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National Provider Identification (NPI) Reminder

Many physicians have obtained NPI numbers and have begun to use them. If you still have not gotten an NPI, you must act quickly, as the May 23, 2007 deadline is rapidly approaching. As of May 23, Medicare contractors, as well as most payors, will only accept NPI numbers on claims. Once you have received your NPI, you should notify all payors of the unique 10 digit number.

The NPI is a HIPAA (Health Insurance Portability and Accountability Act) requirement, which states that physicians who transmit claims and other HIPAA transactions electronically will be required to use an NPI as of May 23, 2007. While HIPAA applies only to physicians who do business electronically, Medicare has made the business decision to require those who bill with paper to obtain and use an NPI.

The CMS 1500 form was modified to allow space for reporting the NPI number. CMS recently announced that, due to incorrectly formatted versions of the new form, the deadline for implementation of the new forms had been extended from the previously announced date of April 2, 2007, until June 1, 2007. Click here for more information and to view the corrected form.

NPIs may be obtained online at the National Plan and Provider Enumeration System (NPPES) website. If you prefer, you may also download and complete a paper application.

NPI applications are also available from the WVSMA office (304) 925-0342 ext. 11 or from NPPES at 1-800-465-3203.

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Aetna

Aetna encourages physician practices to utilize the Aetna website, www.aetna.com, which is available 24 hours a day, 7 days a week. The website contains both medical and patient information, including precertification status, claim checking status, formulary questions, and eligibility information. To sign up for these online services, visit www.aetna.com and register to receive your access code.

Aetna also reminds physicians that the paper referral forms are no longer accepted. All referrals must be submitted on the Aetna secure website or through the WebMD (now Emdeon) electronic referral system. Referrals are good for one year.

For faster reimbursement, Electronic Remittance and Electronic Funds Transfer are available to all physicians. Also, remember that the timely filing period for Aetna claims is 120 days.

Aetna has announced that it will terminate its contract with Laboratory Corporation of America (LabCorp) effective July 1, 2007.

The Aetna Provider Service Center (PSC) may be reached at 1-888-632-3862.

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BrickStreet

BrickStreet's Special Investigations Unit (SIU) has the responsibility of investigating all matters brought to its attention relating to fraud and abuse committed against BrickStreet policyholders. These matters may concern a claimant, a vendor or sometimes a policyholder. The mission of the SIU is to thoroughly investigate and accurately report all findings. Through the investigative process, the SIU hopes to ensure that all resources and benefits provided by BrickStreet for policyholders and their employees are for legitimate needs.

The SIU receives referrals from several sources. The most useful source of referrals comes from BrickStreet employees in our Claims Division. Through training and everyday experience, BrickStreet claims adjusters are astute at recognizing problems and reporting them to the SIU. The claims unit staff is the first line of defense when it comes to the fight against fraud and abuse. The SIU also receives referrals from the general public and policyholders through the fraud hotline: 1-866-926-3469 and the fraud e-mail address: reportfraud@brickstreet.com. The SIU will occasionally receive a referral by mail or walk-ins to the BrickStreet office.

The Special Investigations Unit investigates issues dealing with claimants, employers and medical providers. Examples of these cases range from claimants wrongfully seeking benefits or misrepresenting the extent of their injuries to the conduct of medical providers who prolong treatment patterns. The investigations that concern employers usually deal with underreporting employees and not paying the proper premium. Other cases include investigations where the employer has no coverage at all. West Virginia State Code mandates that BrickStreet report these matters to the West Virginia Insurance Commission for criminal review.

The main phone number for BrickStreet is 1-866-45BRICK and the website is www.brickstreet.com.

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Carelink/Coventry

Carelink has a new user-friendly secure provider site, www.directprovider.com, which may be used to view claims status, remittance advices, eligibility and/or benefit information. This service is free to Coventry healthcare providers. Claims may be viewed by status for any 30 day period, and searched by member name, claim number, or date range. Remittance advices may be searched by check or EFT (electronic funds transfer) number, member name and date of birth, payment date, date of service, claim number or member ID.

To register for this service, log onto directprovider.com and click "register" to fill out the online form. You will then be mailed a temporary password. To reach Directprovider.com's Customer Service, call 1-866-629-3975. The Carelink toll free number is 1-888-388-1744.

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Mountain State Blue Cross Blue Shield

Mountain State reminds physicians that the plan's credentialing standards require that participating physicians must be available to see MSBCBS members at least 16 hours a week. Appointment hours which are sufficient and convenient must be maintained by physicians.

Physicians must also have a means by which to respond to members and direct them to care after hours. Acceptable means of communication include an answering service, on-call beeper, call forwarding to physician's home or other location, written instructions provided to patients or a recorded telephone message with instructions.

A recorded phone message should also provide patients with options for care, such as calling 911 in case of an emergency, or visiting an urgent care center for non-emergencies, rather than simply stating "go to the emergency room".

If you have questions regarding MSBCBS policies or procedures, please contact the Provider Relations Department at 1-800-798-7768.

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PEIA

As of February 5, 2007, Acordia National, the TPA (Third Party Administrator) for PEIA, has changed its name to Wells Fargo TPA. In 2001, Acordia was purchased by Wells Fargo, but the name change did not occur until recently. Although the name has changed, the same staff will still be assisting you as they have done in the past.

The mailing address will remain the same, as will the phone number (1-888-440-7342) but the new web address has changed to www.wellsfargo.com/tpa.

PEIA recently announced that Coventry Health Care has been selected to manage the state's new Medicare Advantage program. Beginning July 1, 2007, Coventry will manage insurance coverage for the 35,000 Medicare-eligible retirees. PEIA plans to minimize changes in the transition to the managed care system.

The out of pocket expenses for retirees will cap at $500 and retirees do not have to switch prescription drug coverage to Medicare Part D at this time.

Immunization and vaccine claims for PEIA insurees have been pended since January 1, 2007 due to issues with the 2007 fee schedule. WVSMA contacted PEIA to raise the issue regarding a backlog of pended claims, PEIA reported they expect to have the fees sent to Wells Fargo by March 18^th so that the claims may be processed and reimbursement sent to physicians. PEIA has also assured physicians that no immunization claims should deny for timely filing due to the delay in pricing the vaccines.

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TRICARE

TRICARE provides access to comprehensive, affordable, quality health care services for active duty and retired members of the uniformed services, their families, survivors, and other eligible beneficiaries.

Health Net Federal Services, Inc. (Health Net) is the Government Operations Division of Health Net, Inc., which was the first company in the United States to develop comprehensive managed care programs for government agencies. For many years, Health Net has provided cost-effective, quality managed health care programs for government agencies. Health Net manages TRICARE standard and TRICARE Prime programs, while claims for TRICARE for Life claims are processed by Wisconsin Physicians Service (WPS) for uniformed services retirees, their spouses and survivors aged 65 and over. They also process claims for TRICARE disabled members.

Health Net's commitment to the TRICARE program is to provide high quality, cost effective managed care and assistance to all TRICARE beneficiaries.

TRICARE for Life, which processes claims for Medicare and those TRICARE members who are disabled, has been notified about an error with Medicare's paper remittance. When Medicare processes a claim, there is notification on the paper remittance the claim has been submitted to WPS and TRICARE for Life for secondary processing. Medicare has omitted this notification even though they are still submitting your claim to WPS and TRICARE for Life. If you have provided services to a TRICARE for Life beneficiary there is no need to resubmit the claim as it has been received electronically from Medicare. Allow thirty days for WPS to process the Medicare electronically submitted claim and if you do not receive a TRICARE for Life Explanation of Benefits, you can log on to www.TRICARE4u.com and check claim status or contact us at 1-866-773-0404.

The claims address for Health Net Federal Services is:

Health Net Federal Services, Inc.
c/o PGBA, LLC/TRICARE Claims
P.O. Box 870140
Surfside Beach, SC 29587-9740

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UniCare

UniCare has announced that they are simplifying some authorization practices on an interim basis. During this interim period, which will end on May 31, 2007, prior authorizations will not be required for certain common services for UniCare Medicaid and SCHIP patients, including the following services:

All radiology
Inpatient stays of one day
Out of Network specialty office visits
All oxygen
All nutritional counseling

Remember that this period of no authorizations required will end on May 31, 2007!

On a regular basis, UniCare does not require authorizations for Emergency room observation, nor are authorizations required for physical, occupational, or speech therapy. Routine maternity services also do not require authorization.

You can find prior authorization forms for the top 10 most popular provider authorization requests on the UniCare website, www.unicare.com. Click on Providers, then click on State Sponsored Plans under the heading Learn More. Click on West Virginia-Medicaid Managed Care, and then click on Prior Authorization Toolkit. The appropriate referral form may then be downloaded and completed.

UniCare is also using a new secure email encryption tool to ensure that members' protected health information (PHI) remains private and secure. UniCare sends an email to notify you that you have a secure email message to access at the portal (https://messages.antehmsecureemail.com/). When using the secure email portal for the first time, you will need to register and create a password protected account. You may also use the portal's Message Center to send encrypted emails to UniCare staff.

To contact UniCare Customer Care Center, you may call 1-800-782-0095. Unicare Provider Services may be reached by calling 1-800-611-9958.

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Unisys

Unisys and the Bureau for Medical Services (BMS) have scheduled Regional Training Sessions throughout the state. These training sessions will include instruction about NPI usage, Billing Instructions, Claim Check and NDC Requirements.

The sessions will begin at 8:30 AM and conclude at Noon and will be offered on the following dates:

Tuesday, March 27, 2007 Flatwoods (Days Inn)

Wednesday, March 28, 2007 Charleston (WVUPC Auditorium, CAMC Campus)

Thursday, March 29, 2007 Beckley (Tamarack)

Tuesday, March 29, 2007 Martinsburg (Holiday Inn)

Wednesday, March 30, 2007 Morgantown (Lakeview Resort)

Thursday, April 5, 2007 Wheeling (Wheeling Downs Conference Center)

For additional questions and registration, please call the Unisys Provider Relations Department at 1-888-483-0793.

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Medicare (Palmetto GBA)

Palmetto GBA is constantly updating their website in order to make it more "user friendly" for physicians and staff. A recent enhancement is designed to make the claim appeal process easier for physicians. The forms for Redetermination Requests (first level of appeal) and Qualified Independent Contractor (Reconsideration) Requests (second level of appeal, formerly "hearings") are now interactive.

Forms may now be directly accessed from the Palmetto GBA web site, completed electronically, printed, and then a paper copy may be submitted with your appeal requests. At this time, Palmetto is able to accept the forms via e-mail due to privacy concerns.

Click here to go to the Palmetto GBA website to obtain the form. To access the interactive forms, take the appeals shortcuts, select the needed form, and then click on "view attachment".

As a reminder, remember to sign the printed forms and submit with the associated documents. Unsigned forms and lack of documentation will cause further delay of payment.

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Palmetto GBA Ultimate Partnership Educational Event

The Palmetto Provider Outreach Committee has been working diligently to set up an Ultimate Partnership Educational Event for West Virginia. It is the first attempt to put together a seminar of this magnitude and they have elected to utilize Charleston Area Medical Center (Memorial Division) for the inaugural event. The Educational Seminar, to be held on Thursday, April 12, 2007, is open to physicians, residents, non-physician practitioners, compliance officers, office managers, billing and coding staff. The all day seminar will be held at the Robert C. Byrd Health Sciences Center Auditorium, 3100 MacCorkle Avenue, SE, Charleston, WV 25304. There is no charge for the seminar and the program has been approved by the Charleston Chapter of the AAPC for a total of 6.5 CEUs (attendance at all sessions required to receive CEUs).

This seminar will be offered in 5 different sessions over the day. The event is sponsored by Charleston Area Medical Center and presented by Palmetto GBA (West Virginia Medicare Carrier) staff.

The sessions for this unique event will include:

Evaluation/Management (E/M) documentation guidelines
Medical Necessity, usage of Medicare 25 modifier, and "Incident-to" Guidelines
Teaching Physician Guidelines
Non-Physician Practitioners: Scope and Guidelines
Medicare "Hot-on-the-Spot" Update: including information on clinical trials, preventive services, Medicare contracting reform, and National Provider Identifiers

The registration for this Ultimate Partnership Event, as well as the course schedule, is included below. Registration information is also available online at the Palmetto website. The deadline for registration is Wednesday, April 4, 2007. If you do not have Internet access, you may register for this event by faxing your registration form to 614-473-6812.

If you have any additional questions, you may contact Palmetto GBA at 1-877-567-9232. For faster service, select option 3 and then option 7.

Course	April 12, 2007
E/M for Physicians and Practitioners	7:00-9:00 AM
"MMI": Medical Necessity, Modifier 25, "Incident to" Guidelines	9:30 - 10:30 PM
Teaching Physician Guidelines	11:00 - 12:30 PM
Nonphysician Practitioners	1:45 - 3:15 PM
Medicare "Hot-on-the Spot" Update	3:30 - 4:30 PM

Medicare Part B Seminar Series

Course Description

*Course*	*Description*
E/M for Physicians and Practitioners	This two-hour course provides participants with an in-depth understanding of Medicare guideline for selecting and documenting the appropriate level of E/M code (e.g. office and hospital visits). The guidelines are industry standard and sanctioned by the AMA and CMS. Find out how your medical decision-making affects the level of service! Palmetto GBA clinical staff members will review documentation guidelines, practical examples, and utilization and error data for various specialties.
M.M.I.	This two-hour course is designed to address: Medical Necessity, beyond the world of E/M (CPT) Modifier 25 documentation guidelines "Incident to" guidelines and requirements
Nonphysician Practitioners	This ninety-minute course is designed to discuss the Medicare rules and the State Law allowances for the use of non-physician practitioners in the medical office setting.
Teaching Physician Guidelines	This one-hour thirty minute course will review: General documentation requirements, including signatures, presence, and supervision Teaching services payable under Part B E/M services and the Primary Care Exception Rule Surgical, high-risk, and complex procedures Assistant at surgery Diagnostic procedures Psychiatric procedures Time-based procedures Other complex procedures Maternity care
Medicare "Hot-on- the-Spot" Update	This one-hour course is designed to give participants an overview of the latest Medicare changes, hot issues, and timely reminders. Find out what you've been missing, and what's just around the corner! Topics will include: Clinical trials Preventive services Medicare contracting reform National Provider Identifiers (NPI)

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Volume III

March 16, 2007


	Inside this issue
	National Provider Identification (NPI) Reminder Aetna BrickStreet Carelink/Coventry Mountain State Blue Cross Blue Shield PEIA TRICARE UniCare Unisys Medicare (Palmetto GBA) Palmetto GBA Ultimate Partnership Educational Event


	Feedback Welcomed! The WVSMA wants to serve you, our physicians, to the best of our ability. If you have comments or suggestions about the WESGRAM Online, please feel free to contact us and let us know how we can improve. You may contact Barbara Good, Physician Practice Advocate, at (304) 925-0342, ext. 11, or via email Barbara@wvsma.com.