Welcome to the Wesgram. This edition contains important information from CMS, Palmetto GBA, PEIA and other payers. You'll also find information about the upcoming Physician Practice conference on March 23, 2018.
March Physician Practice Conference
The WVSMA and the WVMGMA will again combine forces this year to host a conference for physicians, management and staff. Mark your calendars now for
Friday, March 23th at the Embassy Suites in Charleston.
The groups have prepared a wide variety of programming to keep you apprised of all that is happening in the healthcare arena. Plan now to attend! To register for this exciting day, click
CMOM Class Postponed
The CMOM class that was scheduled for February has been postponed until a later date.
T34 – Frostbite with tissue necrosis
T33.5 - Superficial Frostbite of Wrist, Hand and Fingers
J09 – Influenza due to certain identified influenza viruses
V00.212A- Ice-skater colliding with stationary object, initial encounter
X31- Exposure to excessive natural cold, initial encounter
Y93.23 – Activity, snow (alpine) (downhill) skiing, snowboarding, sledding, tobogganing and snow tubing
W00.1 – Fall from stairs and steps due to ice and snow, initial encounter
W00 – Fall due to ice and snow
V00.328 - Snow Ski Accident
V98.3 - Accident Involving a Ski Lift
(information from Palmetto GBA)
Medicare Secondary Payer Form Updated
The Medicare Secondary Payer Inquiry Form has been updated to include a fax number where additional documentation can be sent. This is the preferred method for Palmetto to receive your documentation. If possible, send all information to the fax number instead of via mail services. This will ensure receipt of the information and have it placed immediately into the workflow for quicker processing.
Change to Check Mailing Addresses
Palmetto GBA has reduced the number of addresses used for submitting provider checks to satisfy Medicare debts. Please immediately begin using the addresses below to submit payment for any Medicare Debts. All other PO Boxes will be closed.
Part A and HHH
PO Box 100277
Columbia, SC 29202
PO Box 100246
Columbia, SC 29202
Please note that the new PO Boxes will be reflected on all forms and letters. This will not affect payments being submitted by eCheck
Providers are strongly encouraged to submit payment electronically using eCheck via Palmetto GBAs eServices. Providers can electronically submit their payment and PDF attachments online. Once submitted, you will receive a confirmation from Palmetto GBA indicating that the payment has been received.
It is imperative when responding to the TPE Additional Documentation Request (ADR) that you include the name and number of your designated contact person. Palmetto's medical reviewer will contact your designated person prior to the conclusion of each TPE round to discuss the review summary.
Palmetto GBA will host a Medical Review Hot Topic Teleconference regarding the Targeted Probe and Educate (TPE) Process. All providers and staff are invited to join Palmetto’s Medical Review Subject Matter Experts as they discuss and answer questions concerning the TPE Process.
Conference Call Information
- Date: February 1, 2018
- Time: 10 - 11 a.m. ET
- Teleconference Number: (877) 789-3907
- Confirmation Code: 1391798
Roster billing is a simplified process used by mass immunizers. Palmetto GBA has prepared a packet for health care providers who mass immunize their patients against influenza and pneumonia. The packet contains instructions on how to submit claims using the roster billing method.
Palmetto GBA is pleased to offer secure and fast delivery of HIGLAS (Healthcare Integrated General Ledger Accounting System) generated overpayment demand letters through Palmetto GBA's eServices self-service portal. All providers who are enrolled in eServices will receive both hard copy demand letters and electronic copies through January 2, 2018. Providers have until January 1 to update their eServices profile if you choose to opt out of electronic delivery of these letters. After January 2, 2018, providers who have not opted out will receive only the electronic letter copy. Choose eDelivery instead of US Mail to save time and money.
With healthcare costs rising, many of your patients need assistance. The West Virginia Rx Card can help with those prescription costs and is a free program available to all West Virginia residents. There are no eligibility requirements or forms to fill out. Tell your patients to simply take the card into the pharmacy to get savings of up to 75% on prescription medications for their 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. Your patients can find and print their FREE card
CMS Announces Data Submission Rollout
On January 3, 2018, the Centers for Medicare & Medicaid Services (CMS) launched a new data submission system for clinicians participating in the Quality Payment Program. Clinicians can now submit all of their 2017 Merit-based Incentive Payment System (MIPS) data through one platform on the
website. Data can be submitted and updated any time from
January 2, 2018 to March 31, 2018
, with the exception of CMS Web Interface users who will have a different time frame to report quality data from January 22, 2018 to March 16, 2018. Clinicians are encouraged to log-in early to familiarize themselves with the system.
CMS Announces New Payment Model
On January 9, 2018, the Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (Innovation Center) announced the launch of a new voluntary bundled payment model called Bundled Payments for Care Improvement Advanced (BPCI Advanced). Under traditional fee-for-service payment, Medicare pays providers for each individual service they perform. Under this bundled payment model, participants can earn additional payment if all expenditures for a beneficiary’s episode of care are under a spending target that factors in quality.
Bundled payments create incentives for providers and practitioners to work together to coordinate care and engage in continuous improvement to keep spending under a target amount. BPCI Advanced Participants may receive payments for performance on 32 different clinical episodes, such as major joint replacement of the lower extremity (inpatient) and percutaneous coronary intervention (inpatient or outpatient). An episode model such as BPCI Advanced supports healthcare providers who invest in practice innovation and care redesign to improve quality and reduce expenditures.
BPCI Advanced will qualify as an Advanced Alternative Payment Model (Advanced APM) under the Quality Payment Program. In 2015, Congress passed the Medicare Access and Chip Reauthorization Act or MACRA. MACRA requires CMS to implement a program called the Quality Payment Program or QPP, which changes the way physicians are paid in Medicare. QPP creates two tracks for physician payment – the Merit-Based Incentive Payment System or MIPS track and the Advanced APM track. Under MIPS, providers have to report a range of performance metrics and then have their payment amount adjusted based on their performance. Under Advanced APMs, providers take on financial risk to earn the Advanced APM incentive payment.
In BPCI Advanced, participants will be expected to redesign care delivery to keep Medicare expenditures within a defined budget while maintaining or improving performance on specific quality measures. Participants bear financial risk, have payments under the model tied to quality performance, and are required to use Certified Electronic Health Record Technology. By meeting these requirements, the model qualifies as an Advanced APM. The 32 types of clinical episodes in BPCI Advanced add outpatient episodes to the inpatient episodes that were offered in the Innovation Center’s previous bundled payment model (the Bundled Payments for Care Improvement initiative), including percutaneous coronary intervention, cardiac defibrillator, and back and neck except spinal fusion.
CMS designed this model taking into account rigorous evaluation results from previous CMMI models, industry experience with bundled payment, and stakeholder input from healthcare providers at acute care hospitals, physician group practices, and other providers and suppliers. BPCI Advanced seeks to support and encourage participants who are interested in:
- continuously redesigning and improving care,
- decreasing costs by eliminating care that is unnecessary or provides little benefit to patients,
- encouraging care coordination, and fostering quality improvement,
- participating in a payment model that tests extended financial accountability for the outcomes of improved quality and reduced spending,
- creating environments that stimulate rapid development of new evidence-based knowledge, and
- increasing the likelihood of better health at lower cost through patient engagement, education, and on-going communication between doctors and patients.
The Model Performance Period for BPCI Advanced starts on October 1, 2018 and runs through December 31, 2023.
Like all models tested by CMS, there will be a formal, independent evaluation to assess the quality of care and changes in spending under the model.
For more information about the model and its requirements, or to download a Request for Applications document (RFA), the application template, and the necessary attachments, please visit:
. Applications must be submitted via the
which will close on 11:59 pm EST on March 12, 2018. Applications submitted via email will not be accepted.
Medicare Fee Schedule Issue
Several weeks ago, the WVSMA sent the following message to our members, advising of the reason for lower reimbursement in 2018. As of this date, there has been no change with the GPCI work value, so claims are still processing at the lower reimbursement. We are in touch with CMS and will let you know if anything changes.
Some practices may have already noticed that Medicare reimbursement for 2018 has been reduced, despite the 2018 conversion factor increasing to 35.999.
The WVSMA recently discovered that the 1.0 floor on the work GPCI (geographic practice cost indexes) expired on December 31,
2017, causing a reduction in reimbursement.
In 2015, when the SGR was repealed, it was replaced by MACRA (the Medicare Access and CHIP Reauthorization Act of 2015). Part of MACRA established a 1.0 “floor” for the GPCI. An index above 1.0 raised the Medicare payments. This legislation was good for two years and expired on December 31, 2017.
The work value for WV was reduced to .966, meaning there is a reduction in reimbursement for 2018.
The WVSMA has been in contact with Senator Capito’s office in Washington, DC, and they are aware of the payment decrease. They have confirmed that the 1.0 floor is currently not in place and are working with CMS toward restoration of the work floor. Their expectation is that the work floor section of the GPCI will be restored for another two years; however, there is no timeframe at this point. They also expect that the effective date would be retroactive to December 31, 2017, and the 2018 claims be reprocessed at the higher level.
As always, the WVSMA will keep you updated on any additional information we receive on this and other important issues.
The provider portal of HealthSmart’s website is now in production. Please note the attached overview indicates providers can download an EOB, but this is not available for PEIA since bulk payment is utilized. Click
for additional information regarding this new service.
Reminder: New Requirement for 837P Claim Correction Requests Coming 1/1/18
Requests No Longer Accepted Via Telephone Inquiry or NaviNet
As noted Oct. 25, 2017, on the NaviNet
Plan Central page, Highmark will no longer accept requests for claim corrections via telephone or NaviNet investigations, effective Jan. 1, 2018. Providers instead must submit claim corrections electronically.
Following are the three valid Frequency Types for claim corrections:
- Frequency Type 1 is an original claim.
- Frequency Type 7 is a replacement of a prior claim.
- Frequency Type 7 is used when a claim has been processed for payment but you identify an error on the original claim that requires correction. The information you enter on the replacement claim represents a complete or partial replacement of the previously submitted original claim.
- Frequency Type 8 is a void or cancellation of a prior claim.
- Frequency Type 8 is used only when elimination of a previously submitted claim is required. This code will cause the claim to be completely canceled from Highmark’s claims processing systems.
Please note: The original Highmark assigned claim number is required on all Frequency Type adjustment claims (Types 7 and 8).
In the HIPAA 837P Claim Transaction, the Frequency Type Code is reported in the 2300 Loop, CLM05-3 element. The original claim number is reported in Loop 2300, ORIGINAL REFERENCE NUMBER (ICD/DCN) REF segment.
Adjusted claims can be submitted within the NaviNet
claim entry screen by selecting the appropriate frequency type code and providing the original claim number.
Additional details about electronic claims adjustment requests can be found on Page 21, Chapter 5, Unit 2, of the
Highmark Blue Shield Office Manual
, which is available on our Provider Resource Center under
All providers are encouraged to file electronic claims. However, effective Jan. 1, 2018, you must submit a paper replacement claim if your original claim was submitted on paper. In Box 22, enter the correct Frequency code under Resubmission code, and Original Claim Number under Original Ref. No. to indicate you’re submitting a replacement claim.
Highmark Cancer Collaborative to Launch CanSurround in 2018
Living with cancer requires that patients have access to high-quality cancer care from leading doctors and hospitals. But to heal, patients also need emotional support — including encouragement from family, friends, and other caregivers. That is why, beginning Jan. 1, 2018, Highmark’s member program, the Highmark Cancer Collaborative, will pilot CanSurround, a new online support network for Highmark members who are fighting cancer.
This unique service is intended to encourage and support cancer patients as they progress from diagnosis, through treatment, and beyond. By nature of an exclusive arrangement between Highmark and CanSurround, Highmark and its affiliated health plans will be the only health plans in the Pennsylvania, Delaware, and West Virginia service areas to offer CanSurround.
CanSurround is a unique online network that envelops cancer patients with a wealth of emotional support and encouragement as they confront the disease. Nurses who are knowledgeable in oncology and digital health developed CanSurround based on their experience and research. Patients and caregivers helped to co-design the site, which provides a missing link between medical treatment and recovery. By joining CanSurround, participants gain access to a variety of helpful online tools and resources geared toward nurturing them through their uncertain and stressful journey. These resources include:
Checklists and trackers to help navigate the health care system
Interactive thought inquiry A personal journal and mood/distress tracker Relaxation exercises to reduce stress and promote positive thinking
Timely and inspirational articles relevant to their condition
These support tools are tailored to each patient's specific cancer diagnosis. They provide a more personalized and engaging experience as patients cope, wait on test results, ask questions, and navigate the different stages of the care process.
CanSurround also enables patients to create an online Support Circle of family and friends so they can communicate, share news about their triumphs and challenges, and find encouragement. An informational flier for members is being developed that will explain how CanSurround works and will include instructions for cancer patients on how to join this exclusive online community. What are the health benefits to patients? According to research by Campos1, psychosocial care plays a significant role in the patient care process. Their research claims that such care and support — like that Provider News, Issue 6, 2017 | © 2017 Highmark Blue Cross Blue Shield West Virginia provided by CanSurround — reduces emotional distress, anxiety, and depression, and improves health-related quality of life (Fuller, 2013); shows reduced disease recurrence and death (Andersen, 2008); and shows improved functional status and immunity (Andersen, 2007). Research also shows that psychosocial attention leads to improved health outcomes and survival rates and improved medication adherence.
CanSurround is an independent company that has contracted with Highmark to provide this service to our members who are fighting cancer and to their family and friends. In addition, CanSurround participants who are Highmark members can call Blues On Call at 1-888- BLUE-428 (258-3428) for additional support. Is CanSurround secure and confidential? CanSurround has committed to protecting the information that participants provide when using its services.
United Healthcare Update
Charleston Area Medical Center (CAMC) and UnitedHealthcare have reached an agreement on a new, multi-year relationship to ensure Charleston residents enrolled in UnitedHealthcare Medicare Advantage health plans continue to have in-network access to CAMC facilities and physicians. CAMC is also an in-network provider for UnitedHealthcare employer-sponsored and individual health plans.
Other Important News
New Fees for Health Care Records
The WVSMA has received a number of questions received many questions regarding the new law for Charging for Medical Records. This information was published last summer and is being provided again to help clarify the issue.
Legislation that went into effect July 6 established a new fee structure that physicians and other providers to utilize for providing health records to patients or their representatives.
The law resulting from Senate Bill 578 requires providers to produce records within 30 days of receiving a written request. The provider may charge a patient or their personal representative a fee consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
For someone other than the patient or their personal representative, the provider may charge a $20 search and handling fee, a per-page fee of 40 cents for paper copies, and postage (if mailed), plus any applicable taxes.
If requested, records may be furnished in electronic form, upon agreement of both parties; the per-page fee cannot exceed 20 cents.
In no event can the charge exceed $150, inclusive of all fees, except for applicable taxesnew law also allows for a $10 fee for certification of copies. If someone requests or agrees to an explanation or summary of the records, the provider can charge a reasonable cost-based fee for labor (plus postage and taxes). If records are stored with a third party, or a third party responds to a records request, the provider, “may charge additionally for the actual charges incurred from the third party.”
The per-page fee for copying may be adjusted on Oct.1 of each year to reflect the consumer price index for medical care services.