Task Force Meeting Notes

  • PRIOR AUTHS
    • Healthy Blue
      • Linking beneficiary eligibility to PA request causing PA to approve until end of month only versus up to max allowable (6 months)
        • HB is looking in to this and is advising practices to fax requests in as a workaround
      • Requiring PAs on services/procedures that providers are not accustomed to submitting PAs for such as, obesity screening, operating room for dental procedure, nutrition services, etc.
    • UHC
      • Also linking beneficiary eligibility to PA request
        • UHC is aware but not sure what steps they have taken to correct at this time
      • Missing PA requests
        • UHC had a nationwide system upgrade that caused a disruption with existing PA request which were no longer in the system
          • They are correcting this and on the interim are encouraging providers to contact provider services with UHC Community Plan (NC) to address
        • Requiring PAs on other services/procedures outside of traditional Medicaid
    • Overall inconsistencies across PHPs on PA requirements for procedures, for PA requests, how/where to requests, etc.
      • Not in alignment with how NC Medicaid was handling PAs before; much more burdensome
  • CLAIM DENIALS/PAYMENT ISSUES
    • FQHC core services not being reimbursed by one of the PHPs
      • Resolution is believed to be in the works
    • FQHC in Robeson and Winston Salem receiving denials
      • UHC denying due to NPI: they do not look at individual NPI so claim has to be submitted under group NPI
      • HB claim issues seem to be inconsistent so have not identified a specific trend yet
    • Wellchild visits
      • UHC is denying with modifier (when additional service is provided and submitted)
      • WellCare is paying incorrectly
      • HB is denying with TJ modifier
      • CCH is having issues with payment (resolution is pending)
    • COVID
      • Most issues seem to be with UHC (cpt 99401)
        • UHC website states that cpt 99401 must be billed with CR modifier; there is no requirement for specific dx code
      • CCH wasn’t paying for COVID testing
        • They are aware but unsure of resolution status
    • PT/OT/ST Providers
      • Not receiving CDSA payments
        • DHHS sent out a notice on 7/23 with hardship advance notice
    • Claims, PAs, enrollment seem to be affecting this group of providers across the state and across PHPs
      • □ PHPs are aware and working with practices to resolve ongoing issues
    • NPI/Taxonomy issues still prevalent across practices and PHPs
      • Seems to be a mapping misalignment across systems, whether it be between the PHP/EMR, PHP/State, PHP/Clearinghouse, or provider information is incorrect in NC Tracks
      • This is affecting PA requests, claim payments, provider directory information
        • Providers are being told that they are not enrolled with Medicaid or with the PHP
    • Capitated payments
      • Payments not being received (either from the PHP or CIN)
      • Providers are unclear where to go to check status of payments
        • Some PHPs are directing providers to the live roster view which is ever changing
        • Some are providing an ERA-like summary
          • Some of these summaries are processed based on clinic or by patient panel
          • It would be ideal to have them consistent across PHPs and like traditional Medicaid did before by dollar summary and participant summary based on NPI
    • MAT (Medication Assisted Treatment) Providers
      • Not receiving payment or not being paid correctly from PHPs
        • Seems to be linked with clinical coverage policy
    • Hardship Requests
      • There are a number of independent practices that are not getting paid and are struggling to keep doors open; where should these practices be directed for hardship requests?
        • DHHS states they need to go to the PHPs, but that does not seem to go anywhere
  • PAYMENT METHODS
    • Most PHPs are paying via EFT or paper
    • AmeriHealth requires EFT enrollment or will pay via VCC (virtual credit card)
      • VCC typically have additional fees associated, which the provider is responsible and part of those fees go back to the PHP
      • NCMS does not support VCC and has heard concerns from some provider groups
        • DHHS has been notified and is looking into this and Kristen will discuss with AmeriHealth
      • AmeriHealth EFT enrollment is also creating a little confusion because if the provider does not select the correct box, he/she may incur fees with EFT
    • UHC requires a separate EFT enrollment for capitated payments so if the provider does not complete that enrollment form they will be paid via paper for those payments
  • ENROLLMENT/CREDENTIALING
    • Continue to hear of issues across PHPs with providers not being enrolled in Medicaid or not being credentialed with the plan (when they are) due to variations of system issues with the PHP, which is ultimately creating a barrier for access to care
    • It is also affecting beneficiary assignment
      • NCCHCA stated they have a couple of practices that have unassigned beneficiaries or no beneficiaries assigned at all
        • They have not identified a specific pattern with this yet
  • COVERAGE of SERVICES
    • NC AHEC hearing from MAT providers that beneficiaries with UHC who should be covered to receive MAT are being denied; Optum is adding to the challenge
      • Provider and hospital (in specific area where there is only one MAT provider available) are encouraging patients to switch plans
      • Part of the issue has to do with the patient being penalized (limit count reduction) when a pharmacy (only specific pharmacies offer) does not have the medication in stock, ordering physician is on vacation, etc.
      • Part or possible all of the barrier seems to be linked to clinical coverage policy
        • Dr. Dowler has been made aware
        • Resolution is unknown at this time
  • PROVIDER PORTAL
    • Non-par providers are able to enroll in the provider portal for UHC and HB (not for the other three)
  • TRANSPORTATION
  • ADMINISTRATIVE BURDEN
    • Member ID
      • HB requires the HB member ID on claims; it can be found on the Availity with the DOB and Medicaid ID
      • AmeriHealth requires AHC member ID on claims which can be found on the portal or by phone for non -par providers
    • Website design
      • HB does not have a search function
    • Change Form
      • Providers are requesting a PCP Change form (like the PHP change form)
        • Currently the beneficiary or practice staff has to call to do this which is time consuming, beneficiary does not have all the required info, limitations of practice staff/support, and no record of request or ability to check status
        • Receiving conflicting information from DHHS on whether a form will be forthcoming
  • BEHAVIORAL HEALTH
    • Outstanding confusion about requirements, i.e. PA or visit limits associated with PA
    • FQHC Core Services not being reimbursed
    • Administrative burden (this is prior to tailored plans launch)
    • Portal requirements, i.e. uploading treatment plans that are already in EMR, duplicative/redundant work for providers
      • Hearing this specifically with HB
    • Provisional provider claim denials
    • It was mentioned they heard from a practice with a patient with a mental health crisis (positive depression screen, suicidal behavior) that they could figure out how to get this child help so sent the patient to the ER. Tried calling all of the available numbers/helplines to get to a live person. Eventually they found the right number, which is posted on the NC Peds website. This has been elevated to DHHS and they are looking into it.
      • Practices have a lot of angst around network adequacy with regard to behavioral health providers
        • Specifically with WakeMed (here) and how difficult and time-consuming it is to change PHPs for a beneficiary
          • WakeMed is still only contracted with 2 PHPs and they are the high-risk hospital

FEEDBACK for DHHS and/or PHPs

  • Uniformity with as much as possible
    • Credentialing is supposed to be uniform but there have been a number of issues – learn from these challenges
  • PHPs accept the same coding/modifier combinations and process for all codes
    • Wellchild visits is a good example of discrepancies between Medicaid/PHPs
    • TJ modifier for HC vaccines (Healthy Blue) is another example
  • Coding/Billing Guidance
    • Providers are used to receiving guidance from NC Medicaid on billing and coding guidance but are not receiving that guidance from PHPs
  • Forms
    • PCP change form similar to PHP change form (heard this from everyone)
      • Phone call process is not efficient for a number of reasons including limited staff on Ombudsman side, beneficiary does not have all of the information needed, limited practice staff/support, no record/trail of request or to follow for status updates
  • Payment Summation
    • Each PHP has a different approach to accessing, showing, reporting payment summaries of PMPM/AMH/Care Management
      • A consistent approach
    • It is also confusing what you are being paid for or who you are being paid by from the PHPs
      • AmeriHealth uses ECHO for NC and SC
      • BCBSNC – which line of service
      • WellCare and CCH come across the same so cannot tell who is paying
  • Aledade
    • Reaching out to PC practices to get them to drop their CIN and join Aledade
      • They don’t do care management but the PHP can do that for you
      • They are offering $1k incentive payments for practice referrals
        • It is underwritten by BCBS
      • Creating a lot of confusion for practices/providers (NC AHEC and NCCHCA both hearing this from their practices)
      • Telling practices they can pocket the PMPM since they won’t have to pay a CIN
      • Only signed up with 3 PHPs (versus all 5)

  • NCCHCA
    • Hearing that some FQHCs have submitted questions/issues to Ombudsman and didn’t get a response or a slow response
      • EH stated 10-14 days was the anticipated timeframe for a response
    • Lingering assignment and payment challenges
    • Access issues for patients at certain health centers due to patients being told their provider is not in network, despite the CIN facilitating contract and being told the FQHC is PAR.
  • Provider letters/suspensions due to outdated Medicaid credentials
    • EH stated the info that came over from NCMB was correct to NCTracks but NCTracks was showing (ex. one practice that reported this) different information and that the provider’s credentials were out of date.
    • GG mentioned there was a recent Insider article that the State Auditor dinged Medicaid for paying people who were no longer still licensed in NC.
  • Getting PCS services approved
    • PHPs have different forms and processes
      • Greg has reached out to Dr. Komives to reduce admin burden by creating a standard process and form
      • Greg will send letter so I can forward to Dr. Lawrence
    • Plan Assignment
      • Regardless of determination for practice stating that they are full and not accepting new Medicaid patients
        • Adults being assigned to pediatric practices
      • Follow up with DHHS to find out more
    • DME coverage issues
      • Some plans seem to think 2009 memo is optional but EH stated she has a personal memo from June 2021 stating that the PHPs have been contacted and notified that the 2009 memo is the “rule”
    • CLIA
      • CLIA waived test (respiratory tests) are the issues that Trista is hearing
      • EH mentioned an issue came up about the lipid tests
      • RH mentioned urine drug screens.
    • Health Choice Vaccines
      • EH mentioned that there is still an issue but there seems to be a fix being put in place
    • Staffing shortage
      • There is a nurses volunteer list that NCNA shared around
        • Jill Forcina at AHEC is spearheading effort
      • A big push that people get vaccinated to reduce barriers
      • A lot of travel nurses being pulled in
      • There is an attempt to get a respiratory therapist volunteer list too but has been difficult
    • BCBS (Commercial and Medicaid)
      • Not paying vaccine admin code when COVID vaccine and additional (non-COVID vaccine) is given

20211001_PHP Claim Information_Task Force