
   VI     7587   Vietnamese         1.251%
  VS         5   Visayan            0.001%
  YR         1   Yoruba             0.000%
Total   606704                    100.000%
  AREA           SERVICE UNIT                        FACILITY NAME

PORTLAND   Fort Hall            Not-Tsoo Gah-Nee Indian Health Center
PORTLAND                        Benewah Medical Center
PORTLAND                        Coeur d'Alene Tribal Wellness Center
PORTLAND                        Shoshone-Bannock Tribal Health
PORTLAND                        Kamiah Health Station
PORTLAND                        Kootenai Tribal Health Clinic
PORTLAND   Western Oregon       Chemawa Indian Health Center
PORTLAND   Warm Springs         Warm Springs Health & Wellness Center
PORTLAND                        Warm Springs Community Counseling Center
PORTLAND                        Coquille Tribal Health Center
PORTLAND                        Grand Ronde Health & Wellness Center
PORTLAND                        Wadatika Indian Health Center
PORTLAND                        Klamath Tribal Health & Wellness Center
PORTLAND                        Klamath Tribal Health & Family Services
PORTLAND                        Klamath Youth & Family Intervention Program
PORTLAND                        Wemble Naalam T'at'aksni
PORTLAND                        Coos Tribal Health Clinic
PORTLAND                        Cow Creek Health & Wellness Center
PORTLAND                        Cow Creek Health & Wellness - Annex
PORTLAND                        Siletz Community Health Clinic
PORTLAND                        ASAP Alcohol Program
PORTLAND                        Yellowhawk Tribal Health Center
PORTLAND   Colville             Colville Indian Health Center
PORTLAND                        Colville Conf. Tribes Behavior Health Program
PORTLAND                        Tsapowum
PORTLAND   Wellpinit            David C. Wynecoop Memorial Clinic
PORTLAND   Colville             Omak Health Center
PORTLAND                        Sophie Trettevick Indian Health Center
PORTLAND                        Makah Chemical Dependency
PORTLAND                        Cowlitz Indian Tribal Health Services
PORTLAND                        Cowlitz Tribal Treatment
PORTLAND                        Cowlitz Tribal Treatment
PORTLAND                        Cowlitz ??
PORTLAND   Yakama               Yakama Indian Health Center
PORTLAND   Yakama               White Swan Dental Clinic
PORTLAND                        Yakama Nation Comprehensive Alcoholism Program
PORTLAND                        Yakama Nation Behavioral Health
PORTLAND                        Port Gamble S'Klallam Tribal Clinic
PORTLAND                        Port Gamble S'Klallam Recovery Center
PORTLAND                        Port Gamble S'Klallam Dental Clinic
PORTLAND                        Port Gamble S'Klallam Mental Health Services
PORTLAND                        PGST See-yeets-out Wellness Center
PORTLAND                        Tulalip Dental Program
PORTLAND                        Tulalip Health Clinic
PORTLAND                        Tulalip Tribe's Adult CD
PORTLAND                        Tulalip Tribe's Youth CD
PORTLAND                        Tulalip Tribes Adult Mental Health Treatment Services
PORTLAND                        Tulalip Beda Chelh
PORTLAND                        Chehalis Tribal Wellness Center
PORTLAND                        Chehalis Family Services
PORTLAND                        Inchelium Community Health Center
PORTLAND                        Jamestown Family Health Clinic
PORTLAND                        Jamestown Family Dental Clinic
PORTLAND                        Jamestown S'Klallam Chemical Dependency
PORTLAND                        Jamestown S'Klallam Mental Health
PORTLAND   Kalispel Camas Center for Community Health
PORTLAND   Camas Institute Behavior Health Services
PORTLAND   Lower Elwha Klallam Medical Clinic
PORTLAND   Klallam Counseling Services
PORTLAND   Lower Elwha Klallam Behavior Health Program
PORTLAND   Lower Elwha Klallam Dental Clinic
PORTLAND   Lummi Tribal Health Center
PORTLAND   Lummi CARE Building "A"
PORTLAND   YESS (LTHC Mental Health)
PORTLAND   CARE - Se'eye chen
PORTLAND   Lummi Children's Services
PORTLAND   Safe House
PORTLAND   Youth Enrichment & Social Services (YESS)
PORTLAND   Youth Academy
PORTLAND   Nisqually Tribal Health Clinic
PORTLAND   Nooksack Community Clinic
PORTLAND   Nooksack Community Dental
PORTLAND   Nooksack Behavior Health
PORTLAND   Nooksack Genesis II
PORTLAND   Nooksack Genesis II Treatment Rm
PORTLAND   Nooksack Genesis II Transition House
PORTLAND   Omak Tribal Health Program
PORTLAND   Takopid Indian Health Center
PORTLAND   Puyallup Tribal Treatment Center
PORTLAND   Kwawachee Counseling Center
PORTLAND   Quileute Health Clinic
PORTLAND   Quileute Addictions Program
PORTLAND   Roger Saux Health Center
PORTLAND   Charlotte Kakama Health Station
PORTLAND   Quinault Chemical Dependency Program
PORTLAND   Roger Saux Counseling Center
PORTLAND   Sauk-Suiattle Tribal Community Clinic
PORTLAND   Shoalwater Bay Wellness Center
PORTLAND   Skokomish Health Center
PORTLAND   H.O.P.E. Alcohol and Drug Program
PORTLAND   Tuwaduq Family Services
PORTLAND   Sally Selvidge Clinic (Health & Human Services Dept)
PORTLAND   NW Indian Treatment Center
PORTLAND   NW Indian Treatment Center
PORTLAND   NW Indian Treatment Center
PORTLAND   Stillaguamish Tribal Health Clinic
PORTLAND   Stillaguamish Tribe Chemical Dependency Day Treatment Program
PORTLAND   Stillaguamish Family Dentistry
PORTLAND   Stillaguamish Behavioral Health Programs
PORTLAND   Stillaguamish Mental Health Services
PORTLAND   Island Crossing Counseling Services
PORTLAND   Suquamish Tribe Wellness Program
PORTLAND   Swinomish Health Center
PORTLAND   Swinomish-Upper Skagit Dental Clinic
PORTLAND   Community Services-Wellness/Chemical Dependency
PORTLAND   Community Services-Mental Health
PORTLAND   Upper Skagit Tribal Clinic
PORTLAND   Upper Skagit Tribe Chemical Dependency Treatment Program
PORTLAND   White Swan Tribal Health Clinic
PORTLAND   Muckleshoot Tribe Health & Wellness Center
PORTLAND   Muckleshoot Dental Clinic
PORTLAND   Muckleshoot Optometry Clinic
PORTLAND   Muckleshoot Behavioral Health Program
PORTLAND   Sanpoil Valley Community Health Center
PORTLAND   White Swan Sub Station
PORTLAND   Apas Goudy Health Station
PORTLAND   Tolt Community Clinic
PORTLAND   North Bend Family Clinic
PORTLAND   Raging River Recovery Center
PORTLAND   Snoqualmie Tribe Behavioral Health Program
PORTLAND   Spokane Tribe HHS Behavior Health Program
PORTLAND   Spokane Tribe of Indians Substance Abuse Program
PORTLAND   Samish Indian Nation Wellness Program
                                      PORTLAND AREA FACILITY LIST APRIL 2010
                                              FAC         FAC
     CITY               FACILITY   TITLE                               TYPE OF
                STATE                      OPERATED     OWNED
   LOCATION              TYPE      TYPE                               PROVIDER
                                               BY          BY
Fort Hall        ID        2       IHS         IHS         IHS
Plummer          ID        2        5         Tribe       Tribe          FQHC
Plummer          ID        2        5         Tribe       Tribe          FQHC
Fort Hall        ID      4,6,7,     1         Tribe       Tribe
Kamiah           ID        4         1        Tribe       Tribe
Bonners Ferry    ID        2         1        Tribe       Tribe
Salem            OR         2      IHS         IHS         IHS
Warm Springs     OR         2      IHS         IHS         IHS
Warm Springs     OR         7        1        Tribe       Tribe
Coos Bay         OR         2        1        Tribe       Tribe          FQHC
Grande Ronde     OR         2        5        Tribe       Tribe          FQHC
Burns            OR         2        1        Tribe       Tribe
Chiloquin        OR       2,11       1        Tribe       Tribe          FQHC
Klamath Falls    OR         2        1        Tribe       Tribe          FQHC
Chiloquin        OR         7        1        Tribe       Tribe          FQHC
Klamath Falls    OR        6,7       1        Tribe       Tribe
Coos Bay         OR       2, 11      1        Tribe       Tribe          FQHC
Roseburg         OR         2        1        Tribe       Tribe          FQHC
Canyonville      OR         4        1        Tribe       Tribe          FQHC
Siletz           OR         2        5        Tribe       Tribe    FQHC Medicaid Only
Siletz           OR         6        5        Tribe       Tribe
Pendleton        OR         2        1        Tribe       Tribe           RHC
Nespelem         WA         2      I HS        IHS         IHS
Nespelem         WA        6, 7      1        Tribe       Tribe
Oakville         WA        6, 7      1        Tribe       Tribe
Wellpinit        WA         2      I HS        IHS         IHS
Omak             WA         4        1         IHS        Tribe
Neah Bay         WA         2        5        Tribe       Tribe
Neah Bay         WA         6        5        Tribe       Tribe
Longview         WA        2         1       Tribe       Tribe           FQHC
Longview         WA        6         1       Tribe       Tribe           FQHC
Vancouver        WA        6         1       Tribe       Tribe           FQHC
Seattle          WA        7         1      Contract    Contract
Toppenish        WA        2       I HS        IHS         IHS
Toppenish        WA        11      I HS        IHS         IHS
Toppenish        WA        6         1        Tribe       Tribe
Toppenish        WA        7         1        Tribe       Tribe
Kingston         WA        2         5        Tribe       Tribe          FQHC
Kingston         WA        6         5        Tribe       Tribe
Kingston         WA        11        5        Tribe       Tribe
Kingston         WA        7         5        Tribe       Tribe
Kingston         WA        7         5        Tribe       Tribe
Tulalip          WA        11        5        Tribe       Tribe          RHC
Tulalip          WA         2       5         Tribe       Tribe           RHC
Tulalip          WA         6       5         Tribe       Tribe
Tulalip          WA         6       5         Tribe       Tribe
Tulalip          WA         7       5         Tribe       Tribe
Tulalip          WA         7       5         Tribe       Tribe
Oakville         WA       2, 11     1         Tribe       Tribe
Oakville         WA         7       1         Tribe       Tribe
Inchelium        WA         2       1         Tribe       Tribe          FQHC
Sequim           WA         2       5         Tribe       Tribe    FQHC Medicare Only
Sequim           WA        11       5         Tribe       Tribe
Sequim           WA         6       5         Tribe       Tribe
Sequim           WA         7       5         Tribe       Tribe
Usk              WA      2       5   Tribe   Tribe
Airway Heights   WA      7       1   Tribe   Tribe
Port Angeles     WA      2       5   Tribe   Tribe   Medicare Only FQHC
Port Angeles     WA      6       5   Tribe   Tribe
Port Angeles     WA      7       5   Tribe   Tribe
Port Angeles     WA      11      5   Tribe   Tribe
Bellingham       WA      2       5   Tribe   Tribe
Bellingham       WA      6       5   Tribe   Tribe         FQHC
Bellingham       WA      7       5   Tribe   Tribe         FQHC
Bellingham       WA      6       5   Tribe   Tribe         FQHC
Bellingham       WA      7       5   Tribe   Tribe         FQHC
Bellingham       WA      8       5   Tribe   Tribe         FQHC
Bellingham       WA      7       5   Tribe   Tribe
Bellingham       WA      7       5   Tribe   Tribe         FQHC
Olympia          WA   2,6,7,11   5   Tribe   Tribe
Everson          WA      2       1   Tribe   Tribe         FQHC
Everson          WA      11      1   Tribe   Tribe
Everson          WA      7       1   Tribe   Tribe
Everson          WA      6       1   Tribe   Tribe
Everson          WA      6       1   Tribe   Tribe
Everson          WA      6       1   Tribe   Tribe
Omak             WA      4       1   Tribe   Tribe
Tacoma           WA      2       1   Tribe   Tribe
Tacoma           WA      6       1   Tribe   Tribe
Tacoma           WA      7       1   Tribe   Tribe
LaPush           WA      2       1   Tribe   Tribe
La Push          WA      6       1   Tribe   Tribe
Taholah          WA      2       5   Tribe   Tribe         FQHC
Queets           WA      4       5   Tribe   Tribe         FQHC
Taholah          WA      6       5   Tribe   Tribe
Taholah          WA      7       5   Tribe   Tribe
Darrington       WA      4       1   Tribe   Tribe
Tokeland         WA   2,6,7,11   5   Tribe   Tribe         FQHC
Shelton          WA      2       1   Tribe   Tribe         FQHC
Shelton          WA      6       1   Tribe   Tribe
Shelton          WA      7       1   Tribe   Tribe
Shelton          WA      2       5   Tribe   Tribe
Shelton          WA      7       5   Tribe   Tribe
Shelton          WA      6       5   Tribe   Tribe
Elma             WA      6       5   Tribe   Tribe
Arlington        WA      2       1   Tribe   Tribe         FQHC
Arlington        WA      6       1   Tribe   Tribe
Arlington        WA      11      1   Tribe   Tribe
Arlington        WA      7       1   Tribe   Tribe
Arlington        WA      7       1   Tribe   Tribe
Arlington        WA      7       1   Tribe   Tribe
Suquamish        WA     6,7      1   Tribe   Tribe         FQHC
LaConner         WA      2       5   Tribe   Tribe          RHC
LaConner         WA      11      5   Tribe   Tribe
LaConner         WA      6       5   Tribe   Tribe
LaConner         WA      7       5   Tribe   Tribe
Sedro Woolley    WA      4       1   Tribe   Tribe
Sedro Woolley    WA      6       1   Tribe   Tribe
White Swan       WA      4       5   Tribe   Tribe
Auburn           WA       2      5   Tribe   Tribe
Auburn           WA      11      5   Tribe   Tribe
Auburn           WA       4      5   Tribe   Tribe
Auburn           WA     6, 7     5   Tribe   Tribe
Keller           WA       2      1   Tribe   Tribe
White Swan       WA       4      5   Tribe   Tribe
Wapato           WA       4      5   Tribe   Tribe
Carnation        WA       2      1   Tribe   Tribe
North Bend       WA       2      1   Tribe   Tribe
North Bend   WA   6     1   Tribe   Tribe
Snoqualmie   WA   7     1   Tribe   Tribe
Wellpinit    WA    7    1   Tribe   Tribe
Wellpinit    WA    6    1   Tribe   Tribe
Anacortes    WA   6,7   1   Tribe   Tribe
0

    ACCREDITATION              TRIBE-ORGANIZATION

       AAAHC
       AAAHC                     Coeur d'Alene Tribe
       AAAHC                     Coeur d'Alene Tribe
       AAAHC                   Shoshone-Bannock Tribe
       AAAHC                       Nez Perce Tribe
                                    Kootenai Tribe
       AAAHC
       AAAHC
                             Conf Tribes of Warm Springs
       AAAHC                        Coquille Tribe
                                 Grande Ronde Tribe
                                  Burns Paiute Tribe
                                    Klamath Tribe
                                    Klamath Tribe
                                    Klamath Tribe
                                    Klamath Tribe
                    Coos, Lower Umpqua, and Siuslaw Confederation
                                   Cow Creek Tribe
                                   Cow Creek Tribe
       AAAHC                          Siletz Tribe
        CMS                           Siletz Tribe
       AAAHC                        Umatilla Tribe
       AAAHC
                                    Colville Tribe
                                    Chehalis Tribe
       AAAHC
       AAAHC                        Colville Tribe
       AAAHC                        Makah Tribe
                                    Makah Tribe
       AAAHC                        Cowlitz Tribe
       AAAHC                        Cowlitz Tribe
       AAAHC                        Cowlitz Tribe
                                    Cowlitz Tribe
       AAAHC
       AAAHC
                                     Yakama Tribe
                                     Yakama Tribe
                               Port Gamble of S'Klallam
                               Port Gamble of S'Klallam
                               Port Gamble of S'Klallam
                               Port Gamble of S'Klallam
                               Port Gamble of S'Klallam
                                     Tulalip Tribe
                                    Tulalip Tribe
      State Cert                    Tulalip Tribe
      State Cert                    Tulalip Tribe
      State Cert                    Tulalip Tribe
                                    Tulalip Tribe
                                   Chehalis Tribe
        CMS                        Chehalis Tribe
                                   Colville Tribe
                              Jamestown S'Kallam Tribe
                              Jamestown S'Kallam Tribe
                              Jamestown S'Kallam Tribe
                              Jamestown S'Kallam Tribe
                Kalispel Tribe
                Kalispel Tribe
              Lower Elwha Tribe
              Lower Elwha Tribe
              Lower Elwha Tribe
              Lower Elwha Tribe
 AAAHC           Lummi Tribe
                 Lummi Tribe
                 Lummi Tribe
                 Lummi Tribe
                 Lummi Tribe
                 Lummi Tribe
Pending          Lummi Tribe
                 Lummi Tribe
                Nisqually Tribe
               Nooksack Tribe
               Nooksack Tribe
               Nooksack Tribe
  CMS          Nooksack Tribe
  CMS          Nooksack Tribe
  CMS          Nooksack Tribe
                 Colville Tribe
 AAAHC           Puyallup Tribe
                 Puyallup Tribe
 AAAHC           Puyallup Tribe
                 Quileute Tribe
                 Quileute Tribe
                 Quinault Tribe
                 Quinault Tribe
                 Quinault Tribe
State Cert       Quinault Tribe
               Sauk-Suiattle Tribe
  CMS        Shoalwater Bay Tribe
                Skokomish Tribe
                Skokomish Tribe
                Skokomish Tribe
              Squaxin Island Tribe
              Squaxin Island Tribe
              Squaxin Island Tribe
              Squaxin Island Tribe
 AAAHC        Stillaguamish Tribe
              Stillaguamish Tribe
              Stillaguamish Tribe
              Stillaguamish Tribe
              Stillaguamish Tribe
              Stillaguamish Tribe
                Suquamish Tribe
                Swinomish Tribe
                Swinomish Tribe
                Swinomish Tribe
                Swinomish Tribe
               Upper Skagit Tribe
               Upper Skagit Tribe
                 Yakama Tribe
              Muckleshoot Tribe
              Muckleshoot Tribe
              Muckleshoot Tribe
              Muckleshoot Tribe
                Colville Tribe
               Yakama Tribe
               Yakama Tribe
              Snoqualmie Tribe
              Snoqualmie Tribe
 Snoqualmie Tribe
 Snoqualmie Tribe
   Spokane Tribe
   Spokane Tribe
Samish Indian Nation
             MEDICAID PROVIDER NUMBERS

33989, 33984
804166900, 805801300
804166900, 805801300
WA # 7096811, 6022412
339910, 2264100,
33,988
805862700
278159
273855
164964
165061
126883
276784
129861, 115761, 181550
129861
129861
165383
165772
165772
169841, 051966
169841
171037
7100100, 6021141
1980812
7100407, 6021166
7043516, 6026850
7134083, 6021158, 5400239
1992767
7122898
7122898
7122898

5400064
5400056
1990571
7094972, 7094964
1992825
5031794, 5031810
1980929, 1981125
1981125, 1980929
7056880
7056880
1992791
1992791
1980754
1980952
1143403, 8186140,8361933,9054296,9059304,8173882,5400049,5018338
1992684, 1980838
6008767
7111768
7123433
1991355
1981141
7047053, 7084973
1992866
1980937
7047053
7100605, 6022743, 7101751, 5400213, 1980846, 5400213
1991447
1981086
1981086
1981086
1981086
1981083, 7119068
1981086
704321, 7230055, 5400080, 5017710, 1980887, 1993310
7084346, 1422104
5400023
1981018
1980911, 1981018
1993013

6021372, 7013220, 7090954, 7057813
1980762, 1991256, 1990456
7084486
6016612, 5400155, 9021767, 7082191
6016612, 5400155, 9021767, 7082191
1980788
7082464, 7068331, 1994599, 1980853, 5400106
7048276, 7057508, 5021258, 5400072
1980796, 1981067, 1991512
1980944
1981026
1990696
1981026
7088503, 7088511
Pending
5400015, 5049770
1992619
1981133
1994565
1980895, 1992858
7084320,
5039490
1995216
1981281


7085269
5051446
7085269
1993187/1980861

7086150, 9044942
7086150
7122765
7122765
1994680
1981232
1980770
1995851 Chem D, MH Pending
                                                  Healthy Options
                                                   Blind/Disabled
                                               Implementation Month
               County                            and approx clients
Adams                                  July 2012 Clients 299
Asotin                                 July 2012 Clients 632
Benton                                 July 2012 Clients 3,166
Chelan                                 July 2012 Clients 1,436
Clallam                                August 2012 Clients 1,725
Clark                                  August 2012 Clients 6,668
Columbia                               July 2012 Clients 131
Cowlitz                                August 2012 Clients 3,409
Douglas                                July 2012 Clients 506
Ferry                                  July 2012 Clients 294
Franklin                               July 2012 Clients 1,393
Garfield                               July 2012 Clients 25
Grant                                  July 2012 Clients 2,041
Grays Harbor                           August 2012 Clients 2,648
Island                                 August 2012 Clients 912
Jefferson                              August 2012 Clients 569
King                                   September 2012 Clients 28,621
Kitsap                                 August 2012 Clients 4,981
Kittitas                               July 2012 Clients 518
Klickitat                              July 2012 Clients 619
Lewis                                  August 2012 Clients 2,575
Lincoln                                July 2012 Clients 169
Mason                                  August 2012 Clients 1,514
Okanogan                               July 2012 Clients 1,344
Pacific                                August 2012 Clients 706
Pend Orielle                           July 2012 Clients 466
Pierce                                 September 2012 Clients 17,022
San Juan                               August 2012 Clients 115
Skagit                                 August 2012 Clients 2,255
Skamania                               August 2012 Clients 194
Snohomish                              August 2012 Clients 10,219
Spokane                                July 2012 Clients 12,685
Stevens                                July 2012 Clients 1,250
Thurston                               August 2012 Clients 4,655
Wahkiakum                              August 2012 Clients 77
Walla Walla                            July 2012 Clients 1,103
Whatcom                                August 2012 Clients 4,113
Whitman                                July 2012 Clients 399
Yakima                                 July 2012 Clients 6,514

July 1, 2012 implementation approximate total 34,967
August 1, 2012 implementation approximate total 44,990
September 1, 2012 implementation approximate total 45,643
                                                                 Service Site
                                                                  Location
                                                              (all are in Washington
      Title X Delegate Agency               Service Site                State)            Phone and Fax
Local Health Jurisdictions
Grays Harbor County Public Health      Grays Harbor Clinic   2109 Sumner Avenue        P: 360-532-8631 x239
and Social Services




                                                             Aberdeen 98520            F: 360-533-6272
Jefferson County Public Health         Port Townsend         615 Sheridan              P: 360-385-9400
                                                             Port Townsend 98368       F: 360-385-9401

                                       Quilcene Clinic       294843 Highway 101        P: 360-765-3014
                                                             Quilcene 98365            F: 360-385-9401
                                       Port Townsend High-   1500 Van Ness Street      P: 360-379-4609
                                       School Based Clinic   Port Townsend 98368

                                       Chimacum High School 91 West Valley Road
                                       Based Clinic         Chimacum 98337
King - Public Health - Seattle- King   Administration/       401 5th Avenue, Ste       P: 206-263-8295
County                                 Headquarters          1000
                                                             Seattle 98104             F: 206-296-3808
                                       Federal Way           33431 13th Place          P: 206-296-8410
                                                             South
                                                             Federal Way 98003         F: 206-296-8412
                                       North Public Health   10501 Meridian Ave        P: 206-296-4765
                                       Center                North
                                                             Seattle 98133             F: 206-296-4885
                                       White Center Public   10821 8th Avenue SW       P: 206-296-4646
                                       Health Center
                                                              Seattle 98146            F: 206-205-6695
                                       Eastgate Public Health 14350 SE Eastgate        P: 206-296-4920
                                       Center                 Way
                                                              Bellevue 98007           F: 206-296-0577
                                       Renton Public Health   3001 NE 4th Street       P: 206-296-4700
                                       Center                 Renton 98056             F: 206-296-0568
                                       Auburn Public Health   901 Auburn Way N,        P: 206-296-8400
                                       Center                 Ste A
                                                              Auburn 98002             F: 206-296-8403
                                       Columbia Public Health 4400 37th Avenue         P: 206-296-4650
                                       Center                 South
                                                              Seattle 98118            F: 206-205-6075
Kitsap County Health Department        Bremerton Clinic      345 6th Street, Ste 300   P: 360-337-5235

                                                             Bremerton 98337           F: 360-337-5298
Klickitat County Health Department     Goldendale            228 W Main Street         P: 509-773-4565
                                                             MSCH 14
                                                             Goldendale 98620          F: 509-773-5991
Klickitat County Health Department


                                       White Salmon            501 NE Washington St    P: 509-493-1558

                                       (West End)              White Salmon 98672      F: 509-493-4025
Northeast Tri County Health District   Pend Orielle County     605 Highway 20          P: 509-447-3131
                                                               Newport 99156           F: 509-447-5644
                                       Ferry County            147 North Clark         P: 509-775-3111
                                                               Avenue
                                                               PO Box 584              F: 509-775-2858
                                                               Republic 99166
                                       Stevens County          240 E. Dominion         P: 509-684-6209
                                                               Colville 99114          F: 509-684-9878
Pacific County Public Health &         Long Beach              7013 Sandridge Road     P: 360-642-9349
Human Services Department                                      Long Beach 98631        F: 360-642-9352
                                       South Bend              1216 West Robert        P: 360-875-9343
                                                               Bush Drive
                                                               South Bend 98586        F: 360-875-9323
Skamania County Health Department Skamania County              710 Rock Creek Drive    P: 509-427-3881
                                                               PO Box 790              F: 866-297-2364
                                                               Stevenson 98648
Planned Parenthoods
Planned Parenthood of Greater          Yakima Clinic           1117 Tieton Drive       P: 866-904-7721
Washington and North Idaho                                     Yakima 98902            x8139
                                                                                       F: 509-248-0496
                                       Walla Walla Clinic      828 S. 1st Avenue       P: 866-904-7721 x8401
                                                               Walla Walla 99362       F: 509-522-1940
                                       Kennewick Clinic        7426 W. Bonnie          P: 866-904-7721 x8008
                                                               Kennewick 99336         F: 509-735-2587
                                       Sunnyside Clinic        2934 Covey Lane         P: 866-904-7721 x8301
                                                               Sunnyside 98944         F: 509-837-7322
                                       Ellensburg Clinic       613 N. Pine             P: 866-904-7721 x8201
                                                               Ellensburg 98926        F: 509-925-6732
                                       Valley Health Center    10525 E. Trent          P: 866-904-7721 x8661
                                                               Spokane 99206           F: 509-248-3644
                                       Pullman Health Center   1205 SE Professional    P: 866-904-7721 x8673
                                                               Mall Boulevard, Ste.
                                                               105
                                                               Pullman 99163           F: 509-248-3644
                                       Indiana Health Center   123 E. Indiana Avenue   P: 509-326-2142
                                                               Ste100
                                                               Spokane 99207           F: 509-248-3644
                                       Francis Health Center   1925 E. Francis         P: 866-904-7721 x8665
                                       (North Clinic)          Spokane 99207           F: 509-248-3644
                                       Cheney Health Center    301 2nd Street          P: 866-904-7721
                                                               Cheney 99004            x8665
                                                                                       F: 509-248-3644
                                       Pasco                   3901 W Court Street
                                                               Pasco 99301
Planned Parenthood of the Columbia/ Vancouver Health        5500 NE 109th Court      P: 888-875-7820
Willamette                          Center                  Ste A
                                                            Vancouver 98662-6104     F: 360-694-1631

                                    Salmon Creek Express    2105 NE 129th Ste 105    P: 888-875-7820
                                    Health Center
                                                            Vancouver 98686          F: 360-571-7378
Planned Parenthood of the Great     Administration/         1608 S. Graham Street
Northwest                           Headquarters /
                                    Warehouse               Seattle WA 98108
                                    Lynnwood Clinic         19505 76th Ave W Ste     P: 425-775-3496
                                                            200
                                                            Lynnwood 98036           F: 425-788-3866
                                    Everett Clinic          1509 32nd Street         P: 425-339-3389
                                                            Everett 98201            F: 425-259-1533
                                    Marysville Clinic       10210 State Ave          P: 360-658-7871
                                                            Marysville 98271         F: 360-658-6987
                                    Seattle Clinic          2001 E. Madison Ave      P: 206-328-7700

                                    (Capital Hill Clinic)   Seattle 98122-2959       F: 206-328-7520
                                    Bellevue Clinic         1420 156th NE Ste C      P: 425-747-1050
                                                            Bellevue 98007           F: 425-957-1161
                                    Shelton Clinic          2505 Olympic Hwy N       P: 360-426-2933
                                                            Ste 400                  F: 360-426-1409
                                                            Shelton 98584
                                    Kenmore Clinic          6610 NE 181st Ste 2      P: 425-482-1122
                                                            Kenmore 98028            F: 425-482-1881
                                    Northgate Clinic        2111 N Northgate Way     P: 206-632-2498

                                                            Ste 218                  F: 206-633-0838
                                                            Seattle 98133
                                    Federal Way             1105 S. 348th St Ste     P: 253-661-7002
                                                            B103
                                                            Federal Way 98003        F: 253-661-9132
                                    Kent Valley Clinic      10056 SE 240th Ste A     P: 253-854-2343
                                                            Kent 98031               F: 253-850-2982
                                    Olympia Clinic          402 Legion Way Ste       P: 360-754-5522
                                                            201
                                                            Olympia 98501            F: 360-754-5793
                                    Clallam Clinic          426 E 8th Street         P: 360-452-2954
                                                            Port Angeles 98362       F: 360-457-7683
                                    Forks Clinic            231 Lupine Avenue        P: 360-374-3143
                                                            Forks 98331              F: 360-457-7683
                                    Sequim Clinic           777 N 5th Ave, Ste 109   P: 360-452-2954

                                                            Sequim 98382             F: 360-457-7683
                                    Centralia Clinic        1020 W. Main Street      P: 360-330-2899
                                                            Centralia 98531          F: 360-330-5791
                                    Bremerton Clinic        623 NE Riddell Rd        P: 360-373-6827
                                  Bremerton Clinic
                                                        Bremerton 98310-3028     F: 360-373-1379

                                  Tacoma Clinic         813 Martin Luther        P: 253-779-3900
                                                        King Jr Way
                                                        Tacoma 98405             F: 253-272-2718
                                  Oak Harbor Clinic     3159 N. Goldie Rd        P: 360-679-2235
                                                        PO Box 837               F: 360-679-4019
                                                        Oak Harbor 98277
                                  Puyallup Clinic       702 30th Ave SW          P: 253-445-7441
                                                        Puyallup 98373           F: 253-864-8548
                                  Silverdale Clinic     10030 Silverdale Way     P: 360-662-0800
                                                        Ste 106
                                                        Silverdale 98383         F: 360-307-0943
                                  West Seattle Clinic   9641 28th Ave SW         P: 206-937-3270
                                                        Seattle 98126            F: 206-935-5623
                                  Roosevelt Clinic      5020 Roosevelt Way       P: 206-729-0453
                                                        NE
                                                        Ste 1                    F: 206-729-0499
                                                        Seattle 98105
                                  Issaquah Clinic       75 NW Dogwood St         P: 425-369-0301
                                                        Ste B
                                                        Issaquah 98027-3210      F: 425-369-0725
Mt. Baker Planned Parenthood      Administration/       1509 Cornwall Avenue
                                  Headquarters
                                                        Bellingham 98225
                                  Bellingham Health     1530 Ellis Street        P: 360-734-9095
                                  Center                Bellingham 98225         F: 360-715-8416
                                  Friday Harbor         535 Market Street, Ste   P: 360-378-6010
                                                        E
                                                        Friday Harbor 98250      F: 360-378-6050
                                  Mt. Vernon            900 E College Way        P: 360-848-1744
                                                        Ste 120
                                                        Mt Vernon 98284          F: 360-848-0583
Free Standing Agencies
Family Planning Association of    Family Planning       900 Ferry Street         P: 509-662-2013
Chelan-Douglas Counties



                                                        Wenatchee 98801          F: 509-662-7594
Cowlitz Family Health Center      Longview Clinic               th               P: 360-636-3892
                                                        1057 12 Avenue
                                                        Longview 98632           F: 360-636-4158
                                  North Beach Clinic    21610 Pacific Hwy        P: 360-665-3000
                                                        Ocean Park 98640         F: 360-665-3096
                                  Wahkiakum Clinic      335 Una Avenue           P: 360-795-3201
                                                        Cathlamet 98612          F: 360-795-3209
                                  Woodland Clinic       1251 Lewis River Rd      P: 360-225-4310
                                                        Ste D
                                                        Woodland 98674           F: 360-225-4339
Family Services of Grant County   Mattawa Community     215 1st Street           P: 509-932-4499
                                  Medical Clinic
Family Services of Grant County     Mattawa Community
                                    Medical Clinic            Mattawa 99349               F: 509-932-5365
                                    Moses Lake Clinic         1402 E. Craig               P: 509-765-4001
                                                              Moses Lake 98837            F: 509-766-1840
Okanogan Family Planning            Okanogan Clinic           127 N. Juniper Street       P: 509-422-1624
                                                              Omak 98841                  F: 509-422-0907
                                    Twisp Clinic              115 S. Methow Valley        P: 509-997-2050
                                                              Hwy
                                                              PO Box 222                  F: 509-422-0907
                                                              Twisp 98856
                                    Brewster Clinic           418 West Main               P: 509-689-8900
                                                              Brewster 98812              F: 509-689-9031
Public Health Idaho North Central   Lewiston Clinic                  th                   P: 208- 799-3100
                                                              215 10 Street
District


                                                              Lewiston, ID 83501          F: 208-799-0349




 [1]                                 If service area is a city or town, the associated county is listed in parentheses.
           Service Area[1]

Grays Harbor County




Jefferson County


South Jefferson County

Port Townsend
(Jefferson)

Chimacum
(Jefferson)
King County


Federal Way

(King)
Seattle

(King)
Seattle

(King)
Bellevue

(King)
Renton
(King)
Auburn

(King)
Seattle

(King)
Bremerton

(Klickitat)
East Klickitat County
West Klickitat County



Newport
(Pend Oreille)
Republic

(Ferry)

Colville
(Stevens)
Long Beach
(Pacific)
South Bend

(Pacific)
Skamania County




Yakima County



Walla Walla County

Benton County

Yakima County

Ellensburg (Kittitas County)

Spokane County

Pullman (Whitman)




Spokane County



Spokane County

Cheney
(Spokane)

Pasco
(Franklin)
Vancouver

(Clark)

Vancouver

(Clark)




Lynnwood

(Snohomish)
Everett
(Snohomish)
Marysville
(Snohomish)
Seattle

(King)
King County

Shelton
(Mason)

Kenmore
(King)
Seattle

(King)

Federal Way

(King)
Kent
(King)
Olympia

(Thurston)
Clallam County

Forks
(Clallam)
Sequim

(Clallam)
Lewis County

Kitsap County
Kitsap County


Tacoma

(Pierce)
Oak Harbor
(Island)

Puyallup
(Pierce)
Silverdale

(Kitsap)
Seattle
(King)
Seattle

(King)

Issaquah

(King)




Bellingham
(Whatcom)
Friday Harbor

(San Juan)
Mount Vernon

(Skagit)


Chelan and Douglas Counties




Longview
(Cowlitz)
Ocean Park
(Pacific)
Cathlamet
(Wahkiakum)
Woodland

(Cowlitz)
Mattawa
(Grant)
Moses Lake
(Grant)
Okanogan County

Twisp

(Okanogan)

Omak
(Okanogan)
Asotin County
Telehealth

What is telehealth?
Telehealth is when a health care practitioner uses interactive real-time audio and video telecommunications to del
Using telehealth when it is medically necessary enables the health care practitioner and the client to interact in rea

The following services are not covered as telehealth:
• Email, telephone, and facsimile transmissions;
• Installation or maintenance of any telecommunication devices or systems;
• Home health monitoring; or
• “Store and forward” telecommunication based services. (Store and forward is the asynchronous transmission of m

Who is eligible for telehealth?
Fee-for-service clients are eligible for medically necessary covered health care services delivered via telehealth. The
The Agency will not pay separately for telehealth services for clients enrolled in a managed care plan. Clients enroll

When does the Agency cover telehealth?
The Agency covers telehealth through the fee-for-service program when it is used to substitute for a face-to-face, “

Originating Site (Location of Client)
What is an “originating site”?
An originating site is the physical location of the eligible Agency client at the time the professional service is provid
• The office of a physician or practitioner;
• A hospital;
• A critical access hospital;
• A rural health clinic (RHC); and
• A federally qualified health center (FQHC).

Is the originating site paid for telehealth?
Yes. The originating site is paid a facility fee per completed transmission.

How does the originating site bill the Agency for the facility fee?
• Hospital Outpatient: When the originating site is a hospital outpatient Agency, payment for the originating site fa
• Hospital Inpatient: When the originating site is an inpatient hospital, there is no payment to the originating site f
• Critical Access Hospitals : When the originating site is a critical access hospital outpatient Agency, payment is sep
• FQHCs and RHCs : When the originating site is an FQHC or RHC, bill for the facility fee using HCPCS code Q3014. T
• Physicians’ Offices : When the originating site is a physician’s office, bill for the facility fee using HCPCS code Q301
If a provider from the originating site performs a separately identifiable service for the client on the same day as te

Distant Site (Location of Consultant)
What is a “distant site”?
A distant site is the physical location of the physician or practitioner providing the professional service to an eligible
Who is eligible to be paid for telehealth services at a distant site?
The Agency pays the following provider types for telehealth services provided within their scope of practice to eligi
• Physicians (including Psychiatrists); and
• Advanced Registered Nurse Practitioners (ARNPs).

What services are covered using telehealth?
Only the following services are covered using telehealth:
• Consultations (CPT codes 99241–99245 and 99251-99255);
• Office or other outpatient visits (CPT 99201-99215);
• Psychiatric intake and assessment (CPT code 90801);
• Individual psychotherapy (CPT codes 90804-90809); and
• Pharmacologic management (CPT codes 90862).
Note: Refer to other sections of these billing instructions for specific policies and limitation on these CPT codes.

How does the distant site bill the Agency for the services delivered through telehealth?
The payment amount for the professional service provided through telehealth by the provider at the distant site is
ommunications to deliver covered services that are within his or her scope of practice to a client at a site other than the site w
lient to interact in real-time communication as if they were having a face-to-face session. Telehealth allows Agency clients, par




nous transmission of medical information to be reviewed at a later time by the physician or practitioner at the distant site).


red via telehealth. The referring provider is responsible for determining and documenting that telehealth is medically necessar
 re plan. Clients enrolled in a Agency managed care plan are identified as such in ProviderOne. Managed care enrollees must h


te for a face-to-face, “hands on” encounter for only those services specifically listed in this section.




onal service is provided by a physician or practitioner through telehealth. Approved originating sites are:




 the originating site facility fee will be paid according to the maximum allowable fee schedule. To receive payment for the faci
o the originating site for the facility fee.
 ency, payment is separate from the cost-based payment methodology. To receive payment for the facility fee, critical access h
HCPCS code Q3014. This is not considered an FQHC or RHC service and is not paid as an encounter.
sing HCPCS code Q3014.
on the same day as telehealth, documentation for both services must be clearly and separately identified in the client’s medica




al service to an eligible Agency client through telehealth.

pe of practice to eligible Agency clients:
n these CPT codes.


r at the distant site is equal to the current fee schedule amount for the service provided. Use the appropriate CPT codes with
t at a site other than the site where the provider is located.
ealth allows Agency clients, particularly those in medically underserved areas of the state, improved access to essential health




ctitioner at the distant site).


elehealth is medically necessary. As a condition of payment, the client must be present and participating in the telehealth visi
Managed care enrollees must have all services arranged and provided by their primary care providers (PCP). Contact the mana




To receive payment for the facility fee, outpatient hospital providers must bill revenue code 0780 on the same line as HCPCS c

the facility fee, critical access hospitals must bill revenue code 0789 on the same line as HCPCS code Q3014.


identified in the client’s medical record.
he appropriate CPT codes with modifier GT (via interactive audio and video telecommunications system) when submitting clai
oved access to essential health care services that may not otherwise be available without traveling long distances.




rticipating in the telehealth visit.
 viders (PCP). Contact the managed care plan regarding whether or not the plan will authorize telehealth coverage. It is not ma




80 on the same line as HCPCS code Q3014.

code Q3014.
s system) when submitting claims to the Agency for payment.
ling long distances.




elehealth coverage. It is not mandatory that the plan pay for telehealth.

				
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