New Enrollment and

Revalidation Requirements

New Billing Information,

Requirements and Reminders

ICD-10: Vermont Medicaid

is Ready! Are You?

INSIDE THIS ISSUE

Department of Vermont Health Access ADV I SORY

August 2015

NEW ENROLLMENT AND REVALIDATION REQUIREMENTS

Effective September 1, 2015, Vermont Medicaid must implement the required provider enrollment

and revalidation (formerly known as recertification) processes to be in compliance with the

Affordable Care Act Program Integrity requirements (42 CFR §§455 Subpart E - Provider Screening

and Enrollment).

Vermont Medicaid has launched a new enrollment-specific page on the Vermont Medicaid Portal to

help you successfully navigate the enrollment and revalidation processes. The New Enrollment page

provides specific forms by provider type. Please visit us at: http://www.vtmedicaid.com/Enrollment/

enrollmentindex.html#/.

If you are already enrolled, you do not need to take action until it is time for your revalidation,

(currently tied to your professional license expiration date). If your professional license expires on or

after September 30, 2015, you will need to use the new enrollment application packet in order to

revalidate. You will be notified 90 days prior to your revalidation. Once your new application

packet is submitted and approved, you will have an enrollment period of up to five (5) years.

If you are a new provider enrolling, on or after September 1, 2015, you are required to complete

and submit the new enrollment application and contracts. You will also have an enrollment period of

up to five (5) years once your application is submitted and approved.

What’s Changing?

The application process and forms now include the following:

Distinct forms for Billing/Servicing providers, for Non-Billing providers and residents, and

Medicare Crossover Only providers for New Enrollment and Revalidation

A Disclosing Entity form for persons with an ownership or controlling interest, managing

employees

New General Provider Agreement

Special Provisions by provider type

Vermont Medicaid requires all providers, including residents and out-of-state attending providers to

enroll. Effective October 1, 2015, claims that do not include the enrolled attending providers will

be denied.

If you have additional questions while completing the application packets, please contact HP

Enterprise Services Enrollment Unit, 1-802-879-4450, option 4 or email:

vtproviderenrollment@hp.com.

PROVIDER MANUALS

are revised monthly and

posted to the VT Medicaid

Portal at:

http://www.vtmedicaid.com/

Downloads/manuals.html

VT MEDICAID BANNER PAGE

is your resource for

up-to-date billing, policy

& operational information.

Review weekly, paying close

attention to date specific and

implementation information

http://www.vtmedicaid.com/

Informationwhatsnew.html

ENROLLMENT PAGE

has all you need to know

about enrolling with us.

Located on VT Medicaid

Portal at:

http://www.vtmedicaid.com/

Enrollment/enrollmentindex.html#/

PROVIDER RESOURCES

2

Provider Help Desk Call Modification

To ensure we are serving members of the Provider Community equally, HPES has modified the limit on inquires and questions from

5 per phone call to 5 minutes per call. This change is due to an increased call volume.

We encourage providers with eligibility or claim status inquiries to use our Voice Response System (VRS) by calling

1-802-878-7871, option 1 or use the Vermont Medicaid Portal Transaction Services website at http://www.vtmedicaid.com/. Both

are available 24 hours a day, 7 days a week.

Prior Authorization Required for Applied Behavior Analyst

DVHA is accepting applications from Board Certified Behavior Analysts and Board Certified Assistant Behavior Analysts to become

enrolled as Vermont Medicaid providers. Provider Enrollment forms can be accessed at: http://www.vtmedicaid.com/Enrollment/

enrollmentindex.html#/.

Questions about enrollment may be directed to HPES at 1-800-925-1706, option 4

Effective July 1, 2015, all Applied Behavior Analyst (ABA) services delivered to Vermont Medicaid beneficiaries require Prior

Authorization (PA) to be considered for reimbursement. PA forms and the benefit information can be accessed at: http://

dvha.vermont.gov/for-providers/applied-behavior-analysis-aba/.

Procedure Codes for Inpatient Hospital Billing

ICD PCS (Procedure Classification System) codes should be used when billing inpatient hospital claims for surgery and ancillary

services such as imaging, nuclear medicine, radiation therapy, physical rehabilitation, diagnostic audiology, mental health and

substance abuse treatment. The ICD official guidelines note that PCS codes should be used for “procedures or other actions taken for

diseases, injuries and impairments” and encompass “prevention, diagnosis, treatment and management”. The inclusion of PCS

codes on inpatient hospital claims will ensure that the most appropriate DRG is assigned and the correct reimbursement is received.

Effective October 1, 2015, DVHA will require a valid PCS code for the following revenue codes: 360, 361, 362, 367, 369, 481,

490, 710, 750, 810, 811, 812, 813 and 819. ICD-9 PCS must be used for dates of service prior to October 1, 2015. ICD-10 PCS

must be used for dates of service on and after October 1, 2015.

Update for Group Therapy Code 90853

To ensure Vermont Medicaid and enrolled providers are in compliance with National Correct Coding Initiative (NCCI) guidelines,

effective July 1, 2015, Medicaid implemented one session per day for group psychotherapy (90853), 3 sessions per week.

Medicaid requires all providers to bill group psychotherapy (90853) as per session as opposed to per fifteen minutes. 1 Unit = One

Session.

For additional details related to this update, please refer to the following: http://dvha.vermont.gov/administration/draft-versions-of

-state-plan-changes?portal_status_message=Changes%20saved.

Medicaid Transportation: Out-of-Area/Out-of-State Referrals

Effective July 1, 2015, the mileage limit for out-of-area/out-of-state referrals increased from 30 miles to 60 miles. If a Vermont

Medicaid member has a Medicaid-billable appointment at a participating provider greater than 60 miles from their residence, the

referring provider is required to fill out the Physician Referral Form and fax the completed form to DVHA at (802)879-5919. This

form is not required if the appointment is located within the 60 mile limit.

The form is available at: http://dvha.vermont.gov/for-providers/physician-referral-form.pdf. If you have questions, please contact

DVHA’s Provider and Member Relations Unit at (802)879-5900.

3

The October 1, 2015 date for ICD-10 compliance is rapidly approaching. You should be clear on the

impact ICD-10 will have on your practice and staff, clinical documentation, and claims submission.

Vermont Medicaid will not reimburse claims unless they include a valid ICD diagnosis code.

ICD-10 code books are readily available online. In addition, some professional associations have

produced lists of the diagnosis codes most commonly used by their members. ICD-10 Charts — a not-

for-profit service — offers a template library of ICD-10 diagnosis codes by specialty. See: http://

www.icd10charts.com/templates.

You may also find one or more of the following coding resources helpful:

CMS ICD-10 Code Lookup: https://www.cms.gov/medicare-coverage-database/staticpages/

icd-10-code-lookup.aspx

CDC ICD-10 Transition: http://www.cdc.gov/nchs/icd/icd10cm_pcs_resources.htm

CDx.org: http://icdx.org/cm

AAPC Translator: https://www.aapc.com/icd-10/codes/

ICD10Data Code Converter: http://www.icd10data.com/Convert

ICD-10 Charts & Mobile App: http://www.icd10charts.com/

All links to third-party websites are listed here for convenience only and are not endorsed

by Vermont Medicaid.

Newly Available Resources for Vermont Medicaid Providers

Answers to general ICD-10 questions, and specific questions about provider testing, are now

available on the DVHA ICD-10 website:

ICD-10 FAQ: http://dvha.vermont.gov/for-providers/icd-10-faq.pdf

ICD-10 Testing FAQ: http://dvha.vermont.gov/for-providers/vt-medicaid-testing-faq.pdf

Vermont Medicaid has released a number of presentations that focus on ICD-10 for particular

provider types. “ICD-10: What You Need to Know” covers the information needed to successfully

transition from ICD-9 to ICD-10. It’s currently available in four editions: Mental Health, Home Health

agencies, Assertive Community Care Service (ACCS) and Enhanced Residential Care (ERC), and

Speech-Language Pathologists and Audiologists. Presentations are available at: http://

dvha.vermont.gov/for-providers/icd-10.

Please note that the codes listed in these presentation are only examples. Providers must follow the

correct coding guidelines as published by CMS. The use of appropriate diagnosis codes is the sole

responsibility of the provider.

Special Notice for PES Users

To submit ICD-10 claims, providers must use PES version 2.27 or higher. Providers can check their

version number by logging on to PES, and selecting Help/About from the gray screen. Providers must

upgrade to version 2.27 prior to the October 1, 2015 cutover date for ICD-10. Instructions are

HP ENTERPRISE SERVICES

312 Hurricane Lane

Suite 101

Williston, VT 05495

Hours of Operation

(Provider Services)

Monday - Friday

8:00am - 5:00pm

Out-of-State Phone:

(802) 878-7871

In-State Phone:

(800) 925-1706

Fax:

(802) 878-3440

http://

www.vtmedicaid.com

DEPARTMENT OF

VERMONT HEALTH

ACCESS

312 Hurricane Lane

Suite 201

Williston, VT 05495

Hours of Operation

Monday - Friday

7:45am - 4:30pm

Phone:

(802) 879-5900

Fax:

(802) 879-5651

http://dvha.vermont.gov

Please share the

information contained in

this publication with all

staff members,

Thank you!

Continued on pg. 4

CONTACT US

4

Cherie Bergeron

Account Executive ∙ HP Enterprise Services

Steven M. Costantino

Commissioner ∙ Department of Vermont Health Access

DISCLAIMER; CPT® is a registered trademark of the American Medical Association (AMA). Current Procedural Terminology / CPT® codes, descriptors, and other data only are copyright 2012 AMA. All Rights Reserved. Applicable

FARS/DFARS restrictions apply to government use. Fee Schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use.

The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

available in Procedures for Upgrading PES User Software. Click on “Upgrade Instructions” at http://www.vtmedicaid.com/

Downloads/software.html. Send any PES upgrade questions to: vtedicoordinator@hp.com

ICD -10 Resources:

Vermont Dept. of Health Access: http://dvha.vermont.gov/for-providers/icd-10

Vermont Medicaid Provider Portal: http://www.vtmedicaid.com

CMS Road to 10: http://www.roadto10.org

To receive ICD-10 updates and notifications, email VT-ICD-10@hp.com and request to be added to the VT ICD-10

Distribution list

Continued from pg. 3