Kids First Payor Update

July 3, 2006

Medicaid CMOs

  • Specialists Participating with Medicaid CMOs-Since going live with the Medicaid CMOs June 1, findingspecialists that are participating with the Medicaid CMO plans has been difficult. Kids First has been working to get a listof these specialists.After a lot of seeking and asking, we have finally received a list of the specialistsfrom CHOAthathave signedwith the Medicaid CMOs and which plans they take. This list was attached to an email from April Binion on 6/30/06, and is also attached to this email.

WELLCARE

  • Incorrect reimbursement-Kids First is aware that some procedures, such as higher level health checks,standard E&M visits, and nurse practitioner reimbursements, have been paying lower than the 107% of the Medicaid fee schedule as contracted. We have informed WellCare of this situation, and will let you know more when we have more information.
  • Billing Vaccines-Kids First has been informed that several practices did not bill the vaccine administration code with Medicaid. WellCare has stated that you need to bill the administration code as well as the vaccine code. Of course, you do not get reimbursed for the vaccine if it is a “Vaccines for Children” vaccine, but you still need to bill both the immunization and administrationcodes, and then make adjustments after receiving your reimbursement from WellCare.
  • Throat Culture prior approval-The requirement of prior approval for throat cultures has not been removed by WellCare. Please continue to obtain prior approval for throat cultures. WellCare of GA is working with the corporate office to have this requirement removed, as soon as Kids First is informed that this requirement has been changed, we will let you know.
  • Calling WellCare-There has been a lot of contradicting information given by WellCare representatives. WellCare does operate in several states. The rules and regulations are different for each state. When you call WellCare the call is answered at their corporate office in Tampa.It is very important when speaking with the WellCare reps that you get their name, and also let them know that you are in Georgia. If they give you information clarify with them that the information given is relative and pertinent to the state of Georgia. By documenting names, we can forward the information to WellCare so that they mayeducate employees who areerroneouslygiving out the wrong information. (Communicated in email from April Binion 6/30/06)
  • Members receiving calls from WellCare regarding health check status-Kids First was informed of a member receiving a call from WellCare stating their coverage would be termed if the member did not get a health check within 90 days. This patient was actuallycompliant, and just had a health check in March 2006. WellCare has informed us that they only received the last few months of health checkinformation from the state before going live June 1. If a patient gets a call pertaining to this,the patient needs to inform WellCare that they are current and compliant.
  • X-Rays requiring prior authorization-Kids First communicated in the Medicaid Payor Update on June 9 that x-rays at participating facilities had to be pre-authorized. WellCare has changed this requirement. Plainx-rays at a participating free-standing imaging center do not need to be pre-authorized. However, if the patient goes to a hospital for the x-ray it must be pre-authorized.
  • Use of EPSDT codes with Billing Health checks-Kids First was originally informed by WellCare that the use of the EPSDT/condition codes with health check billing did not need to be used. That has changed.You do need to use the EPSDT codes when billing health checks with WellCare.WellCare has confirmed that you do not need to resubmit claims that were filed without the EPSDT. WellCare has reprocessed and will continue reprocessing June claims that were submitted without the EPSDT codes. Starting July 1 you need to make sure you include the EPSDT codes on all health checks. (Communicated in email from April Binion on 6/22/06)
  • Injectable Antibiotics-There has been question as toif injectable antibiotics need to be pre-authorized with WellCare. WellCare has confirmed that yes, injectable antibiotics must be pre-authorized.The Medical Director at WellCare of Georgiaunderstands the frequent use of these antibiotics, such as Rocephin, and is trying to have this requirementchangedwith the Corporate office. (Communicated in email from April Binion on 6/22/06) If an injectable antibiotic is given over the weekend when WellCare is closed, the authorization may be obtained on the next business day.
  • Use of “EP” modifier and POS 99 on health checks-WellCare has been back and forth with the proper way to bill health checks.WellCare is automatically reprocessing all claims with or without "EP" modifier and POS 99. You do not need to re-file these claims. You need to be sure that by July 1 you are using the correct codes, modifiers, and POS. (Communicated in email from April Binion on 6/22/06)

PEACHSTATE

  • PeachState Cap/Case Management Payments-Kids First was informed by PeachState that cap checks for June had already been mailed.After learning that no one had received their cap checks within the time frame thatPeachState gave us, Kids First went to PeachStateletting them know that none of the Kids First practices had received their cap checks. PeachState researched this issue, and informed us that severalof the Kids First practices' checksweremailed on June 22, four practices chose the reimbursement with no patient management fee, and a couple they had to research. For future reference, you should receive your cap check no later than the 15th of the month. (Communicated in email from April Binion on 6/28/06)
  • PeachState Claims Payments-In the last Medicaid CMO Payor Update (June 21) Kids First informed you that PeachState was not releasing any money at the time. The reason the claimswerebeing heldwas due to an audit. The audit was a test deposit of a penny into the accounts ofpractices that elected to receive payment via EFT.PeachState has informed us that the audit has been completed, and your claims payments should have been released Wednesday, June 28.If you have not received a call or letter from PeachState confirming the deposit of the penny audit, you will receive paper checks with paper remits until you hear from PeachState. Even though PeachState had the EFT enrollment information prior to the go live date it is taking them a while to get around to everyone. (Communicated in email from April Binion on 6/28/06)