Welcome to the March Wesgram. This edition contains important updates from CMS, Palmetto and other payers, as well as information about upcoming educational opportunities.  Happy Spring!
March 24 -- this Friday
Annual Physician Practice Conference
Embassy Suites, Charleston, WV
ICD-10 Latest News
Here are some fun ICD-10 codes for 
H72.00          Central perforation of tympanic membrane, unspecified ear
T78.05XA      Anaphylactic reaction due to tree nuts and seeds
62351            Rabbit fever
Z91.012         Allergy to eggs
T63.441A      Toxic effect of bee sting
J30.1             Allergic rhinitis due to pollen
(information from Palmetto GBA)
I Revised CMS-855O Application: Enrollment Solely to Order, Certify or Prescribe

Physicians and non-physician practitioners must use the revised CMS-855O application (Eligible Ordering, Certifying, and Prescribing Physicians and Other Eligible Professionals) beginning January 1, 2018. The revised application will be posted on the CMS Forms List    by early summer. Medicare Administrative Contractors will accept both the current and revised versions of the CMS-855O through December 31, 2017. Visit the Medicare Provider-Supplier Enrollment webpage for more information about Medicare enrollment.
Changes to the form include:

     •    New title: Non-enrolled practitioners who prescribe Part D drugs also use this form
     •    New specialties:  Added Interventional Cardiology and 5 other specialties; Oral Surgeons (Dentist     Only) split into Oral Surgeon and Dentist
    •     Now optional for providers to add an additional contact person
     •    Editorial and formatting corrections in response to public comments

Setting up a CERT Point of Contact

Palmetto GBA encourages providers to set up a CERT point of contact (POC). This person will be responsible for receiving all correspondence regarding the CERT program. Some facilities designate the compliance officer, Health Information Management, facility practice manager, etc. To supply or update the CERT contractor with a new POC, access certprovider.com.

Gain Insight Into Your Billing Patterns and Utilization Services: Use Electronic Comparative Billing Reports (eCBRs)

Palmetto GBA uses electronic Comparative Billing Reports (eCBRs) as an educational tool for providers to use in order to provide insight into your billing patterns and utilization of services in comparison to your peers. eCBR will provide you with the ability to view and download your individual CBR online.

E/M Tip: History Component- Use of Diagnoses
The Review of Systems (ROS) refers to signs and/or symptoms that the patient may be experiencing or has experienced, not a list of diagnoses (i.e., denies CHF (chronic heart failure), diabetes, etc.).


With the rising cost of healthcare today, families are in need of assistance. The West Virginia Rx Card can help with those prescription costs and is a free program available to all West Virginia residents. No eligibility requirements or forms to fill out, simply take the card into the pharmacy to receive savings of up to 75% on prescription medications for the whole family. West Virginia Rx Card is a proud supporter of Children’s Miracle Network. A donation will be made to your local CMN hospital each time a prescription is processed through the West Virginia Rx Card. Go to www.westvirginiarxcard.com and print your free card today.

Important Medicare News

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently confirmed that the HHS OIG Hotline telephone number is being used as part of a telephone spoofing scam targeting individuals throughout the country. These scammers represent themselves as HHS OIG Hotline employees and can alter the appearance of the caller ID to make it seem as if the call is coming from the HHS OIG Hotline 1-800-HHS-TIPS (1-800-447-8477). The perpetrator may use various tactics to obtain or verify the victim’s personal information, which can then be used to steal money from an individual’s bank account or for other fraudulent activity. HHS OIG takes this matter seriously. The OIG is actively investigating this matter and intend to have the perpetrators prosecuted.

It is important to know that HHS OIG will not use the HHS OIG Hotline telephone number to make outgoing calls and individuals should not answer calls from 1-800-HHS-TIPS (1-800-447-8477). We encourage the public to remain vigilant, protect their personal information, and guard against providing personal information during calls that purport to be from the HHS OIG Hotline telephone number. We also remind the public that it is still safe to call into the HHS OIG Hotline to report fraud.  We particularly encourage those who believe they may have been a victim of the telephone spoofing scam to report that information to us through the HHS OIG Hotline 1-800-HHS-TIPS (1-800-447-8477) or spoof@oig.hhs.gov. Individuals may also file a complaint with the Federal Trade Commission 1-877-FTC-HELP (1-877-382-4357).

Quality Insights Chosen to Provide Support for Small Practices in CMS Quality Payment Program
(Press Release provided by Quality Insights)

The Centers for Medicare & Medicaid Services (CMS) has awarded a contract to Quality Insights to help small practices in Delaware, New Jersey, Pennsylvania and West Virginia prepare for and participate in the new Quality Payment Program, established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

This technical assistance, authorized and funded under MACRA, brings direct support to thousands of Merit-based Incentive Payment System (MIPS) eligible clinicians in small practices with 15 or fewer clinicians, including small practices in rural locations, health professional shortage areas, and medically underserved areas across the country. The direct technical assistance is available immediately, free to all MIPS eligible clinicians, and will deliver support for up to a five-year period.

 “An initial evaluation of the Quality Payment Program showed that small practices would need the most help to succeed,” Sven T. Berg, MD, Quality Insights Chief Executive Officer said. “We are pleased that CMS has recognized our ongoing assistance efforts by entrusting us with this opportunity to help small, rural and undeserved practices survive, thrive and provide quality care during this big transition.”

 Based on ongoing assessments of practice needs, Quality Insights will provide customized technical assistance to MIPS eligible clinicians, which may include, but is not limited to, the following:

     Conveying the MIPS expectations and timelines
     Explaining the MIPS feedback report
     Creating a MIPS-score improvement plan
     Evaluating practice readiness for joining an Advanced Alternative Payment Model (APM)
     Assessing and optimizing Health Information Technology
     Supporting change management and strategic planning
     Developing and disseminating education and training materials
     Enabling peer-to-peer learning and local partnerships
Quality Insights can be reached via email at qpp-surs@qualityinsights.org.

For more information on the Quality Payment Program, visit qpp.cms.gov or contact the Quality Payment Program by calling 1-866-288-8292 or emailing qpp@cms.hhs.gov.
Payor News
PEIA Update

Out of State/Out of Network Laboratory Services

PEIA would like to clarify a benefit change effective July 1, 2016. Out-of-state, non-network services are no longer covered in any of the PEIA PPB Plans. Patients will be responsible for 100% of billed charges from non-network providers outside West Virginia, except in a medical emergency or when approved in advance by HealthSmart. This benefit change includes out-of-state, non-network laboratory services.

The PEIA Finance Board adopted benefit changes for Plan Year 2017, which began on July 1, 2016. A comprehensive list of these changes is available at www.wvpeia.com under News Center.

If you have questions about PEIA’s benefits or payment policies, please contact HealthSmart at 1-888-440-7342.

Maternity Services: Cesarean Sections

Effective 4/1/2017, any Cesarean section, labor induction, or delivery that follows labor induction and that occurs prior to 39 weeks of gestation will be denied if the procedure is not considered to be, and documented as, medically necessary or the result of spontaneous labor.

Physician claims for obstetric delivery will require one of the following modifiers:

     UB-Medically necessary delivery prior to 39 weeks of gestation
     UC-Delivery at 39 weeks of gestation or later
     UA-Non-medically necessary delivery prior to 39 weeks of gestation

Records will be subject to retrospective review. If a Cesarean section, labor induction, or delivery following labor induction fails to meet the criteria for medical necessity, payments made will be subject to recoupment. Recoupment will apply to the physician charge for delivery.

If you have questions, you may call HealthSmart Benefit Solutions at 1-888-440-7342 or PEIA at 1-888-680-7342.

Molina Medicaid Provider 2017 Spring Provider Workshops Scheduled

April 3-13, 2017

4/3      Martinsburg-Holiday Inn
4/4      Wheeling-Oglebay Resort/Pine Room
4/5      Morgantown- Waterfront Resort
4/6      Vienna- Grand Pointe Conf. Center
4/10    Roanoke- Stonewall Resort
4/11    Charleston- Beni Kedem
4/12    Huntington- St. Mary's Conf Center
4/13    Beckley- Tamarack

Registrations begins at 8:00am Workshops are from 9:00-1:00pm and a light breakfast will be provided.

RSVP by March 17th by completing a registration form online https://www.wvmmis.com/default.aspx
Email :  WVProviderFieldRepresentative@MolinaHealthCare.com
Subject Line:  Attn:  Spring 2017 Provider Workshop

You may also have received the flyer and you can fax or mail that registration to
304-348-3380 Fax:  Attn:  Spring 2017 Spring Workshop

Mail:  Attn: Spring 2017 Provider Workshops
Molina Medicaid Solutions
PO Box 625
Charleston, WV  25322-0625

UniCare News

As of April 1, 2017, UniCare will no longer accept and review claims with medical records attached instead of prior authorizations.  

If a claim for a service requiring a prior authorization (PA) is received with medical records attached in place of a required PA, the claim will be denied for lack of PA.

Certain services require a PA from the Utilization Management department.  To determine which services require PA, use the PA tool on the Provider Resources page on the plan’s website, www.UniCare.com.    
Other News

Update on the WV Rx Card
While the Medicaid outpatient prescription drug benefit is not a mandatory benefit, all states provide this benefit in their Medicaid programs. As of 2014, Medicaid spending on outpatient prescription drugs registered at $27 billion, or about six percent of Medicaid spending. As a significant cost center, states continue to struggle with controlling Medicaid prescription drug spending including the high-cost of "specialty" drugs. Emerging issues such as specialty drugs will continue to have broader implications for the administration of the Medicaid Drug Rebate Program (MDRP).
The West Virginia Rx Card is a free resource for you to help lower out-of-pocket prescription costs.  If you have a high deductible or take a medication not covered by insurance or do not have prescription coverage, the West Virginia Rx Card can save you up to 75%.  Log onto  www.westvirginiarxcard.com or  www.wvsma.org to print a free card.  You can also walk into any CVS/pharmacy and request to use the West Virginia Rx Card program.  Contact Charlie Hartung at chartung@westvirginiarxcard.com or 1-877-669-6569 for more information.
Educational Opportunities 
WVMGMA Plans Regional Meetings

The West Virginia Medical Group Management Association is planning regional meetings during the week of May 15, 2017.   Meetings will be held in  Morgantown, Parkersburg, Teays Valley and Beckley.  

Watch for more details on these great educational meetings!