WV Medicaid Update

MCO Pharmacy Benefits Transitioning to Fee for Service Program

As previously printed, as of July 1, 2017, the WV Medicaid Fee for Service Program will provide retail Point of Sale (POS) pharmacy services for all Medicaid MCO patients   Prior authorization obtained from the MCOs will be transferred to the Molina system and will be honored for the amount of time through which they were issued by the MCOs.

Medicaid members should experience no disruption in service and can continue to take their prescriptions to the pharmacy of their choice.

Drug services billed with a CPT or HCPCS code (buy-and-bill), administered by a healthcare professional, will continue to be reimbursed by the Medicaid member’s individual MCO.

To obtain a prior authorization after June 30, 2017 for retail pharmacy POS services, please contact the Rational Drug Therapy Program by fax at 800-531-7787 or by phone at 800-847-3859.

WV Medicaid Exclusion Screenings

As a reminder, West Virginia Medicaid is required by CMS to direct physicians to:   

     Screen employees and contractors for excluded persons to prevent Medicaid payments for items/services furnished or ordered by excluded individuals or entities.              
      Search the Office of Inspector General’s (OIG) List of Excluded Individuals and Entities (LEIE) monthly to capture new exclusions or reinstatements that occurred since the last search.

If you are not currently screening your employees and need more information, please contact the WVSMA for assistance. 

PEIA Claims Information

As a reminder, providers can check the status of a claim online through the HealthSmart provider portal.  This is the best way to ensure your payments are correct. 

Highmark Updates

Changes Occurring for Locum Tenens Service Time Frames

Effective August 22, 2017, locum tenens service time frames may not exceed 60 consecutive days for Medicare Advantage or commercial networks.  Highmark requires all physicians who provide services to our members to be credentialed and contracted.  However,under certain circumstances, Highmark allows for locum tenens arrangements.  A locum tenens provider is defined as a practitioner who is covering for
another practitioner when they are absent for reasons of illness, retirement, death, medical leave, vacation, military leave or continuing medical education.  

If a regular physician is absent longer than 60 days without returning to work, the locum tenens must be credentialed and enrolled as if he or she were joining your practice as a new physician.

Highmark to Update Laboratory Fees Effective July 1, 2017

Effective July 1, 2017, Highmark Blue Cross Blue Shield West Virginia will adjust the Laboratory Fee Schedule to 85 percent of the current Centers for Medicare & Medicaid Services (CMS) lab fee schedule.

Also, the Highmark West Virginia Medicare Advantage fee schedule will align to the Highmark Pennsylvania Medicare Advantage fee schedule of 70 percent of the Commercial fee schedule.

This change will impact independent clinical laboratory allowances for the Clinical Diagnostic Laboratory Fee Schedule in the West Virginia region.

As always, fee information is available via NaviNet®, and the updated clinical laboratory fees will be viewable on July 1, 2017.

Molina Update

Save the Date!   Molina Announces Fall 2017 Workshop Dates

Flatwoods 9/18

Charleston 9/19

Huntington 9/20

Beckley 9/21

Martinsburg 9/25

Morgantown 9/26

Wheeling 9/27

Parkersburg 9/28