JULY 2012
In this issue:
Health System Transformation
Other provider updates
Health system transformation – waiver approved
On July 3, the Centers for Medicare and Medicaid Services approved the waiver giving Oregon more flexibility to move forward towards our goal of improving health and health care for Oregon Health Plan members.
Under the agreement, Coordinated Care Organizations (CCOs) will have more flexibility to pay for services that improve health and lower costs, but are not traditionally covered by Medicaid. Examples include preventive services to reduce unnecessary hospital visits and acute care, more primary care, and greater emphasis on local community health workers who can help OHP members manage chronic illnesses.
In a news release earlier this month, Governor Kitzhaber thanked federal partners noting that “this waiver is the final building block to creating a better model of care, and Oregon is ready to demonstrate how local communities can lead the nation in keeping people healthier over the long term in a more effective way.”
Next steps and status update on CCOs
Eight new CCOs will enroll 175,000 OHP members on August 1, 2012. On June 29, a letter was sent to those members notifying them about this change. The letter includes the name of their current managed care plan and the name of their new CCO. For those members moving to a CCO on September 1, a letter will be sent on August 1.
To make the transition as seamless as possible for members, members will follow their Managed Care Organization (MCO) into the new CCO. Their benefits and doctors will stay the same.
An additional phone line has been added at the central processing center to field calls from families regarding CCOs. Members can call 1-855-226-6170 with their questions about CCOs.
Information about CCOs is available on the Oregon Health Plan Web site and www.health.oregon.gov to help answer questions families may have about CCOs. Materials include a fact sheet and FAQ in English and Spanish.
Some codes incorrectly closed for payment July 1 through July 18
This week, we learned that codes were incorrectly closed to payment in the MMIS effective July 1. We reopened these codes July 19 and will reprocess any July claims that denied July 1 through July 18 because of this error. The codes were for the following services:
- Family planning: A4261 and A4266-A4269
- Incontinence supplies: T4521-T4537
- Prosthetics: L3956, L3971, L3973, L3975-L3978, L3980, L3982, L3984, L3995, L3999, L4000, L4002, L4010, L4020, L4030, L4040, L4045
Because DMAP’s quarterly fee schedule only includes procedure codes open to payment, the July fee schedule does not include the affected codes. We will update the July fee schedule to include these codes as soon as possible.
We are still researching whether other codes were incorrectly closed; if there are more codes affected by this error, we will let you know.
DMAP does not require billing of 2012 CPT genetic test codes (81200-81408)
The 2012 CPT genetic test codes 81200-81408 (tier 1 and 2 molecular pathology) are not open for payment and not on Medicare’s Clinical Laboratory Fee Schedule, so they are not payable by DMAP. DMAP reimbursement for clinical lab services is based on a percentage of Medicare’s fee schedule.
However, if you also bill Medicare and want to bill the same for both Medicare and DMAP, please note the following:
- Medicare asks providers to bill for each genetic testing procedure using two lines: one for the "stacked" (older) code still in CPT, which describes the testing procedure; and a second line for the corresponding 2012 code, which describes the gene tested. Medicare will pay the "stacked" codes and zero-pay the 2012 codes.
- If you bill DMAP with both the “stacked” and 2012 codes, we will pay the “stacked” codes as appropriate and deny the 2012 codes.
Contact DMAP Provider Services for all provider appeals and reconsiderations
Fee-for-service providers should contact DMAP Provider Services for all provider appeals (redetermination of non-covered services), including administrative errors and claims over one year old, reconsiderations related to CAWEM coverage, and reconsiderations for pharmacy prior authorization (PA) denials:
Mail to: DMAP Provider Services, 500 Summer St NE, E44, Salem, OR 97301-1079
Fax to: 503-945-6873
Do not use DMAP's central PA numbers (503-378-5814 and 503-378-3435) to fax information about pharmacy PA reconsiderations. If you do this, we may not receive your request for review.
DHS Medical Care ID name change
As we work to integrate all types of care under Coordinated Care Organizations (CCOs), we want client materials to reflect accurately this new focus on overall health. Therefore, the DHS Medical Care ID card is now called the Oregon Health ID.
The information on the card (client name, ID number and card date of issue) is the same. Clients with a DHS Medical Care ID will only receive an Oregon Health ID if their name or Client ID number changes. Please accept both versions of the card at health care visits when verifying eligibility.
Clients moving to a CCO will not get a new card; their DHS Medical Care ID is still valid.
Reminder: Client IDs are not proof of OHP eligibility
See Oregon Administrative Rule 410-121-1140 in DMAP’s General Rules for more information. Reduce claim denials and billing errors by verifying OHP eligibility and health plan enrollment prior to delivering services. All providers must answer the following questions before providing services:
Does the client:
- Have current OHP coverage?
- Have an OHP benefit package that covers the service you provide?
- Have a health plan that covers the service you provide? If so, work with the plan.
Is the service:
- Covered for the client’s stated medical condition, according to the Prioritized List of Health Services?
- Subject to prior authorization (PA) requirements? If so, request PA from the client’s plan or DMAP, as appropriate.
Use the Provider Web Portal, Automated Voice Response at 866-692-3864, or 270/271 electronic data interchange transaction to get the answers.
Oregon.gov Web site changes
The OHP Web site, along with most DHS and OHA Web sites, recently moved to a new format. You may have noticed the following changes:
- Pages are slower to load, including when you click on a top navigation bullet to "jump" to a certain section of a Web page.
- Pages now begin with www.oregon.gov/oha/healthplan/Pages and end in .aspx instead of .shtml. Any oha/healthplanlinks now go to the correct oha/healthplan/Pages page.
- If you use a www.oregon.gov/DHS/healthplan bookmark/Favorite, you will get a 404 - Page not found error.
DHS/OHA is working on these issues. In the meantime, please update your bookmarks so that they say "OHA" instead of "DHS" in the Web address. For faster Web page viewing, scroll down the page instead of using the top navigation bullets. You can also report incorrect links for OHP and DMAP Web pages to dmap.distribution@state.or.us.
We are also updating links found in the Provider Web Portal at https://www.or-medicaid.gov with the correct links.
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