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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 220.127.116.11 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 18.104.22.168 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 22.214.171.124 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 firstname.lastname@example.org 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. 126.96.36.199 Language agencies contract with individual (freelance) Utilization 188.8.131.52 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: 184.108.40.206 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 220.127.116.11 18.104.22.168 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 22.214.171.124 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, 126.96.36.199, 188.8.131.52, or 11.6.1 2) Would attestation qualify as sufficient 184.108.40.206 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. 220.127.116.11 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. 18.104.22.168 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. 22.214.171.124 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 126.96.36.199. 188.8.131.52 184.108.40.206 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 114 220.127.116.11 - 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 18.104.22.168 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 22.214.171.124 – 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: 126.96.36.199 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. 188.8.131.52.1 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. 184.108.40.206.2 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 §220.127.116.11. 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 email@example.com 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 18.104.22.168.4 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 22.214.171.124 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 126.96.36.199). 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 188.8.131.52) 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 184.108.40.206 “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 firstname.lastname@example.org 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 All Plan Meeting - QMCO questions April 5, 2012 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? 71 All Plan Meeting - QMCO questions April 5, 2012 72 All Plan Meeting - QMCO questions April 5, 2012 73 All Plan Meeting - QMCO questions April 5, 2012 74 All Plan Meeting - QMCO questions April 5, 2012 75 All Plan Meeting - QMCO questions April 5, 2012 76 All Plan Meeting - QMCO questions April 5, 2012 77 All Plan Meeting - QMCO questions April 5, 2012 78 All Plan Meeting - QMCO questions April 5, 2012 79 All Plan Meeting - QMCO questions April 5, 2012 80 All Plan Meeting - QMCO questions April 5, 2012 81 All Plan Meeting - QMCO questions April 5, 2012 82 All Plan Meeting - QMCO questions April 5, 2012 83 All Plan Meeting - QMCO questions April 5, 2012 84 All Plan Meeting - QMCO questions April 5, 2012 85 All Plan Meeting - QMCO questions April 5, 2012 86 All Plan Meeting - QMCO questions April 5, 2012 87 All Plan Meeting - QMCO questions April 5, 2012 88 All Plan Meeting - QMCO questions April 5, 2012 89 All Plan Meeting - QMCO questions April 5, 2012 90 All Plan Meeting - QMCO questions April 5, 2012 91 All Plan Meeting - QMCO questions April 5, 2012 92 All Plan Meeting - QMCO questions April 5, 2012 93 All Plan Meeting - QMCO questions April 5, 2012 94 All Plan Meeting - QMCO questions April 5, 2012 95 All Plan Meeting - QMCO questions April 5, 2012 96 All Plan Meeting - QMCO questions April 5, 2012 97 All Plan Meeting - QMCO questions April 5, 2012 98 All Plan Meeting - QMCO questions April 5, 2012 99 All Plan Meeting - QMCO questions April 5, 2012 100 All Plan Meeting - QMCO questions April 5, 2012 101 All Plan Meeting - QMCO questions April 5, 2012 102 All Plan Meeting - QMCO questions April 5, 2012 103 All Plan Meeting - QMCO questions April 5, 2012 104 All Plan Meeting - QMCO questions April 5, 2012 105 All Plan Meeting - QMCO questions April 5, 2012 106 All Plan Meeting - QMCO questions April 5, 2012 107 All Plan Meeting - QMCO questions April 5, 2012 108 All Plan Meeting - QMCO questions April 5, 2012 109 All Plan Meeting - QMCO questions April 5, 2012 110 All Plan Meeting - QMCO questions April 5, 2012 111 All Plan Meeting - QMCO questions April 5, 2012 112 All Plan Meeting - QMCO questions April 5, 2012 113 All Plan Meeting - QMCO questions April 5, 2012 114 All Plan Meeting - QMCO questions April 5, 2012 115 All Plan Meeting - QMCO questions April 5, 2012 116 All Plan Meeting - QMCO questions April 5, 2012 117 All Plan Meeting - QMCO questions April 5, 2012 118 All Plan Meeting - QMCO questions April 5, 2012 119 All Plan Meeting - QMCO questions April 5, 2012 120 All Plan Meeting - QMCO questions April 5, 2012 121 All Plan Meeting - QMCO questions April 5, 2012 122 All Plan Meeting - QMCO questions April 5, 2012 123 All Plan Meeting - QMCO questions April 5, 2012 124 All Plan Meeting - QMCO questions April 5, 2012 125 All Plan Meeting - QMCO questions April 5, 2012 126 All Plan Meeting - QMCO questions April 5, 2012 127 All Plan Meeting - QMCO questions April 5, 2012 128 All Plan Meeting - QMCO questions April 5, 2012 129 All Plan Meeting - QMCO questions April 5, 2012 130 All Plan Meeting - QMCO questions April 5, 2012 131 All Plan Meeting - QMCO questions April 5, 2012 132 All Plan Meeting - QMCO questions April 5, 2012 133 All Plan Meeting - QMCO questions April 5, 2012 134 All Plan Meeting - QMCO questions April 5, 2012 135 All Plan Meeting - QMCO questions April 5, 2012 136 All Plan Meeting - QMCO questions April 5, 2012 137 All Plan Meeting - QMCO questions April 5, 2012 138 All Plan Meeting - QMCO questions April 5, 2012 139 All Plan Meeting - QMCO questions April 5, 2012 140 All Plan Meeting - QMCO questions April 5, 2012 141 All Plan Meeting - QMCO questions April 5, 2012 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  If service area is a city or town, the associated county is listed in parentheses. Service Area 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.
"Retrieve Document - Health Care Authority"