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May 2016
In this issue:
Health System Transformation
- Transforming a CCO’s community engagement on the frontier
- Medicaid Electronic Health Records (EHR) Incentive Program
Other provider updates
- Learn about Medicaid Program Integrity on the CMS website
- Learn the eight dimensions of wellness
- Prioritized List changes effective July 1, 2016
- CCOs will cover applied behavior analysis services starting July 1, 2016
- Changes to OHP adult dental benefit effective July 1, 2016
- Adjust both the header and detail dates when adjusting Web claims
- Updated resources for pharmacies
- Guides for managing someone else’s money
- Save the date: 33rd Annual Oregon Rural Health Conference
- Reminder: Monthly payment recovery for OHP newborn claims
Transforming a CCO’s community engagement on the frontier
While member engagement is challenging, it can be one of the most rewarding aspects of being a community health improvement coordinator – to help members participate in meaningful policy decisions for their CCOs. These decisions are making a real impact for their members.
“Member engagement is one of the things I love best,” said Charlotte Dudley. But it’s not always easy in frontier Oregon.
As community health improvement coordinator for Greater Oregon Behavioral Health, Dudley works closely with the Eastern Oregon Coordinated Care Organization (CCO) community advisory councils (CACs). These councils bring the consumer voice into local health system transformation, with a focus on preventive care and population health. While many CCOs serve two or three counties, Eastern Oregon CCO is unique in that it serves twelve – about half the state. “We have twelve advisory councils and they’re very local… we very much value our current members, but it’s been a challenge to get as many folks involved as we like,” Dudley said. CCOs need diverse perspectives to help understand how to best serve their communities.
To advance this CAC member engagement work, Dudley has participated in several opportunities through the Oregon Health Authority Transformation Center. For example, her CCO was connected to consultant Liz Baxter through the Technical Assistance Bank, which allows CCOs to request help from outside experts to give their health system transformation efforts a boost.
“Liz helped us take a step back,” said Dudley, “to think about relationships and how to ask engaging questions” to keep advisory council members involved.
Dudley also uses a CAC 101 presentation to orient new members. The presentation includes an overview of CCOs and Oregon’s health system transformation and will soon be available in Spanish.
Currently, Dudley is on a statewide committee to plan an event for CAC leaders to share strategies for recruiting and engaging CAC members, which is part of the Transformation Center’s efforts to provide more focused support to CCOs and CACs. To have meaningful conversations about systems change and barriers, it’s essential to have consumer voices at the table.
“The Transformation Center provides a nice link for Eastern Oregon CCO members and local CAC members to be heard at the state level,” said Dudley. “Sometimes we feel isolated out here. I love when we can be more collective and remember that this is a local project, a regional project, and it’s also statewide. The Transformation Center can provide that collective way to think about health care. The support and encouragement are really valuable.”
One way CAC members in Eastern Oregon are making a real difference is by guiding their CCO’s local transformation projects. For example, Union County CAC members identified the lack of transportation as an issue in their rural community and helped implement a project to provide transportation to same-day health care appointments and pharmacy deliveries, leading to fewer missed appointments and fewer unnecessary trips to the emergency room.
Medicaid Electronic Health Records (EHR) Incentive Program
Year 2015 updates for eligible professionals:
- Eligible professionals can now submit their Program Year 2015 Meaningful Use attestations until August 31, 2016.
Year 2016:
- Eligible professionals can now submit their Program Year 2016 Adopt, Implement or Upgrade and Meaningful Use (First Year) attestations until March 31, 2017.
- Program year 2016 is the last year to begin the program (coming in under AIU or MU Payment Year 1). Eligible professionals can receive an incentive payment for adopting, implementing or upgrading certified EHR technology in their first year of participation.
What is the Medicaid EHR Incentive Program?
The program provides federal incentives, up to $63,750 paid over six years to certain eligible providers who adopt, implement, upgrade or achieve meaningful use of certified electronic health record technology (CEHRT).
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Eligible professionals must choose to participate in either the Medicare or Medicaid EHR Incentive Program.
- Most but not all of the eligible hospitals in Oregon meet the federal requirements to participate in both the Medicare and Medicaid EHR Incentive Programs.
- Hospitals that receive payments under both programs must first attest to Medicare and then attest for a payment through Medicaid.
- Once payments begin in Medicare, hospitals must attest to demonstrating meaningful use every year to receive an incentive and avoid a payment adjustment.
For more information
Learn about Medicaid Program Integrity on the CMS website
The Center for Program Integrity provides educational resources to educate providers, beneficiaries and other stakeholders in promoting best practices and awareness of Medicaid fraud, waste and abuse.
Resources include print and electronic media, toolkits, train-the-trainer guides, webinars, videos, and other innovative strategies. CMEs and CEUs are available for many of these educational offerings.
Visit the Medicaid Program Integrity Education (MPIE) website to get updates such as:
We have added a link to this website on our Tools for Providers page.
Learn the eight dimensions of wellness
The federal Substance Abuse and Mental Health Services Administration (SAMHSA) has a new poster, Learn the Eight Dimensions of Wellness: Connecting All Aspects of Behavioral Health.
A part of SAMHSA’s Wellness Initiative, the Eight Dimensions can help people live longer and improve quality of life. They may also help people better manage their condition and experience recovery.
To learn more about the Eight Dimensions of Wellness, visit www.samhsa.gov/wellness.
Prioritized List changes effective July 1, 2016
OHA has announced that the delayed changes to the Prioritized List involving the treatments for conditions of the back and spine will be implemented on July 1, 2016. (The implementation was delayed from its original planned date of January 1, 2016).
These changes will result in expanded coverage for the assessment and conservative treatment for uncomplicated back pain under the Oregon Health Plan.
Coverage of surgical services and medications has been updated to align with evidence about optimal management of these conditions.
For technical details on the changes to the Prioritized List, as well as history on the development of these changes, please see the Health Evidence Review Commission’s News and Information page.
CCOs will cover applied behavior analysis services starting July 1, 2016
Starting July 1, 2016, CCOs will coordinate applied behavior analysis (ABA) services for their members. This means that CCO members will need to have their CCO approve ABA services scheduled on or after July 1. The CCO also will be responsible for payment.
To learn more about this change, please read our May 3 letter to ABA providers currently serving CCO members: This letter explains that providers need to contact the CCO regarding services delivered on or after July 1.
To learn more about ABA coverage under the Oregon Health Plan, please visit the Behavioral Health provider guidelines page.
Changes to OHP adult dental benefit effective July 1, 2016
Effective July 1, 2016, OHA will expand dental coverage as follows for non-pregnant adults who receive OHP Plus (BMH, BMM, BMD) benefits:
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Periodontal scaling and root planing: Cover once every two years.
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Full mouth debridement: Cover once every two years.
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Periodontal maintenance: Cover once every six months.
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Stainless steel crowns (D2930/D2931): Cover for anterior primary teeth and posterior permanent or primary teeth.
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Dentures – full: Cover once every 10 years if dentally appropriate.
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Dentures – partial: Cover once every 5 years if dentally appropriate.
To learn more, please read our May 31 letter to fee-for-service dental providers.
Adjust both the header and detail dates when adjusting Web claims
As you know, when billing claims, the dates of service on the detail line should, be within the dates on the claim header. This is also true when you copy or adjust/resubmit claims on the Provider Web Portal (PWP) at https://www.or-medicaid.gov, and if you are changing dates of service.
Please be sure to change dates both on the header and on the detail line(s) to match. Otherwise, the claim will suspend due to a date mismatch, and OHA staff will need to manually work the claim.
For more tips on successful billing, please visit our OHP Billing Tips page.
Updated resources for pharmacies
We have updated the Pharmacy Billing Handbook and the Pharmaceutical Services Provider Guide. They now contain a reminder to also refer to the Oregon Board of Pharmacy rules defining specific requirements relating to patient counseling, record keeping and screening, as noted in Oregon Administrative Rule OAR 410-121-0100 – Drug Use Review.
To view all resources and guidelines for fee-for-service prescription coverage, please visit the Pharmaceutical Services provider guidelines page.
Guides for managing someone else’s money
Millions of Americans are managing money or property for a loved one who is unable to pay bills or make financial decisions. To help financial caregivers, the federal Consumer Financial Protection Bureau released easy-to-understand Managing Someone Else’s Money guides.
They are written for these audiences:
- Agents under a power of attorney,
- Court-appointed guardians,
- Trustees, and
- Government fiduciaries (Social Security representative payees and VA fiduciaries).
Oregon-specific guides are also available. To learn more, visit http://www.consumerfinance.gov/managing-someone-elses-money/.
Save the date: 33rd Annual Oregon Rural Health Conference
This conference continues to be the largest gathering in Oregon dedicated to presenting the most innovative approaches to addressing today’s health care issues.
Bringing together providers, administrators, patients, activists, policy makers and others who are concerned about health care in rural Oregon, it is an opportunity to exchange ideas, information, and expertise among individuals and organizations engaged in or concerned with rural health care issues.
Reminder: Monthly payment recovery for OHP newborn claims
Every month, OHA recovers a small number of payments made in the preceding month for services to newborns who are now enrolled in a CCO.
- Once the birth is reported, we enroll children born to CCO members in the mother’s plan.
- However, depending on when the birth is reported to us, this process may take three or more weeks to complete.
To avoid future recoveries for newborn services:
What you will see on the paper remittance advice (RA), electronic remittance advice (ERA) or PWP:
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On the paper RA: Adjusted claims will have an ICN beginning with “52”. The “Detail EOBs” for these ICNs will list Explanation of Benefits (EOB) code EOB 0090 – Service is covered by a managed care plan. Claim must be billed to the appropriate managed care plan.
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On the ERA or PWP: The ERA should list these adjustments as overpayment recoveries. PWP will show the adjustment ICN as a denied claim. In both ERA and PWP, the reason for recovery will be Adjustment Reason Code 24 - Charges are covered under a capitation agreement/managed care plan.
To learn more about recovery of overpayments or appeals, please see Oregon Administrative Rules 410-120-1397(7), 410-120-1560 and 410-120-1580 in the General Rules guidelines.
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