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Medicaid Provider Manual

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Medicaid Provider Manual MHS Health Wisconsin Medicaid Provider Manual MHS Health Wisconsin© 1 February, 2016 Introductory Information - MHS Health at-a-Glance .............................................................................................................. 3 MHS Health Wisconsin History ............................................................................................................................................... 5 Section 1 Secure Provider Portal ............................................................................................................................................ 7 • Registration on the portal • Changing Provider information on the portal Section 2 Other Resources for Network Providers ................................................................................................................. 9 • Quick Reference Guide Section 3 Guidelines for Providers ........................................................................................................................................ 13 • PCP, Specialist and hospital responsibilities • Reporting requirements Section 4 Quality Improvement Program ............................................................................................................................. 20 Section 5 Medical Records .................................................................................................................................................... 24 Section 6 Eligibility Verification/Member Enrollment .......................................................................................................... 26 Section 7 Routine, Urgent and Emergent Services ............................................................................................................... 28 Section 8 Covered Services ................................................................................................................................................... 30 Section 9 Health Check ......................................................................................................................................................... 33 Section 10 Medical Management ......................................................................................................................................... 36 • Authorization requirements • Services which do not require authorization Section 11 Pharmacy Benefit ................................................................................................................................................ 49 Section 12 Billing Information and Guidelines ...................................................................................................................... 50 • Claims submission and claim forms • EDI claims and EFT information • Payment protocol • Claim form completion guidelines • Emergency Department hospital claims adjudication process Section 13 Provider Complaints, Grievances and Appeals ................................................................................................... 97 Section 14 Member Services ............................................................................................................................................... 102 • Member complaints and grievances Section 15 Provider Credentialing ...................................................................................................................................... 108 Section 16 Transportation................................................................................................................................................... 112 2 Introductory Information - MHS Health at-a-Glance MHS Health Wisconsin and Network Health Plan Electronic Claim Submission More than 10,000 clinicians and 90 hospitals service MHS Clearinghouses and payor IDs: For all Health and Network Health Plan (NHP) members through MHS Health and NHP claims for the below BadgerCare Plus, Medicaid SSI, and Medicare Advantage - payors - 68069 Special Needs Plan (SNP), and our Ambetter from MHS Availity Allscripts/Payorpath Capario Health Wisconsin commercial plans. Claim Remedi Claimsource CPSI Location DeKalb First Health Care GatewayEDI MHS Health Wisconsin GHNonline IGI McKesson 10700 W. Research Dr., Suite 300, Milwaukee, WI 53226 MDonLine Physicians CC Practice Insight Smarta Data SSI Viatrack MHS Provider Inquiry Line RelayHealth Using Interactive Voice Recognition (IVR), check the (NDC/per Se) following: • Eligibility Provider Inquiry Line Emdeon WebMD Envoy • Claims information MHS/NHP.............................................. 39187 • 1-800-222-9831 Benefits Managed Health Services Advantage ...68056 • Authorization status Networks MHS/NHP/Advantage........... 96822 • Authorization requests Please have your NPI or Tax Identification Number or the member’s Medicaid ID number. Paper Claim Submission and Correction MHS Health Wisconsin Medical Services FAX lines: Attn: Claims Department P.O. Box 3001 Prior authorization requests: Farmington, MO 63640-3801 866-467-1316 Notification of Pregnancy Form: 866-681-5125 Refund Overpayment (on Provider check stock) MHS Health Wisconsin NurseWise® 24-hour Nurse Advice Line 6417 Paysphere Circle Chicago, IL 60674-6417 800-280-2348 Return checks Behavioral Health - Cenpatico 800-589-3186 MHS Health Wisconsin Attn: Returned Checks PO Box 3001 Pharmacy Benefit for Medicaid only Farmington, MO 63640-3801 For Medicaid, please bill the following as fee-for-service to the State: Prescription drugs, radiopharmaceuticals, To request a review of a “medical code denial” injectable biopharmaceuticals and other injectables MHS Health Wisconsin administered in a home health facility, an MD office, a Attn: Medical Review Unit skilled nursing facility, and most outpatient environments. PO Box 3001 Farmington, MO 63640-3800 Visit the website at www.mhswi.com to: Administrative Claim Appeal • Obtain a list of MHS Health and NHP patients and their MHS Health Wisconsin benefit and eligibility details, including other insurance, Attn: Appeals Department member care gaps, PCP and eligibility history. PO Box 3000 • Search for network Providers (updated weekly) Farmington, MO 63640-3800 • Submit and view authorizations Medical Necessity Claim Appeal • Use code-auditing software MHS Health Wisconsin • Submit claims including other insurance payment Attn: Medical Necessity Appeals • Export, download and check claim status, payment 10700 W. Research Dr., Suite 300 history, payment amounts & dates which are updated Milwaukee, WI 53226 every 24 hours Member Services- 888-713-6180 3 MHS Health and NHP refers to the BadgerCare Plus, Medicaid SSI members of MHS Health Wisconsin and Network Health Plan 4 MHS Health Wisconsin History MHS Health Wisconsin is one of the State’s oldest Medicaid plans, created in 1984, solely to manage the healthcare of the Medicaid population. Today, the MHS Health network consists of more than 10,000 clinicians and 94 hospitals. We serve our members through these programs: • BadgerCare Plus • BadgerCare Plus Childless Adults Program • Medicaid SSI • Medicare Advantage, Special Needs Plan (SNP) • Ambetter Marketplace Plan MHS Health Wisconsin is a wholly-owned subsidiary of Centene Corporation, St. Louis, MO. Centene Corporation, a Fortune 500 company, is a diversified, multi-national healthcare enterprise that provides a portfolio of services to government-sponsored healthcare programs, focusing on under-insured and uninsured individuals. The Company operates local health plans and offers a range of health insurance solutions. It also contracts with other healthcare and commercial organizations to provide specialty services including behavioral health management, care management software, correctional healthcare services, dental benefits management, in-home health services, life and health management, managed vision, pharmacy benefits management, specialty pharmacy and tele health services. Our beliefs MHS Health Wisconsin believes that successful managed care is the delivery of appropriate, medically necessary services and not the elimination of such services. We believe in providing healthcare that is managed by a local team to conveniently service your needs. Our philosophy is to provide access to high-quality, culturally-sensitive healthcare services to our members. We do so by combining the talents of primary care Providers and specialty Providers with an experienced, highly successful managed care administrator. We take privacy seriously At MHS Health Wisconsin, we take the privacy and confidentiality of our members’ health information seriously. We have processes, policies and procedures that comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the HITECH amendment to HIPAA and State privacy law requirements. HIPAA does permit Providers to share information such as telephone numbers, addresses and so forth when such information is in regard to a current member. This is considered part of treatment, payment, and health care operations and is allowable under HIPAA. It is the policy of MHS Health Wisconsin to conduct its business affairs in accordance with the standards and rules of ethical business conduct and to abide by all applicable federal and State laws. If you have any questions about our privacy practices, please call the MHS compliance officer at: 1-800-222-9831. MHS Health and Betty Brinn MHS Health Wisconsin and the market have changed in many ways since 1984. Yet, we are essentially the same organization that Maxicare Health
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