Provider Enrollment and the Affordable Care...

HP Provider Relations

August 2012

Provider Enrollment

and the

Affordable Care Act

Provider Enrollment and the ACA August 2012 2

Agenda

– Session Objectives

– Provider Enrollment Web Pages

– Affordable Care Act (ACA) Impact

– Risk Levels

– Revalidation

– Disclosed Individuals

– Profile Updates

– Provider Screening

– Background Checks

– Associated Fees

– Ordering, Prescribing and Referring Providers


Objectives

– Know the screening tasks that apply to your provider type

– Understand the impact of your assigned risk level

– Understand the revalidation and recertification processes

– Learn about enrolling ordering, prescribing and referring (OPR) providers

Explain Indianamedicaid.com

5 Provider Enrollment and the ACA August 2012




Select your

provider type


Define What is the ACA?

Provider Enrollment and the ACA August 2012

11

Affordable Care Act (ACA) Impact on Provider Enrollment

– Centers for Medicare & Medicaid

Services (CMS) Rule 6028-FC of the

ACA provides procedures under

which screening activities are

performed for providers who want to

participate in Medicare and state

Medicaid programs

– Screening activities place heightened

emphasis on program integrity

designed to reduce fraud, waste, and

abuse in the Medicare and Medicaid

programs


12

Affordable Care Act Impact on Provider Enrollment

– On January 1, 2012, the Indiana Health

Coverage Programs (IHCP) adopted

and enacted new provider enrollment

and screening requirements mandated

by the ACA

– Screening and pre-enrollment

procedures apply to:

• New providers enrolling for the first time

• Providers reenrolling due to a change of

ownership

• Existing providers adding new service locations

• Existing providers revalidating their enrollment

Identify Risk Levels


Risk Levels

– The risk level categorization is established by the CMS, based on an assessment of potential for fraud, waste, and abuse for each provider type/specialty

– All provider types and specialties are assigned to one of the following risk levels:

• High

• Moderate

• Limited

– Waiver (atypical) providers are assigned risk levels at the subspecialty level

– Providers are subject to screening tasks based on their assigned risk level

• The risk level assignment may be increased at any time at the discretion of the State. In these instances, the provider will be notified by the State, and the new risk level will apply to processing enrollment-related transactions.

• Providers who have been subject to payment suspension will automatically have their risk level assignment set to „High‟

– The Provider Type Application Fee and Risk Assignment Matrix (for Non-Waiver and Waiver providers) provides a full list of provider types and their assigned risk level

• Note: Review this document before revalidating to review current requirements

http://provider.indianamedicaid.com/media/60200/ihcp provider enrollment risk category and application fee matrix - non-waiver providers for web.pdf



http://provider.indianamedicaid.com/media/60197/ihcp provider enrollment risk category and application fee matrix - waiver providers for web.pdf


15

Risk Levels

• Newly enrolling home health agency (HHA)

• Newly enrolling hearing aid dealer

• Newly enrolling pharmacy with durable medical equipment (DME) or home medical equipment (HME) specialty

• Newly enrolling DME supplier

• Newly enrolling nonemergency transportation provider

• Newly enrolling waiver specialized medical equipment and supplies provider

• Newly enrolling waiver attendant care providers

Risk Level - High

High


16

Risk Levels

• Rehabilitation facility with comprehensive outpatient rehab facility specialty

• Revalidating home health agency

• Hospice

• Clinic with therapy clinic specialty

• Mental health provider with community mental health center (CMHC) specialty

• Physical therapist

• Revalidating hearing aid dealer

• Revalidating pharmacy with DME/HME specialty

• Revalidating DME supplier

• Ambulance and air ambulance provider

• Revalidating nonemergency transportation provider

Risk Level - Moderate

Moderate


17

Risk Levels

• Independent lab, mobile lab, independent diagnostic testing facility (IDTF), mobile IDTF

• Mobile X-ray clinic

• Revalidating waiver provider offering specialized medical equipment and supplies, or waiver physical therapy provider

• Revalidating waiver attendant care provider

• Newly enrolling waiver consultative clinical and therapeutic service provider

• Newly enrolling waiver flex funds provider

• Waiver Community Alternatives to Psychiatric Residential Treatment Facilities (CA-PRTF) habilitation providers

• Waiver wraparound facilitation care coordinators

• Waiver wraparound technicians

Risk Level - Moderate

Moderate


18

Risk Levels

• Hospital

• Ambulatory surgical center (ASC)

• Extended care facility

• Federally Qualified Health Center (FQHC)

• Rural health clinic (RHC)

• Advanced practice nurse (APN)

• Pharmacy

• Dentist

• End-stage renal disease (ESRD) clinic

• Physician

• Clinic

• Birthing center

Risk Level - Limited

Limited


19

Risk Levels

• Outpatient mental health clinic

• Health service provider in psychology (HSPP)

• School corporation

• Public health agency

• Podiatrist

• Chiropractor

• Occupational therapist

• Speech/hearing therapist

• Optometrist

• Optician

• Audiologist


Limited


20

Risk Levels

• Case manager

• Family member transportation provider

• Freestanding X-ray clinic

• All waiver providers not listed as High or Moderate risk

• Extended care facility

• Rehabilitation facility

• Medical clinic

• Family planning clinic

• Nurse practitioner clinic

• Dental clinic


Limited

Describe Revalidation


22

Revalidation

– Revalidation initially impacts all providers and suppliers that were enrolled in the

IHCP prior to January 1, 2012

• For these providers, revalidation is scheduled for completion by December 31, 2014

– All states are required to revalidate enrolled providers at intervals not to exceed

every five years

– Durable and Home Medical Equipment (DME / HME) providers and pharmacy

providers that have DME / HME specialties will revalidate at intervals not to exceed

every three years

– Providers enrolled in the IHCP after January 1, 2012, will be required to revalidate

beginning calendar year 2017 (calendar year 2015 for DME and HME providers)

– Revalidating providers are subject to all required screening activities based on

their provider type and specialty

– Revalidation requires timely completion and submission of a new enrollment

packet, but does not require the payment of any application fees

Provider re-enrollment


Revalidation Notification Time Line

– In March 2012, the IHCP began revalidating existing providers in

phases based on provider type

– Notification for revalidation is sent to the „Mail To‟ address listed on the

provider‟s profile

– Providers should not attempt to revalidate their enrollment prior to

receiving their notification

– Providers receive notification 90 days prior to their respective deadline

to revalidate

– Providers that have not submitted their paperwork to the IHCP by 60

days from their notification deadline receive a second notice

– Providers are encouraged to verify their „Mail To‟ address on file by

accessing the Provider Profile feature of Web interChange


Revalidation Notification

– Providers that fail to answer notifications prior to the established revalidation deadline are disenrolled from IHCP participation

– Claims billed with dates of service on or after the revalidation deadline or disenrollment date will be denied

– Managed care members assigned to a primary medical provider (PMP) are automatically reassigned to another eligible PMP

– Services for members with level-of-care (LOC) benefits or members in the Right Choices Program (RCP) could be delayed.

– Disenrolled providers that submit revalidation materials and meet all federal and state guidelines will be reenrolled in the IHCP

– Backdating enrollments for disenrolled providers who did not meet their revalidation deadline, but who are eligible to reenroll, is prohibited

Providers are highly encouraged to return revalidation paperwork timely


Revalidation Notification via Web interChange – Web interChange users are able to

view a list of providers that are due

for revalidation

• Users must have “view” access within

Provider Profile to see the list of names

• Provider names are listed under the “View

Upcoming Providers for Revalidation” link

under the Provider Profile feature

• Providers‟ names are removed from the list

when the revalidation deadline passes


Revalidation Notification via Web interChange

Your unique Web interChange

User ID and Password



Select the link to

view a list of

providers due for

revalidation



Provider Name Service Location Address Revalidation Date

XXXXXXX XXXXXX

XXXXXX

XXXXXX

XXXXXX

XXXXXX

XXXXXX

XXXXXXX XXXXXX

XXXXXX

XXXXXX

XXXXXX

XXXXXX

XXXXXX

XXXXXXX XXXXXX

XXXXXX

XXXXXX

XXXXXX

XXXXXX

XXXXXX


Revalidation Recap

• Required by the Affordable Care Act

• Required for all currently enrolled

providers at intervals of three or five years

• Involves completing a revalidation

enrollment application

• Requires performance of all risk-

appropriate screening activities

• Does not require the payment of any

application or enrollment fees

• Providers are not to attempt to revalidate

their enrollment prior to receiving

notification to do so

Describe Recertification


31

Recertification Keeping your enrollment current and in good standing

– Required by the state of Indiana

– Required for currently enrolled out-of-state providers of certain specialties:

• Hospital – Upon renewal of license or Joint Commission on the Accreditation of Healthcare

Organizations (JCAHO) certification

• Some Extended Care Facilities – Annual submission of a newly signed Provider Agreement

• Ambulance – Upon issuance of a renewed Emergency Medical Service (EMS) certificate or

EMS Air Ambulance certificate

• Transportation – Upon issuance of a renewed Motor Carrier Services (MCS)

certificate/operating authority or Livery license and insurance policy

– Requires completion of the IHCP Provider Recertification Form

– Does not require completion of a new enrollment application

– Does not require completion of screening activities

– Does not require payment of any type of fee

Understand Disclosed Individuals


33

Disclosed Individuals Paper Enrollment Application

– Schedule C, sections C.1 through C.3 of the IHCP Provider Enrollment

Application collects the names of disclosed individuals

– Disclosure information refers to the identification of:

• Business owners

• Officers

• Administrators

• Members of the Board of Directors

• Directors and Managers responsible for day-to-day operations

• Subcontractors

– The ACA mandates background checks for disclosed persons with a

5% or more ownership in a High risk provider entity


34

Disclosed Individuals Web interChange

– Disclosure information is also collected via the

Provider Profile feature of Web interChange

• Applies to providers assigned to the Limited risk category

only

– A field has been added to the Provider

Maintenance section to capture, store, and

display the date of birth for all disclosed

individuals

– Web interChange requires the addition of the

date of birth for new entries and updates to

existing entries for disclosed individuals and

rendering providers


35

Disclosure Information

Update Provider Profile



Choose

an

update

form


Profile Updates

– Providers may continue to use paper update forms to perform maintenance to their profile

– Recent modifications were made to the following maintenance forms: • IHCP Name Address Maintenance Form

• IHCP Claim Certification Statement for Signature on File Addendum

• IHCP CLIA Certification Maintenance Form

• IHCP Delegated Administrator Addendum

• IHCP Electronic Funds Transfer Addendum

• IHCP Medicare Number Maintenance Form

• IHCP Recertification Form

• IHCP Disenrollment Form

• IHCP Specialty Maintenance Form

• IHCP Tax Identification Maintenance Form

• IHCP Psychiatric Hospital Bed Addendum

• IHCP PRTF Attestation Letter Information

Paper maintenance forms

Modifications include the addition

of Social Security number and

date of birth fields, a fee payment

form, and background/fingerprint

check form


Profile Updates

– For providers assigned to the High and Moderate risk levels, the

following Web interChange updates are not allowed:

• Service Location address change

− Unannounced, unscheduled site visits will be conducted before the address change

is approved

• Addition and removal of names from the disclosure information

− Disclosed individuals are subject to screening activities before changes are

approved

• Addition of Specialty

− Those that acquire a higher-risk specialty than previously assigned may not update

on Web interChange

Note: These profile updates must be performed using the paper forms

Determine Provider Screening


42

Provider Screening Screening tasks

– Prior to completing enrollment processing, providers are subject to

screening tasks based on their risk category

– High risk category

• Unscheduled, unannounced site visits; site visits are conducted prior to and after an

approved enrollment

• Fingerprint-based background check of disclosed individuals with a 5% or more

ownership interest

• Validation of disclosed individuals with the OIG Excluded Individuals database, the

Excluded Parties List System (EPLS) and the Social Security Death Master List

• License verification

• Proof of Medicare enrollment, if Medicare-enrolled

• Validation of the National Provider Identifier (NPI) with the National Plan and Provider

Enumeration System (NPPES)


43

Provider Screening Screening tasks

– Moderate risk category

• Unscheduled, unannounced site visits; site visits are conducted prior to and after an

approved enrollment


EPLS, and Social Security Death Master List



– Limited risk category


EPLS, and Social Security Death Master List



– For all risk categories, all screening tasks are performed for each

service location individually


44

Provider Screening Database checks

– The names of healthcare providers and disclosed individuals for provider

entities are validated on the following databases:

• Excluded Parties List System (EPLS) – Identifies individuals that are debarred, suspended,

excluded, or disqualified from receiving federal contracts, subcontracts, financial, and

nonfinancial assistance and benefits

• Office of the Inspector General (OIG) Exclusion List – Identifies individuals that are excluded

from participation in Medicare, Medicaid, and Title XX programs

• Social Security Death Master List (SSDML) – Validates that an individual is deceased

• Medicaid and CHIP State Information Sharing System (MCSIS) – Identifies individuals

excluded from participation in other states‟ Medicaid programs; and those whose Medicare

eligibility has been terminated

− Persons appearing on the above databases are not eligible to participate in

the IHCP

• National Plan and Provider Enumerator System (NPPES) – Identifies NPIs assigned to

healthcare providers

• Provider Enrollment Chain and Ownership System (PECOS) – Identifies providers enrolled

in Medicare


45

Provider Screening Provider / Employer –based screenings

– The IHCP reminds providers of their

responsibility to screen disclosed

individuals and employees prior to

hiring and periodically thereafter

• Please refer to the Provider Manual,

Chapter 4, page 8, available at

indianamedicaid.com.

Detail Background Check


Background Check

– Disclosed individuals with a 5% or

more ownership in a “high risk”

provider entity are required to

undergo a fingerprint-based

background investigation

– The IHCP will contract with a

vendor to provide fingerprint-

based background investigation

services


48

Background Check Process

– Disclosed individuals access the links on indianamedicaid.com to

make arrangements for fingerprinting

– Disclosed individuals will make an appointment at a nearby collection

site using the links on indianamedicaid.com

– Fingerprints are sent electronically to the Federal Bureau of

Investigation (FBI) for processing

– The FBI will return the Criminal History Reports to the IHCP

– Each disclosed individual requiring fingerprinting will pay a separate

$25 administration fee to the fingerprint collection site

– This process is yet to be implemented, however disclosed individuals

will receive notice to complete at a future date (required post-

enrollment)

Inform Application Fees


Fees – The CMS sets the application fee amount annually; the fee for 2012 is

$523 • This is a one-time fee assessment applied at enrollment. It is not an annualized fee.

– The application fee is not assessed by IHCP for providers who are enrolled in Medicare or who have paid the fee to another state Medicaid program

– Out-of-state providers that enroll or revalidate with the IHCP must provide proof of payment of the application fee if paid to their state‟s Medicaid program

– The application fee only applies to certain provider types • The Provider Type Application Fee and Risk Assignment Matrix (for Non-Waiver and Waiver

providers) on indianamedicaid.com provides a full list of provider types, and indicates which providers are subject to the application fee.

• Generally, the application fee applies to "institutional" providers, as defined by CMS, and not to individual professionals, such as physicians.

– The application fee is applies to: • Newly enrolling providers

• Entities executing a change of ownership

• Existing providers adding a new service location

http://stage-acc-provider.mm.inxix.sod.eds.com/media/60200/ihcp provider enrollment risk category and application fee matrix - non-waiver providers for web.pdf



http://stage-acc-provider.mm.inxix.sod.eds.com/media/60197/ihcp provider enrollment risk category and application fee matrix - waiver providers for web.pdf


Fees

– Application fee

• Institutional providers will pay a fee to enroll in the Medicare or Medicaid programs

• Dually-enrolled providers will pay the fee only to Medicare

• Medicaid-only providers will pay the fee to Medicaid

• EACH service location must pay the fee upon enrolling

• Review the Provider Type Application Fee and Risk Assignment Matrix (for Non-Waiver

and Waiver providers) on indianamedicaid.com to determine if an application fee is

required for your provider type

• Payment methods

• Check

• Money order

• Credit/debit card using HP Convenience Pay

• Electronic check including Automated Clearing House (ACH) and electronic funds

transfer (EFT)




http://stage-acc-provider.mm.inxix.sod.eds.com/media/60197/ihcp provider enrollment risk category and application fee matrix - waiver providers for web.pdf


Fees

– The IHCP will use HP Convenience

Pay to process credit/debit card

payments of the application fee

– The Convenience Pay Services

Client Access Portal provides

authorized users with online, real-

time access to ACH/EFT self-service

capabilities

– HP Convenience Pay must be

accessed from the link on the ACA

Requirements page on

indianamedicaid.com

http://stage-acc-provider.mm.inxix.sod.eds.com/become-a-provider/affordable-care-act-(aca)-requirements.aspx

http://stage-acc-provider.mm.inxix.sod.eds.com/become-a-provider/affordable-care-act-(aca)-requirements.aspx

Learn

Ordering, Prescribing and Referring Providers


Ordering, Prescribing and Referring (OPR) Providers – For Medicaid to reimburse for services or medical supplies that result from a provider‟s

order, prescription, or referral, the Affordable Care Act (42 CRF Parts 405, 447, 455, 457, and 498) requires that the ordering, prescribing, or referring providers be enrolled in Medicaid.

– Enrollment of OPR providers began June 2012.

– OPR practitioners are classified as non-billable providers and their corresponding National Provider Identifier (NPI) must be for a specified individual provider; not a group or organizational entity.

– The NPI for OPR providers must be affixed properly to each claim.

– All institutional and medical claims submitted with dates of service on or after October 1, 2012 will be denied if the correct OPR information is not listed on the claim, or if the OPR provider is not enrolled with the IHCP.

– Pharmacy services dispensed October 1, 2012 thru December 31, 2012, inclusive, will remain eligible for payment. However, pharmacy claims submitted for dates of service on or after January 1, 2013 will be denied if the required OPR information is not attached to the claim, or if the OPR provider is not enrolled with the IHCP.

• Please refer to indianamedicaid.com for a future notification regarding this rule


Begins at indianamedicaid.com

OPR Provider Enrollment








OPR Enrollment

– OPR providers will utilize a shorter, abbreviated enrollment form for

enrollment in IHCP

– Below is a sample of the first page of the OPR Provider Enrollment

and Maintenance Packet:


Special Note for Existing Medicaid Providers – Existing Medicaid providers will need to

verify that the OPR providers from whom

they receive orders, prescriptions and

referrals are enrolled in the IHCP.

– Claims that deny because the OPR

provider is not IHCP-enrolled may be

resubmitted after enrollment is

completed by the OPR provider

• The OPR provider must specify the needed

enrollment effective date on their enrollment

application


OPR Provider Search


OPR Provider Search/Directory


OPR Provider Search

National Provider Identifier here

From and To Date of Service here

Find Help Resources Available


65

Helpful Tools Avenues of resolution

– Provider Enrollment page at

indianamedicaid.com

– HP Convenience Pay – go to the ACA

Requirements Page on indianamedicaid.com

http://provider.indianamedicaid.com/become-a-

provider/affordable-care-act-(aca)-

requirements.aspx

– IHCP Provider Manual, Chapter 4 (Web, CD, or

paper)

– Provider field consultant directory

• provider.indianamedicaid.com/contact-us/provider-relations-

field-consultants.aspx

http://www.indianamedicaid.com/

http://provider.indianamedicaid.com/become-a-provider/affordable-care-act-(aca)-requirements.aspx













http://provider.indianamedicaid.com/contact-us/provider-relations-field-consultants.aspx










66

Helpful Tools Avenues of resolution

– Provider Enrollment Phone Line

• 1-877-707-5750

– Contact Provider Enrollment for answers to

questions about:

• Enrollment

• Provider file information

– Visit indianamedicaid.com and access the

„Contact Us‟ link for additional phone

numbers and addresses

Q&A

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