- Important Reminder
- CHPW Now Offering Select 90 Day Fills
- Medicare Crossover Claims
- Medicare Diabetes Prevention Program
- New Provider Portal Coming this Fall
- Provider Guidelines for Service Location on Claims (Box 32)
- Billing Requirements for Diagnosis Code Limits
- Provider and Staff Training Programs
- Care Management Referral Process
- Caring for Your Diverse Community
- Single Preferred Drug List - Phase 2 implementation
- Behavioral Health Resources
- New Customer Service Process to Access Children’s Mental Health Services
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. Please send updates to us as soon as possible. You can send updates at any time; you do not need to wait for us to reach out.
To ensure compliance, it is important to notify CHPW timely (60 days in advance) of all provider changes, including:
- Facility/clinic relocations/closures/additions
- Contact information (address, phone number, fax number, website, TIN, NPI)
- Provider terminations or additions
- Staffing changes at clinics and facilities
- PCP only: Practice open or closed to new patients
- Practicing locations for each provider
- Float providers: A float or floating provider is one who provides temporary care by “floating” within a clinic or facility or from one location to one or more additional locations. Specific provider types are not permitted for inclusion in the provider directory (such as hospital based providers; radiology provides and certified registered nurse anesthetists). Please indicate on all rosters submitted to CHPW any providers that are float providers.
Thank you for helping us ensure our provider data and our Provider Directory are accurate and up to date.
In an effort to improve medication adherence and quality outcomes for CHPW members, we are excited to share the launch of a “90 Day Fill List”. Starting now, all CHC pharmacies and select 90-day contracted pharmacies will be able to bill a 90 day supply for CHPW members for any of those medications.
For the full list of medications available for 90 day fills, please see the April Pharmacy Preferred Newsletter.
What is Medicare Crossover?
Medicare crossover is the process by which Medicare, as the primary payer, automatically forwards Medicare Part A (hospital) and Part B (medical) claims, including durable medical equipment (DME) claims, to Community Health Plan of Washington (CHPW) as the secondary payer for processing.
CHPW has entered into an agreement with Benefits Coordination & Recovery Center (BCRC) to electronically crossover Part A and Part B claims from Medicare to CHPW beginning in June, 2018.
Who is Affected?
This change affects Medicaid members who are enrolled in Washington Apple Health and Integrated Managed Care who have traditional Medicare as their primary plan and CHPW as their secondary plan.
How Does it Work?
CHPW sends a monthly enrollment file to BCRC identifying our Medicaid members that have traditional Medicare fee-for-service as their primary plan, and CHPW as secondary.
Providers, you must include the Medicare Health Insurance Claim Number (HICN) and/or Medicare Beneficiary Identifier (MBI) on all your claims where the member has dual coverage. This allows CHPW to confirm the member has Medicare as primary and cross over claims without delay.
Benefits of the Crossover Process
This process eliminates the need for the member, provider, or facility to submit a claim twice: first to traditional Medicare, then to CHPW. No Medicare explanation of benefits (EOB) is needed to be sent to CHPW. This reduces administrative efforts for secondary claims submissions, as well as improves turnaround time and claims payment accuracy.
Please see this page for complete information.
As of April 1, 2018, Medicare now reimburses registered providers for the Medicare Diabetes Prevention Program (MDPP). CHPW will reimburse for MDPP for our Medicare Advantage members if the provider is registered with the Centers for Disease Control and Prevention (CDC). Please click the links below for more information and to apply for CDC recognition.
Full CDC requirements are available here. The CDC encourages organizations to read the CDC Diabetes Prevention Recognition Program Standards and Operating Procedures, available here, before applying for CDC recognition.
Apply for CDC Recognition
You must register with the CDC to be eligible for reimbursement for these services. Visit this page to apply.
The CDC National Diabetes Prevention Program Registry is available here.
CMS MDPP Presentation
CHPW will follow Centers for Medicare & Medicaid Services (CMS) guidelines for the benefit. Please see this PDF for more information.
CHPW is excited to announce our new HealthMAPS (Health Member and Provider Services) portal. Launching this fall, HealthMAPS will be an upgrade and replacement for the current Health Information Portal, or HIP.
Why are we changing?
HIP is an old version of the health plan portal software. It lacks modern standards, provides limited browser support, and is not as user-friendly as similar online services.
In addition, our providers and members have requested specific self-service options that the current HIP cannot accommodate.
What’s in it for you?
HealthMAPS will deliver:
- Additional browser support
- A modern user interface, creating an improved user experience
- A visually rich, easy to interpret, graphical format
- Easy navigation to high-level information with the option to drill down to details
- Enhanced ability to send and receive benefit/eligibility (270/271) and claim status (276/277) transactions
- The ability to send clean claims and corrected claims directly to CHPW
- Accessibility anywhere, anytime from mobile devices, tablets, and laptops
- Enhanced security, including annual HIPAA and security assessments and upgrades
Providers, you will be able to view your dashboard (with notifications and news, claims and membership information, and more); access authorization and referral requests (via a link to Jiva); submit patient claims; and request claim reviews.
Members will be able to view their dashboard (with member news, coverage summary, overview of authorization and referral requests, etc.); get details about medical plans and benefits; view claims and explanations of benefits; report other health insurance; request ID cards; request PCP updates; update demographic information; and search for physicians and facilities.
Providers and members alike will be able to send and receive secure messages with CHPW.
What can you expect for timing and go-live?
CHPW is planning for go-live this fall, 2018. Look for additional communications coming soon to announce the exact launch date.
CHPW and Dr. Bear will keep you updated with provider bulletins, training, and testing opportunities. User acceptance testing (UAT) is scheduled to begin in July. Contact EDI.Support@chpw.org if you’d like to participate in testing.
CHPW would like to remind providers about our policy regarding the service location on claims.
National guidelines state that a service location is always required. However, to reduce potential claim denials, CHPW’s policy is more lenient.
If a street (physical) address is present in the billing address field and the billing and service addresses are the same, CHPW will not deny the claim if the service location is blank.
If the addresses are different or if the billing address is a PO Box, then you must provide both the service location and the billing address.
Claims that do not meet the above requirements will be denied using CHPW message code CDNSL, “NO SERVICE LOCATION SUBMITTED ON CLAIM.”
The CMS 1500 (professional) claim form, also known as the HCFA 1500, specifies Box 32 for the service location and Box 33 for the billing address.
For electronic claims, or 837P transactions:
- Loop 2010AA is the billing provider
NM1*85*2*ABC GROUP PRACTICE*****XX*1234567890
N3*123 MAIN STREET*STE 600
- Loop 2010AB is the pay to address
N3*PO BOX 1234
N4*SALT LAKE CITY*UT*841250608
- Loop 2310C is the service facility
N3*123 MAIN STREET, SUITE 700
Please contact the following if you have questions about these guidelines.
Questions about paper claims:
- Washington Apple Health (Medicaid) Customer Service, (800) 440-1561
- Integrated Managed Care Customer Service, (866) 418-1009
- Community HealthFirst™ (Medicare) Customer Service, (800) 942-0247
Questions about electronic claims: EDI.Support@chpw.org
Providers may also wish to review the following.
- CHPW’s Provider Manual, “Electronic Data Interchange (EDI) / Electronic Transactions / Electronic Claims Submission” section
- Medicare Claims Processing Manual, Chapter 26 - Completing and Processing Form CMS-1500 Data Set.
- Washington State Health Care Authority HIPAA Electronic Data Interchange (EDI) page
- EDI Implementation Guide, available for purchase from Washington Publishing Company
ANSI X12 electronic claim transactions have the following limits for diagnosis codes.
- 837P (professional) limit: 12 diagnosis codes.
- 837D (dental) limit: 4 diagnosis codes.
- 837I (institutional): Allows for 24 “other” diagnosis codes in addition to principal diagnosis, admitting diagnosis, patient’s reason for visit, or external cause of injury.
If you have Medicare, Apple Health, or Integrated Managed Care patients that have more than the allowed number of diagnoses on one claim, please submit additional claims to capture all diagnoses for the patient:
- One with the procedure code(s) for the service(s) rendered with the allotted diagnosis codes.
- The additional claim(s) 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 and Medicaid do not cover this code, so CHPW, CMS, and the Washington State Health Care Authority (HCA) will not pay on the one cent. However, the encounter data will be sent to both CMS and the HCA with the additional diagnoses included. Please contact email@example.com if you have any questions.
CHPW is committed to provide training and education to our providers and their staff. We are dedicated to develop your knowledge and understanding through a variety of mandatory and optional training programs.
To access our on-line 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 prefer an in-person training session, or if you have any questions regarding our training programs, please contact our Provider Relations Department at Provider.Relations@CHPW.org.
- Referral to CM can occur via the following process:
- Phone: 866-418-7003
- Fax: 206-652-7073
- Email: CareMgmtReferrals@chpw.org
- Jiva: Preferred method for Jiva users.
- Referrals will be triaged per following timeframes:
- Urgent member need: within 3 business days
- Non-urgent member need: within 5 business days
- If you know which program a member should be in, program specific staff can be reached by phone and fax:
- Case Management: 866-418-7004 or Case.Management@chpw.org
- SNP Case Management: 866-418-7005 or Case.Management@chpw.org
- Care Coordination & Community Linkages: 866-418-7006 or CareCoordCommLinkage@chpw.org
- Population Health: 866-418-7008 or PopHealthRequests@chpw.org
- Transitions of Care: 866-418-7009 or TOCRequests@chpw.org
As a provider in the CHPW network, we want to thank you for your ongoing commitment to meeting the needs of CHPW’s diverse membership. To support you in your efforts to care for your community, we have created the 2018 CHPW Regional Demographics Report [linked]. This report includes race/ethnicity and language needs of each region of Washington State, as well as tools and resources that may assist you in better serving your patients.
In addition to understanding your community needs, these simple steps can help you work towards health equity:
- Recognize the importance that culture plays in health care by promoting cultural humility
- Provide translated materials in languages frequently spoken in your region
- Ensure interpretation services are easily accessible and widely promoted
Community Health Plan of Washington (CHPW) is committed to meeting the needs of Washington State’s diverse communities. We believe that by providing care that is culturally and linguistically responsive, we can work together to improve quality of care and begin to reduce health disparities in racial and ethnic minorities.
The Health Care Authority (HCA) is underway with the creation of the 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.
HCA is using a phased approach to build the PDL. The first phase was launched January 1, 2018, which consisted of 13 drug classes. The second phase is launching July 1, 2018, consisting of 57 drug classes. Managed care plans will continue to use their own preferred drug lists for drugs that are not included in the Apple Health PDL.
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.
More information on phase two can be found in the CHPW Pharmacy newsletters here.
In an effort to reduce the administrative burden for provider credentialing in Washington State, effective June 1, 2018, House Bill 2335 will require all insurance carriers to use ProviderSource. The Bill will also require providers to submit credentialing applications using OneHealthPort's secure login. House Bill 2335 also requires that effective June 1, 2018, the Community Health Plan of Washington must approve or deny the complete application no later than 90 days after receipt. A complete application is one that is not missing any information. This requirement changes to 60 days effective June 1, 2020.
Insurance carriers, physicians and other providers must use ProviderSource to submit and process credentialing applications. ProviderSource is a free health care credentialing tool operated by OneHealthPort, the State’s lead health information technology provider. You can access the site here for step-by-step instructions for setting up your profile before logging into ProviderSource.
Members can access mental health and substance use disorder services without a PCP referral. CHPW Customer Service is available to assist members in making an appointment (1-800-440-1561). Information on mental health for patients can also be found on the Mental Health Resources website.
There are also a number of clinical resources available to support providers with managing members with a variety of behavioral health needs across the state:
Weekly Case Conferences
UW Psychiatry and Addictions Case Conference?? (UW PACC)
Regional peer learning and support network series focused on treating mental health and addictions. This conference is offered for primary care providers including MDs, ARNPs, PAs and psychiatrists that includes a presentation and in-depth case consultation from community clinicians.
Providers receive didactics and community submitted case presentations for feedback from a panel of clinical specialists with a range of expertise related to the management of challenging chronic pain problems.
Cognitive Behavioral Therapy for psychosis (CBTp)
The CBT ECHO Clinic is the first ECHO program in the world focused exclusively on schizophrenia spectrum disorders and the first ECHO program to assist providers in developing competencies in group or individual evidence-based psychotherapeutic interventions. Clinics run weekly and are open to all providers who have participated in preliminary in-person training.
Child and Adolescent Consultation
Partnership Access Line (PAL)
Diagnostic clarification, medication adjustment or treatment planning provided by Seattle Children’s Hospital’s child and adolescent psychiatrists.
Call 866-599-7257 Monday–Friday, 8 a.m. to 5 p.m.
UW Perinatal Psychiatry Consultation Line
Consultation, recommendations, and referrals to community resources from a UW psychiatrist with expertise in perinatal mental health. Consultations on any mental health-related questions for patients who are pregnant, in the first year postpartum, or who have pregnancy-related complications (e.g. pregnancy loss, infertility). Topics may include depression, anxiety, or other psychiatric disorders; adjustment to pregnancy loss, complications, or difficult life events; risks of psychiatric medications; and non-medication treatments.
Call 206-685-2924 and leave your name and phone number. Perinatal psychiatrists respond to calls Monday through Friday between 3:00-5:00 PM, usually within one working day.
Suicide Prevention Resources
Department of Health
Resources and planning strategies for suicide prevention for adults and youth.
Main line: 1-800-273-8255
Teen Link: 1-866-833-6546
Crisis Text Line: 741741
Providers seeking mental health treatment for their young CHPW patients are no longer burdened with making multiple calls.
CHPW has a new customer service process to take on the responsibility of ensuring access to an appropriate mental health provider for children seeking treatment.
This policy comes in response to state legislation (RCW 74.09.340) requiring all managed care organizations to “ensure that children with mental health needs secure an appointment with an appropriate Mental Health Provider.”
The new CHPW process is designed to reduce challenges faced by parents, caregivers and youth calling multiple providers looking for mental health providers to find those taking new patients. Since providers often help patients access specialty services, including behavioral health, we want to let providers know about the new process for members to call Community Health Plan of Washington customer service for children’s mental health. Parents, caregivers or youth seeking mental health services can ask CHPW customer service for help in accessing mental health services for patients up to age 20. The call to customer service will trigger a connection to training care management staff that will identify available mental health and substance use providers in the area until we secure an appointment for your patient.
Children’s Mental Health Requirements
The legislation also requires MCOs to follow up with members to ensure that the appointment has been secured with an appropriate mental health provider and ensure that the child’s mental health provider(s) and primary care provider are coordinating on individual treatment plans and medication management.
While we are happy to be your single point of contact to secure appointments, you still have a vital role in securing the right care for your patient.
If you are a Behavioral Health Provider in an Integrated Managed Care (IMC) region, you’re responsible for conducting an initial assessment for first-time patients to assess their level of need, coordinating with your patient’s primary care provider, and securing an appointment with an appropriate behavioral health provider by either calling CHPW to coordinate care or securing the appointment yourself.
If you are a Behavioral Health Provider in a non-IMC region, you are responsible for conducting an initial assessment to determine treatment needs and whether they meet Washington’s Access to Care Standards, and securing a follow-up appointment with an appropriate behavioral health provider, which you can do by calling CHPW to coordinate care.
If you are a primary care provider, you are responsible for coordinating with your patient’s behavioral health provider. You do not need to submit a referral for your patient’s mental health or substance use treatment. If you need help finding an appropriate behavioral health provider for your patient, please call CHPW, or direct your patient to call on their own behalf.
As we move toward full integration and see an increase in mandates on children’s mental health care access, CHPW is further emphasizing our role as care managers. We are your single point of contact for care coordination assistance, access to specialists, community resources, and any other needs you or your patient may have. We will continue to be collaborative, supportive partners to you and your practice.