Provider Data Quality Assurance — Roster Requests

As a health plan, we are committed to regularly reviewing our provider directory for our Medicare and Medicaid (Washington Apple Health and Integrated Managed Care) products to ensure that we are compliant with state and federal regulations that require current, accurate, and complete online provider directories.
 
CHPW needs your help to ensure we have the correct provider information for you. As of October 2017, we will email a Provider Roster Request Letter and FAQ to contracted providers annually along with the provider’s roster. It is very important that you return the attestation to CHPW along with the roster.
 
The roster includes practice details such as Tax ID, National Provider Identifier (NPI), Licensure, Specialty, office location addresses, phone numbers, office hours, whether you are accepting new patients, etc. We also need to verify demographic information such as ADA access; any additional languages spoken by staff other than English; and gender or age restrictions. All practice locations where your providers render services under your agreement should be included in the roster.
 
You can send updates to us at any time; you do not need to wait for us to request a roster update.

As a reminder, it is important to notify CHPW timely of provider changes, including:

  • Staffing changes at clinics and facilities
  • Facility relocations and clinic moves
  • Contact information (address, phone number, fax number, website)
  • Practicing locations for each provider
  • Provider terminations

Please submit any additions, changes, or terminations to CHPW via the Provider Add Change Term (PACT) form on our website or email Provider.Changes@chpw.org.

 
 

Provider and Staff Training Programs

CHPW is committed to providing training and education to our Providers and their Staff. We are dedicated to developing your knowledge and understanding through a variety of mandatory and optional training programs.
 
To access our online training programs, go to our website at www.chpw.org. From the home page, select “For Providers” and from the menu, select Orientation, Training and Education.
 
If you would prefer an in-person training session, or if you have any questions regarding our training programs, please contact our Provider Relations Administrator, Carmen Switzer at Carmen.Switzer@chpw.org or (206) 613-8827.

 
 

Single Preferred Drug List (PDL)

The Health Care Authority (HCA) has begun to create an Apple Health (Medicaid) preferred drug list (PDL) in partnership with managed care plans that serve Apple Health clients. HCA is working to ensure the Apple Health PDL provides access to clinically effective and appropriate drug therapies in each class. We are committed to a transparent process and fair decisions.

Starting January 1, 2018, the Apple Health PDL will consist of 13 drug classes. HCA will use a phased approach to build the PDL, adding to it later in 2018. All managed care plans and the Apple Health fee-for-service program will use the PDL. The managed care plans and HCA will use established channels to notify clients whose drug coverage changes. We will communicate with you throughout the phased implementation. Managed care plans will continue to use their own preferred drug lists for drugs that are not included in the Apple Health PDL on January 01, 2018. 
 
No changes are being made to the prior authorization (PA) processes each managed care plan currently uses.
 
HCA, not a managed care plan, currently pays for certain drugs, such as those for Hepatitis C. This arrangement will continue after we implement the Apple Health PDL. Drugs that managed care plans don’t cover will reject at point of sale with direction to bill Apple Health fee-for-service.
 
Click here for more information on the CHPW formulary.


 
 

Opioid Policy

As of November 1, 2017, a new HCA clinical policy pertaining to opioid prescriptions has taken effect. The new policy is intended to help combat the opioid crisis. The policy aligns with recommendations from the CDC, AMDG, and Bree Collaborative regarding safe and appropriate opiate prescribing.

Limitations to the quantity of opioids which may be prescribed to opiate naïve, non-hospice patients for non-cancer pain are:

  • No more than 18 tablets or capsules (roughly 3-day supply) for patients age 20 or younger
  • No more than 42 tablets or capsules (roughly 7-day supply) for patients age 21 or older

Chronic use of opioids requires attestation to following best practices, which includes checking the Prescription Monitoring Program prior to prescribing, informing patients of the risk, and using a pain contract. Exemptions exist when medically necessary. Click here for more information on opioid prescriptions.

 
 

 
 

Whole Person Model of Care

As your health plan partner in the provision of the highest quality comprehensive care to our members, CHPW is proud to announce important changes to our service model and enhanced support for the whole person model of integrated care. You’ll be seeing more and more of us as we expand our support for local care programs and reorganize our care management services to be delivered locally, in closer coordination with you, the provider. Existing regional programs are being reinforced and new ones are being created to proactively identify and address the behavioral, social, and physical needs of our members and to best support whole person care.

Operationally, you do not need to worry about new rules or additional requirements for referrals and authorizations. Our members, however, will benefit from a more supported, integrated approach to their health. We are making changes to better connect and coordinate the components of care and remove barriers among the Plan and providers as well as community organizations. We are developing systems to identify and address needs that impact the health of our members both within the clinical setting and beyond.

So what specifically are we changing? Internally, we are forming a new Health Services Division. This locally-based team will encompass Utilization Management, Complex Case Management, Population Health, Transition of Care Management, and Community Care Linkages and Coordination. We are also working with our delivery system to support local resources on the ground. The new division and programs will be in place by March 1st, and we are excited to welcome new staff with diverse professional experience and a commitment to our mission and the integrated care model.

We recognize the important role that you play in connecting with your community’s resources and building trusted local relationships for your patients and we are excited for the expanded role we will play together to remove barriers and ensure better health outcomes for our members. Please look for additional information on the programs under development for our members and patients in the next newsletter.

 

 
 

Billing Instructions for Medicare Patients with More Than 12 Diagnoses

If you have Medicare patients that have more than 12 diagnoses on one claim, please submit two claims:

  • One with the procedure code(s) for the service(s) rendered with 12 diagnosis codes.
  • The second with procedure code 99080, billed amount 0.01 (one cent) with the additional diagnoses. Because code 99080 is not a duplicate procedure billed for the member on the same date of service, it will not be denied as a duplicate. Medicare does not cover this code, so CHPW and CMS will not pay on the one cent; however, CMS does accept denied encounters and all diagnoses would be captured in both the CHPW claims system and the CMS encounter data.

Please contact edi.support@chpw.org if you have any questions.

Capitated Claims Enhancement for 835

Several Community Health Centers have requested that CHPW’s 835 files (electronic remittance advices) include the allowed amount on capitated claims. CHPW is pleased to announce that effective November 5, 2017 the 835s include the allowed amount for capitated claims on the 835 files.

With this enhancement, capitated claims will report the allowed amount in the X12 on two lines: one with the provider’s write-off amount, the other with the contractually allowed amount for the claim line.

Click here to see an example of the new 835 files.

 


Prior Authorization List Update

CHPW periodically reviews and applies updates to the Prior Authorization List. The following change will be effective December 18, 2017:

  • We are adding a Prior Authorization requirement for Medicaid and Medicare on Enteral Nutrition Thickeners for ages 0 to 1.

For more information, please see the Prior Authorization requirements.
Should you have any questions, please contact Provider.Relations@chpw.org

2018 Health Benefit Exchange

Community Health Plan of Washington will no longer be participating in the Health Benefit Exchange effective January 1, 2018.

CHPW currently participates in the Health Benefit Exchange under the branding of Community HealthEssentials Plus for both Gold and Silver medal products in the following counties:  Adams, Douglas, Ferry, Franklin, Grant, Lewis, Pacific, Pend Oreille, Spokane, Stevens, Thurston, Wahkiakum, Walla Walla and Yakima.

There will be no need to amend your contract as a result of this change.

If you have any questions, please contact CHPW’s Customer Care team at 800 440-1561.

New Behavioral Health Integration Codes

There are a number of new advances in payment for behavioral health in primary care. In July 2017, the WA State Legislature passed a bill (SSB 5779) that required the HCA to review and revise payment rules for behavioral health services delivered in primary care as well as allocated $4 million to reimburse for Collaborative Care services.

The guidance around these payments from the HCA is being released in 4 phases, addressing funding for Medicaid services. Phase 1 and 2 guidance has been finalized. Phase 1 includes Health and Behavior Codes intended to support behavior interventions for patients with primarily physical health problems. Phase 2 includes additional Behavioral Health Codes that include SBIRT, Smoking and Tobacco Cessation and other codes. Phase 3 of this process includes the Collaborative Care billing codes that reimburses for this specific type of integrated care service. The draft guidance for the Collaborative Care codes has been released with a planned implementation date of January 1, 2018. The final guidance on these codes and updates on fee schedules will be released in the coming weeks. Phase 4 includes screening for children and caregivers for depression.

In addition to the WA State efforts, CMS just finalized 1 additional Collaborative Care billing code to support Medicare payment for this service for FQHCs and RHCs. Information on these codes can be found on the CMS website for FQHCs, the AIMS Center and from CHPW.

Remember, CHPW Has Moved!

Community Health Plan of Washington has moved. Please note, our mail forwarding expired in October. Our offices are now located at:
1111 Third Avenue, Suite 400
Seattle, WA 98101

Please note the Claims address remains the same:
PO Box 269002
Plano, Texas 75026-9002