In July of 2008, the Medicare Improvements for Patients and Providers Act (MIPPA) was enacted. MIPPA placed new requirements on Special Needs Plans (SNPs), one of which is the transition of care requirement. Transition of care is defined as the movement of a member from one care setting to another as the member's health status changes. According to the third edition of Case Management: a Practical Guide for Education and Practice, transition of care is "the process of moving a member from one level of care to another. Another way of looking at transition of care is the act of handing off the responsibility for a member's care from one provider to another, from one care setting to another or from one level of care to another."
The purpose of the MIPPA requirement is to help better manage member transitions and prevent unplanned transitions. The National Committee for Quality Assurance (NCQA) also requires SNPs to have policies and procedures in place for transition of care. Some examples of transition of care situations are the following:

• Home to Hospital
• Hospital to Skilled Nursing Facility (SNF)
• Hospital to Swing Bed
• Home to Emergency Room (ER)
• Home to Customized Living
• SNF to Home
• Home to Inpatient Mental Health Facility

During a transition of care, the county case manager is responsible for the following:

• Providing consistent support to the member throughout the transition
• Identifying planned and unplanned transitions
• Communicating with the facility, providers, members, and/or responsible party about the transition process and changes in the member's health status and care needs
• Reaching out to the member after his/her return to the usual setting of care to prevent readmission or ER visits. This includes the following:
• Reviewing medication changes and making sure new prescriptions are filled
• Helping the member with durable medical equipment supplies
• Helping the member with follow-up appointments and transportation
• Understanding changes in the member's functional needs
• Increasing member knowledge and understanding of the disease process

The county case manager is also responsible for the following communications with the primary care provider and facility:

• Ensuring that all necessary information is provided to pertinent parties within one business day to make the transition as successful as possible
• Contacting the primary care provider/clinic to notify staff of the admission (if not involved in the admission); contacting the receiving facility
• Contacting the discharge planner to share what services are currently being provided and who is providing the services

The overall goal of the transition of care process is to reduce instances of fragmented or unsafe care and to reduce unnecessary readmissions. We hope that this process will assure that plan of care/transfer/discharge instructions are followed when members are transferred or discharged. If you have questions, contact Becki Pender, RN, CCP, Senior Care Manager at 1-320-335-5204, 1-888-588-4420 ext. 5204 (toll free), or becki.pender@primewest.org; or Elaine Carlquist, BSN, PHN, CCP, EW Senior Care Coordinator, at 1-320-335-5354, 1-888-588-4420 ext. 5354 (toll free), or elaine.carlquist@primewest.org; or Jennifer Bundy, RN, BSN, PHN, CCP Disability Care Coordinator at 1-320-335-5351, 1-888-588-4420 ext. 4420 (toll free), or jennifer.bundy@primewest.org.

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To view the latest Minnesota Department of Human Services (DHS) provider update on customized living (CL), please go to the DHS website and view provider update # 10-25-03.

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Authorization requirements for TENS (Transcutaneous Electrical Nerve Stimulator) Units are changing. Effective July 1, 2010, PrimeWest Health will require Service Authorizations for the purchase or rental of all TENS units. Service Authorization decisions are based on medical necessity. TENS Units are not medically necessary for the treatment of chronic low back pain, defined as low back pain from any cause lasting six weeks or more.

This change in authorization requirements is being made to align PrimeWest Health more closely with the Minnesota Department of Human Services' (DHS) authorization requirements. Please refer to the PrimeWest Health Provider Manual for more information.

Service Authorization requests should be faxed to PrimeWest Health's Utilization Management department at 1-866-431-0804 (toll free).

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For quality purposes, PrimeWest Health continually monitors the volume of calls to our Provider Contact Center. Findings indicate that there are more calls in the morning than late afternoon. To better serve you, effective June 1, 2010, the Provider Contact Center hours will be Monday - Friday, 8 a.m. - 4:30 p.m. This change will allow us to provide additional coverage during peak times. The Provider Contact Center number is 1-866-431-0802 (toll free).

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As part of the E3 initiative, PrimeWest Health is working toward reducing paper transactions. As a result, PrimeWest Health is only accepting provider Appeals that are sent via fax.

Please submit all Appeals to PrimeWest Health via fax to 1-320-335-5285. Appeals will not be considered unless they are submitted via fax. Your fax will be processed entirely on an electronic basis.

Thank you in advance for your cooperation. If you have any questions, please call the Provider Contact Center at 1-866-431-0802 (toll free).

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PrimeWest Health recently mailed a letter to primary care clinics asking site managers to complete an online access and accessibility survey. As a reminder, you will need to complete the survey for each individual primary care clinic site.

The survey is available on the DHS website from May 1 - May 31, 2010. Please complete this survey before May 31, 2010.

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The transition of General Assistance Medical Care (GAMC) members from PrimeWest Health to Fee for Service (FFS) Medicaid was effective April 1, 2010. If you receive calls from GAMC enrollees, you may refer them to the Minnesota Department of Human Services (DHS) Member Help Desk at 1-651-437-2670 or 1-800-657-3739 (toll free).

Chemical dependency (CD): Chemical dependency treatment for GAMC enrollees who were previously enrolled in PrimeWest Health will be covered under the Consolidated Chemical Dependency Treatment Fund (CCDTF). GAMC enrollees must use providers covered under the host county contracts to receive methadone treatment or other CD treatment services. Rule 25 assessments and placement authorizations (when the provider has a host county contract) done while the enrollee was a PrimeWest Health member will be honored under FFS.

There may be providers that participated in-network with PrimeWest Health that are not CCDTF providers. In these cases, the providers must also inform the GAMC enrollee that in order to retain public funding, the enrollee must transfer to a CCDTF provider.

Pharmacies: Work with prescribers and GAMC recipients to identify GAMC FFS covered products (GAMC FFS only covers drugs made by manufacturers who participate in the GAMC rebate program, which may differ from PrimeWest Health's drug coverage). Also work with prescribers and recipients to use preferred drug agents when appropriate.

Inpatient Hospital: For GAMC enrollees who are hospitalized prior to and remain hospitalized on or after April 1, 2010, PrimeWest Health will continue to be the payer that is billed for the stay. The member would show up as FFS in MN-ITS.

Please refer to DHS for MHCP Provider Updates as they become available.

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Recently, PrimeWest Health has received questions from Skilled Nursing Facility (SNF) providers asking if PrimeWest Health requires "shadow billing" for Minnesota Senior Health Options (MSHO)* members.

Shadow billing is not a PrimeWest Health requirement. However, shadow billing is a Centers for Medicare & Medicaid Services' (CMS) requirement for any member in a skilled inpatient SNF stay who has his/her Medicare coverage through a Medicare Advantage plan.

When a PrimeWest Health MSHO member is in a skilled level of care, in addition to submitting your claims for the skilled stay to PrimeWest Health for reimbursement, Medicare requires that a shadow bill be submitted to CMS. This allows CMS to track the days and deduct them from the 100-day SNF benefit period.

Claims for shadow bills must be submitted to CMS on a monthly basis. Once a member falls below a skilled level of care, these claims no longer need to be submitted to CMS.

Claims for shadow bills must be submitted as covered with a condition code 04, signifying the resident has an HMO.

When a resident falls below a skilled level of care, bill the last claim as a 214 or 211, with a 04 discharge status code.

You can find additional information on CMS billing requirements on the CMS website.

*PrimeWest Health's name for this program is PrimeWest Senior Health Complete (HMO)

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Minnesota Rural Health Conference, Leading Change for Rural Health, to be held June 28 and 29 in Duluth, Minnesota. Health care professionals, state and local policymakers, and students will gather for this two-day event to discuss how rural health care providers and communities can flourish in this time of change. The annual Minnesota Rural Health conference is a joint venture of the Minnesota Department of Health's Office of Rural Health and Primary Care, the Minnesota Rural Health Association, and the Rural Health Resource Center. You can read more about the conference and register via the Minnesota Department of Health's website.

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Effective May 15, 2010, PrimeWest Health will require Home and Community Based Service (HCBS) and Elderly Waiver (EW) claims to be submitted without an individual rendering provider on the claim. The only exception to this requirement is for Personal Care Assistance (PCA) claims.

The individual rendering provider section of the claim should remain blank for all claims for HCBS and EW services, except for PCA claims. For electronic claims, the individual rendering provider section of the claim is Loop 2310B, Segment NM109; for Office Ally and paper claims, it is box 24.

Claims for HCBS and Elderly Waiver services should be billed with only the billing (facility) provider information, including the correct National Provider Identifier (NPI) or Unique Minnesota Provider Identifier (UMPI) in the billing section. For electronic claims, the billing section is Loop 2010AA, Segment NM103; for Office Ally and paper claims, it is box 33.

Claims received on or after May 15, 2010, with rendering provider information entered will be denied.

If you have questions on this change to claim submission, please call the Provider Contact Center at 1-866-431-0802 (toll free).

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The Compliance Monitoring Division of the Minnesota Department of Health (MDH) and the Office of Emergency Preparedness released a memo on March 15, 2010, directed to Minnesota nursing homes concerning bed availability in the event of evacuation due to flood.

To learn more, you can go to the MDH web page on which this memo is posted or go directly to the memo.

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Rural Workforce Development Funding Opportunity
The federal Office of Rural Health Policy (ORHP) announced a new funding opportunity focused around Rural Workforce Development. This one-time funding opportunity will support the development of rural health networks that focus on activities relating to the recruitment and retention of emerging health professionals (students and residents). The program seeks to support a range of different approaches to community-based training and can include a focus either singularly or collectively on professions such as medicine, nursing, pharmacy and other allied health professions.

Approximately 20 awards are expected. The deadline to submit applications is April 20, 2010. Eligibility requirements are:

1. The applicant organization must be located in a rural area or in a rural census tract of an urban county, and all services must be provided in a rural county or census tract. Determine eligibility: http://datawarehouse.hrsa.gov/RuralAdvisor. OR
2. The applicant organization exists exclusively to provide services to migrant and seasonal farm workers in rural areas and is supported under Section 330G of the Public Health Service Act (documentation of status as a Section 330G Migrant and Seasonal Farm Workers organization must be uploaded as Attachment 10). These organizations are eligible regardless of the urban or rural location of the administrative headquarters. OR
3. The applicant is a tribal government whose grant-funded activities will be conducted within their federally-recognized tribal area
   

For further information, go to www.grants.gov, then click on Find Grant Opportunities, Basic Search and type in the funding opportunity number HRSA-10-193. The Office of Rural Health Policy will hold a technical assistance call on Thursday, April 1, 2010 at 2 p.m. Eastern Time to assist applicants in preparing their applications. The toll-free number is (800) 369-1914. The Passcode is Workforce. The Technical Assistance call will be recorded and available for playback within one hour of the end of the call and will be available until April 11, 2010. The phone number to hear the recorded call is 866-378-7476.

For further information, contact the program coordinator: Christina Villalobos at cvillalobos@hrsa.gov or (301) 443-3590.

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The billing requirements outlined below are effective for claims submitted on or after April 25, 2010.

Billing for members enrolled in PrimeWest Health Medicare-based programs

• Bill separately (multiple claims) for hospital and mental health unit.
• Use the hospital National Provider Identifier (NPI) for hospital claim(s) and the mental health unit NPI for mental health unit claim(s). This will ensure the correct Medicare/OSCAR (Online Survey, Certification and Reporting) number is used.
  

Billing for all other PrimeWest Health members

• Bill one claim, regardless of transfers (combine hospital claim[s] and mental health unit claim[s]).
• Use the hospital NPI only.
  

In all cases, the correct admit origin and discharge status should be used to indicate the internal transfer. PrimeWest Health Medical Administration should also be notified of the transfer.

• Phone: 1-866-431-0803 (toll free)
• Fax: 1-866-431-0804 (toll free)

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The "E3" initiative is a statutorily-mandated set of three electronic health care transaction requirements that went into effect in Minnesota at various times in 2009. PrimeWest Health is compliant with all three elements of the initiative.

Electronic submission of electronic data interchange (EDI) claims became mandatory on July 15, 2009. Paper claims are permitted for billing only in rare instances. Please refer to MN Stat. sec. 62J536 at www.revisor.mn.gov/statutes/?id=62J.536 to determine if your claim meets the eligibility requirements for exemption from mandatory EDI submission.

The requirements for submitting extra diagnosis codes (more than 4 diagnosis codes per claim) are described below.

EDI claims
For electronic claim submission using the 837P EDI formats, enter all relevant diagnosis codes in the appropriate diagnosis placeholder fields in the EDI template. It is not permissible, and would be considered a Health Insurance Portability and Accountability Act (HIPAA) violation, to submit this data in a field not designated for its specific purpose. Notes or comment fields are not valid for submitting diagnosis information. All diagnosis codes submitted via EDI must be entered in Loop 2300, Segment HI in order to be compliant.

Please check with your individual EDI clearinghouse to ensure their system allows additional diagnosis codes.

Paper claims
Effective with claims received on or after April 20, 2010, PrimeWest Health will no longer recognize additional diagnosis codes added to box 19 of the paper CMS-1500 claim form. Instead, additional diagnosis codes must be submitted as attachment information, following PrimeWest Health's instructions for indicating and submitting attachments via electronic means. Please review Chapter 4 of our Provider Manual for instructions on submitting attachments.

If you have questions, about this requirement, please call the Provider Contact Center at 1-866-431-0802 (toll free).

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PrimeWest Health allows vision care providers to select eyewear for a PrimeWest Health member from any optical laboratory the provider normally works with. Vision care providers are not required to work with any specific State-contracted laboratory in order to serve PrimeWest Health members.

Providers must bill PrimeWest Health their usual and customary charge for their services. PrimeWest Health will pay the amount billed or the maximum allowable, whichever is lower.

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PrimeWest Health has always required notification of inpatient admissions, including swing bed admissions. Effective March 15, 2010, PrimeWest Health will require electronic submission of the Swing Bed Notification Form. The Swing Bed Notification Form replaces the existing MSHO Communication Form. The Swing Bed Notification Form must be submitted electronically through the PrimeWest Health website before a member transitions from acute care to swing bed status. Eligibility should be verified before services are rendered and as needed after that.

PrimeWest Health will only apply Medicare Swing Bed Admission Criteria to determine swing bed medical necessity; however there may be additional questions on the Swing Bed Notification Form and all blanks on the form must be completed. All Swing Bed Notification Forms will be reviewed on a retrospective basis to ensure appropriate swing bed utilization. Failure to meet Medicare Swing Bed Admission Criteria may result in non-payment. A Service Authorization does not guarantee payment if medical necessity is not met.

SUBMITTING THE SWING BED NOTIFICATION FORM
Critical Access Hospitals ONLY

• Online
  The Swing Bed Notification Form will be located on the PrimeWest Health website at https://www.primewest.org/apps/swingbedauditform. This form should be filled out online and submitted to PrimeWest Health using the "submit" button. Please note, this form will not be available until March 15, 2010.

UPDATING SNF BED AVAILABILITY
SNFs ONLY

• Online
  For SNFs, PrimeWest Health will provide the SNF Bed Availability site at http://www.primewest.org/apps/snfbeds/snfbedsadmin/. PrimeWest Health will send your facility a login to use when updating your facility's SNF bed availability. For instructions on how to update your facility's SNF bed availability, visit our "How-to" on the PrimeWest Health website at http://www.primewest.org/apps/HowTo/UpdateSNFBedAvailability.aspx. Please note, the SNF Bed Availability site will not be available until March 15, 2010.

SPECIAL NOTE: PrimeWest Health care coordination staff members are available to help with any questions regarding transition from inpatient to swing bed status. Prompt notification of a pending or planned change in member status from inpatient to swing bed will help the process and ensure that members receive appropriate and necessary care. If you would like assistance coordinating this transition of care, please call PrimeWest Health clinical administration staff at 1-866-431-0803 ext. 5204 (toll free), Monday – Friday, 8 a.m. – 4:30 p.m. If you call after normal business hours, leave a message and a care coordinator will return your call as soon as possible.

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Effective March 1, 2010 PrimeWest Health will be following DHS and will require telemedicine services (99499) to be submitted with the HK modifier. The HE modifier for these services will no longer be valid after this date.

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Effective for dates of service beginning January 1, 2010, PrimeWest Health, following Medicare guidelines, will no longer recognize Current Procedural Terminology (CPT) consultation codes for office/outpatient settings (CPT codes 99241 - 99245) or inpatient consultation codes(CPT codes 99251 - 99255). This applies to Medicare-covered services only. Telehealth consultation G codes will not be affected by this change, and PrimeWest Health will continue accepting consultation codes for Medicaid-covered services.

For additional information, please refer to Medicare Learning Network (MLN) Matters article MM6740.

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PrimeWest Health is following the Minnesota Department of Human Services' (DHS) code changes for Adult Mental Health Crisis Services.
Please see DHS provider update MHS-09-01 for additional information.

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The Minnesota Department of Human Services (DHS) is offering a training video conference to answer questions and address concerns that prospective applicants have on the 2011 Community Services and Community Services Development (CS/SD) Request for Proposal (RFP). Click here to learn more.

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Click here for more information.

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(published in PrimePointers, January/February 2009 issue)

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(PDF - PW_2010_026)

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click here for more information.

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Effective February 20, 2010, when a PrimeWest Health member leaves the hospital against medical advice (AMA) within the initial hours after an inpatient hospitalization admission, any services that have been provided to the member should be billed as outpatient services.

Please refer to chapter 13 of the PrimeWest Health Provider Manual for additional information.

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Please keep the following in mind when submitting fitting codes (dispensing fees):

• Fitting codes 92340 - 92342 should only be included on the claim when billing for a complete set of glasses (frame and two lenses)
• Claims for lenses only or replacement of frames (V2020 or V2025 with the RA modifier) cannot be billed with a fitting code 
• Fitting code 92370 should be used when billing for repair of frames (V2020 or V2025 with the RB modifier)

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PrimeWest Health providers can now check eligibility using Emdeon Office (formerly WebMD) through the Emdeon clearinghouse. Through this service, providers can transmit and view information regarding PrimeWest Health member eligibility, including benefits and copay information. If your office would like more information on Emdeon products, please contact Emdeon at 1-866-369-8805 (toll free) or http://www.emdeon.com/.

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PrimeWest Health is following the Centers for Medicare & Medicaid Services' (CMS) requirement for dispensing supplies or accessories. Per CMS:

A beneficiary or their caregiver must specifically request refills of supplies before they are dispensed. The supplier must not automatically dispense a quantity of supplies on a predetermined basis, even if the beneficiary has "authorized" this in advance. As referenced in the Medicare Program Integrity Manual (Internet-Only Manual, CMS Pub. 100-8, Chapter 4.26.1) "Contact with the beneficiary or designee regarding refills should take place no sooner than approximately 7 days prior to the delivery/shipping date. For subsequent deliveries of refills, the supplier should deliver the DMEPOS product no sooner than approximately 5 days prior to the end of usage for the current product."

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Pursuant to MN Stat. sec 62J.536, the Minnesota Administrative Uniformity Committee (AUC) adopted standards for the Minnesota Uniform Companion Guide for the Implementation of the Health Care Claim Payment and Remittance Advice Electronic Transaction (the "Guide"). As part of the AUC standards, all providers in the state of Minnesota should prepare to receive remittance advices electronically by December 15, 2009. More information...

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Please see the DHS provider update DEN-09-01 for dental coverage limitations and policy changes that are effective beginning January 1, 2010.

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Effective January 1, 2010, porcelain crowns will no longer be covered

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Effective January 1, 2010, anti-scratch coating for eye glasses will no longer be covered

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The RP modifier has been discontinued as of 1/01/2009.

For dates of service (DOS) on or after 1/01/2009:

• Bill replacement frame or lenses using the appropriate frame or lens code with modifer RA.  Do not bill a dispensing code for repairs or replacement of just the frame or lenses.
• Bill repairs to frames using V2020 with modifier RB.
• Bill dispensing fees only for a complete set of frame & lenses.

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Based on a decision by the 2009 Minnesota Legislature, changes to the Personal Care Assistance (PCA) program affecting access, assessment, and authorization will go into effect January 1, 2010. All PCA service recipients who are not on a waiver program must be reassessed using the new criteria.
Providers are responsible for submitting the PCA referral form (DHS-3324P) to the lead agencies 60 days before the end of the service agreement. In addition, providers are responsible for coordinating changes to the PCA Care Plan with the PrimeWest Health member based on the new assessment.
Detailed information regarding the reassessment schedule, Service Authorizations, and links to multiple resources about the PCA 6-Month Reassessment Project can be found on the PCA page of the Minnesota Department of Human Resources (DHS) website or in DHS Bulletin #09-56-02.

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