Prior Authorization Announcements and News

Please be advised of a new schedule of more Webinar trainings on the APS CareConnection (C3) system. APS is almost finished implementing all review areas for WV Medicaid prior authorization for medical services into the C3 system. Due to this, APS is now available to offer more training, in response to requests they have received from several providers. You can access a complete schedule of training sessions. Please look at all of the dates and choose which dates are more suitable for you. You can attend as many as you would like. Attendance is on a first come, first serve basis, and each meeting can only hold 150 attendees. You can also access instructions on how to logon to the webinars. Please see the instructions with no meeting number. You do not need a meeting number in order to logon.

Attention all orthotics/prosthetics providers:
Please see your section of trainings. The very last week, starting Tuesday, May 28, 2013, is for Orthotic and Prosthetic providers only. APS will soon be ready for you to begin exclusive use of the APS CareConnection system and would like to provide training now. APS will keep you posted of the actual date that you will begin use of the system.

APS thanks you for your time, for your patience, and for your attention to this matter. As always, if you need further information, and/or assistance regarding the trainings, or have any questions, comments, or concerns, please do not hesitate contact APS at wvmedicalservices@apshealthcare.com or 1-800-346-8272.

Reference this screen capture which indicates where to find determinations in C3

Please view the following information and screen captures related to radiology requests.

From the afternoon of Friday, May 24, 2013, through Tuesday morning, May 28, 2013, https://c3wv.apshealthcare.com and https://providerportal.apshealthcare.com WILL BE UNAVAILABLE.

While we apologize for any inconvenience this downtime may cause, this downtime is necessary for system maintenance and within industry standards. THIS SYSTEM WILL BE UNAVAILABLE THROUGHOUT THE MEMORIAL DAY WEEKEND. To accommodate providers who operate in a 24/7 setting—any request with a Service Start Date (SSD) between May 24, 2013 and May 27, 2013 will be accepted as WITHIN TIMELINES FOR PRIOR AUTHORIZATIONS IF THE REQUEST IS SUCCESSFULLY SUMBITTED BY MAY 31, 2013.

Any request with a SSD of 5/28/13 or thereafter will need to be submitted timely and any request with a SSD PRIOR to 5/24/13 will be considered a retrospective request and treated accordingly. Please be sure to submit any requests with a SSD PRIOR to 5/24/13 by 12:00PM EST on 5/24/13 to avoid failure to obtain PA because the request is out of timelines.

From the afternoon of Friday, May 24, 2013, through Tuesday morning, May 28, 2013, the HTTPS://C3.APSHEALTHCARE.COM WV Nursing Home PAS web application will be fully unavailable for submissions, application reviews (Level I & II) and determinations. We apologize for any inconvenience that this interruption may cause—this scheduled downtime is necessary for system maintenance.

If you anticipate the need to submit a WV PAS application and to have it fully processed for nursing home placement during the downtime, we ask that you realize the medical review of applications will not resume until Tuesday morning plus the full review period allowable by the Bureau for Medical Services may be necessary to process each application. The review periods are as follow:
• Level I: 2 Business Days
• Level II: 7-9 Business Days

Attention Providers: All requests for procedures that result in sterilization require a copy of the consent to be attached to the request. You may attach this information, to the record, if submitting electronically. Providers who are unable to attach, but choose to submit the remainder of the review electronically should fax a copy of the consent to WVMI, and note this in the electronic submission.

Providers submitting their request via fax or mail should include a copy of the consent with the request. Failure to provide this information will result in a delay in processing of the request.

Leniency on timeframes in the c3 system ends April 12, 2013. At that time, APS Healthcare and WVMI will enforce the Bureau for Medical Services’ (BMS) policy regarding timely submissions. Therefore, as of 04/12/2013, DME providers will be required to submit prior authorization requests prior to providing the supply or service either on the new fax form or via the c3 system. These are per BMS requirements. Requests sent in after the timeframes will be denied for the BMS Retro Policy.

Access the request form, the Certificate of Medical Necessity (CMN), and also Frequently Asked Questions (FAQs).

If you have any questions, comments, or concerns, please feel free to call us at 1-800-346-8272, or email us at wvmedicalservices@apshealthcare.com.
Thank you for your time and your attention to this matter.

Effective April 29th, an APS-WVMI cost invoice calculation form will need to be completed for all un-priced codes and submitted with an unaltered cost invoice. Beginning on this date, WVMI will no longer accept cost invoices submitted without this form.

As many of you know, there is a new way to request prior authorizations for Medicaid members. This direct data entry system, c3, was made available on February 11, 2013 to all West Virginia Medicaid-enrolled providers. If you are currently registered with APS Healthcare, that is great. If you are not, we ask that you contact APS at: 1-800-346-8272 or wvmedicalservices@apshealthcare.com for registration materials.

The last day to use WVMI’s fax forms is March 31, 2013. As of April 01, 2013, you will be required to either directly enter your prior authorization requests into the c3 system or use the new fax form located on WVMI’s website. If you send in the old fax form after this date it will be faxed back to you without review. 

Please note: The Bureau for Medical Services requires that all Radiology/Imaging requests, whether entered in c3 or faxed in, MUST include the physician’s order. If you send in any request WITHOUT THE PHYSICIAN’S ORDER, the request will be pended for two days, giving you time to fax it in. If you do not fax in the order within that time frame, your request will be closed and you will be required to resubmit your request.

Downoad the most up-to-date outpatient surgery code list, with group codes. It has been formatted properly and can be used to determine if a code needs a prior authorization. Any procedure code that is NOT on the list does not need to prior authorized. If you have any questions, comments, or concerns, please contact APS either by phone at 1-800-346-8272, or by email at wvmedicalservices@apshealthcare.com. 

As many of you know, there is a new way to request prior authorizations for Medicaid members. This direct data entry system, c3, was made available on March 04, 2013 to all West Virginia Medicaid-enrolled providers. However, because of limited registration and feedback from providers, we have extended our registration period through the end of March. Therefore, we ask that all Orthotics and Prosthetics providers continue to request prior authorizations the way you always have until we announce your new “Go-Live” date in our c3 computer system. If you are currently registered with APS Healthcare, that is great. If you are not, we ask that you contact APS Healthcare at: 1-800-346-8272 or wvmedicalservices@apshealthcare.com for registration materials.

APS Healthcare will send updated information out as it is made available and once all O&P providers are registered. This information will include additional webinars and trainings as well as the new Go-Live date where you will be asked to start inputting your prior authorization requests into the c3 system.

Please feel free to contact APS Healthcare with any questions you may have. Thank you for your patience.

Effective March 4, 2013, DME and O&P Providers will be permitted to input WV Medicaid Prior Authorization Requests electronically—this method is commonly referred to as DDE (direct data entry)—on the APS CareConnection® (C3) web-portal. Faxed requests will also be accepted and processed. The updated Prior Authorization Request Forms for C3 will be made available to providers just before the “go-live” date.  Read the attached welcome announcement for more information.

West Virginia Medicaid Lab, and/or Radiology Providers: Please click here for an important announcement from APS Healthcare concerning inputting WV Medicaid Prior Authorization Requests electronically and upcoming training sessions sponsored by APS Healthcare.
 

Effective Monday, January 21, 2013, no phone reviews will be performed for authorization requests for Outpatient Surgery except for cases which are considered medically urgent.
Medically urgent is defined as: 

• A delay could seriously jeopardize the life or health of the consumer or,
• The ability of the consumer to regain maximum function or
• In the opinion of a physician with knowledge of the consumer’s medical condition, would subject the consumer to severe pain that cannot be adequately managed without the care or treatment that is the subject of the case.

Effective Monday, February 11, 2013, no phone reviews will be performed for imaging authorization requests except for cases which are considered medically urgent. Medically urgent is defined as: 

• A delay could seriously jeopardize the life or health of the consumer or,
• The ability of the consumer to regain maximum function or
• In the opinion of a physician with knowledge of the consumer’s medical condition, would subject the consumer to severe pain that cannot be adequately managed without the care or treatment that is the subject of the case.

APS Healthcare, the prime Utilization Management Contractor (UMC), for prior authorization of West Virginia Medicaid Medical and Behavioral Health services, in conjunction with subcontractor WVMI, would like to inform you of the following important information:

• Effective January 21, 2013, Outpatient Surgery Providers will be permitted to input WV Medicaid Prior Authorization Requests electronically—this method is commonly referred to as DDE (direct data entry)—on the APS CareConnection® (C3) web-portal. Faxed requests will also be accepted and processed. The updated Prior Authorization Request Forms for C3 will be made available to providers just before the “go-live” date.
   
• Either means of submission, DDE or Fax, will require each Molina enrolled WV Medicaid Provider/Group to register/enroll independently online at the C3 Self-Enrollment Portal. You may begin C3 registration/enrollment at any time by accessing the following web-portal: https://c3wv.apshealthcare.com.

• Regardless of submission method, all determinations for prior authorization requests will be available exclusively online. Verbal and/or faxed confirmations will be phased out upon the “go-live” date referenced above.
   
• Outpatient Surgery services will be reviewed by West Virginia Medical Institute (WVMI) under the existing BMS Manual and criteria.
   
• Ten web-training sessions have been scheduled and devised to assist with the self-enrollment process, as well as with technical assistance in regards to DDE and determination retrieval. Registration for the sessions listed below is not required.

TRAINING SESSION ONE:
APS WV CareConnection Medical Prior Authorization Technical Training for
Outpatient Surgery Services
Meeting Location: https://apshealthcare.webex.com
Date:   Monday, January 7, 2013
Time: 11:00 am, Eastern Standard Time
(This meeting does not require a meeting number or password.)
Audio is a separate function.
Please call 1.888.242.1836
Use Access Code 8489942

TRAINING SESSION TWO:
APS WV CareConnection Medical Prior Authorization Technical Training for
Outpatient Surgery Services
Meeting Location: https://apshealthcare.webex.com
Date: Tuesday, January 8, 2013
Time: 1:00 pm, Eastern Standard Time
(This meeting does not require a meeting number or password.)
Audio is a separate function.
Please call 1.888.242.1836
Use Access Code 8489942

TRAINING SESSION THREE:
APS WV CareConnection Medical Prior Authorization Technical Training for
Outpatient Surgery Services
Meeting Location: https://apshealthcare.webex.com
Date: Wednesday, January 9, 2013
Time: 1:00 pm, Eastern Standard Time
(This meeting does not require a meeting number or password.)
Audio is a separate function.
Please call 1.888.242.1836
Use Access Code 8489942

TRAINING SESSION FOUR:
APS WV CareConnection Medical Prior Authorization Technical Training for
Outpatient Surgery Services
Meeting Location: https://apshealthcare.webex.com
Date: Thursday, January 10, 2013
Time: 10:00 am, Eastern Standard Time
(This meeting does not require a meeting number or password.)
Audio is a separate function.
Please call 1.888.242.1836
Use Access Code 8489942

TRAINING SESSION FIVE:
APS WV CareConnection Medical Prior Authorization Technical Training for
Outpatient Surgery Services
Meeting Location: https://apshealthcare.webex.com
Date: Friday, January 11, 2013
Time: 2:00 pm, Eastern Standard Time
(This meeting does not require a meeting number or password.)
Audio is a separate function.
Please call 1.888.242.1836
Use Access Code 8489942

TRAINING SESSION SIX:
APS WV CareConnection Medical Prior Authorization Technical Training for
Outpatient Surgery Services
Meeting Location: https://apshealthcare.webex.com
Date:   Monday, January 14, 2013
Time: 11:00 am, Eastern Standard Time
 (This meeting does not require a meeting number or password.)
Audio is a separate function.
Please call 1.888.242.1836
Use Access Code 8489942

TRAINING SESSION SEVEN:
APS WV CareConnection Medical Prior Authorization Technical Training for
Outpatient Surgery Services
Meeting Location: https://apshealthcare.webex.com
Date: Tuesday, January 15, 2013
Time: 1:00 pm, Eastern Standard Time
(This meeting does not require a meeting number or password.)
Audio is a separate function.
Please call 1.888.242.1836
Use Access Code 8489942

TRAINING SESSION EIGHT:
APS WV CareConnection Medical Prior Authorization Technical Training for
Outpatient Surgery Services
Meeting Location: https://apshealthcare.webex.com
Date: Wednesday, January 16, 2013
Time: 1:00 pm, Eastern Standard Time
(This meeting does not require a meeting number or password.)
Audio is a separate function.
Please call 1.888.242.1836
Use Access Code 8489942

TRAINING SESSION NINE:
APS WV CareConnection Medical Prior Authorization Technical Training for
Outpatient Surgery Services
Meeting Location: https://apshealthcare.webex.com
Date: Thursday, January 17, 2013
Time: 10:00 am, Eastern Standard Time
(This meeting does not require a meeting number or password.)
Audio is a separate function.
Please call 1.888.242.1836
Use Access Code 8489942

TRAINING SESSION TEN:
APS WV CareConnection Medical Prior Authorization Technical Training for
Outpatient Surgery Services
Meeting Location: https://apshealthcare.webex.com
Date: Friday, January 18, 2013
Time: 2:00 pm, Eastern Standard Time
(This meeting does not require a meeting number or password.)
Audio is a separate function.
Please call 1.888.242.1836
Use Access Code 8489942

Message to Providers for Registration
If you provide and get paid for outpatient surgery services for WV Medicaid members, please keep reading. The way you request prior authorizations for dental and orthodontic services will be changing soon. You will still be able to mail and fax in your requests, but soon you will be able to enter your requests into the computer. This decreases review time and errors!

IRG d/b/a APS Healthcare, the primary Utilization Management Contractor (UMC) for all WV Medicaid Prior Authorization services, in conjunction with their subcontractor, WVMI, would like to inform you of some very important upcoming information. The scheduled “Go-Live” date for Prior Authorization Requests in the new CareConnection® (C3) direct data entry web-portal is January 21, 2013.

WV Medicaid Providers are required to register in C3 prior to the scheduled “Go-Live” date.  You must complete the following steps:

• Self-Enroll/Register on the Production Site
  • https://c3wv.apshealthcare.com                
• Upon registering, you must print, sign, and fax a hard-copy of the required Provider Portal Signature Page to 1-866-209-9632. (See Attached)
• Successfully link all “WV Medicaid Molina Enrolled Providers” to your registered organization
• Receive full access to the production site via email from APS Healthcare

For in-the-moment assistance, in regards to self-enrollment, training sessions, prior authorizations, please feel free to direct your questions, comments, or concerns to APS Healthcare. You may contact us by phone: 1-800-346-8272, or by email: wvmedicalservices@apshealthcare.com.

Leniency on timeframes in the c3 system ends January 21st. At that time, APS Healthcare and WVMI will enforce the Bureau for Medical Services’ (BMS) policy regarding timely submissions.

The attached BRCA Codes are now covered by BMS effective from April 1, 2012. Providers who need to request this service prior to laboratory services being available in the APS Medical CareConnection(r) system (slated for February 2013) may contact APS at 1-800-378-0284 for instructions on submitting a request.

APS Healthcare, the prime Utilization Management Contractor (UMC), for prior authorization of West Virginia Medicaid Medical and Behavioral Health services, in conjunction with subcontractor WVMI, would like to inform you of the following important information:

• Effective December 17, 2012, Dental Providers will be permitted to input WV Medicaid Prior Authorization Requests electronically—this method is commonly referred to as DDE (direct data entry)—on the APS CareConnection® (C3) web-portal. Faxed requests will also be accepted and processed. The updated Prior Authorization Request Forms for C3 will be made available to providers just before the “go-live” date.
• Either means of submission, DDE or Fax, will require each Molina enrolled WV Medicaid Provider/Group to register/enroll independently online at the C3 Self-Enrollment Portal. You may begin C3 registration/enrollment at any time by accessing the following web-portal: https://c3wv.apshealthcare.com.
• Providers are asked to self-enroll on the C3 system prior to December 17, 2012, to avoid any interruption in services.
• Regardless of submission method, all determinations for prior authorization requests will be available exclusively online. Verbal and/or faxed confirmations will be phased out upon the “go-live” date referenced above.
• Dental services will be reviewed by West Virginia Medical Institute (WVMI) under the existing BMS Manual and criteria.
• Ten web-training sessions have been scheduled and devised to assist with the self-enrollment process, as well as with technical assistance in regards to DDE and determination retrieval. Registration for the sessions listed below is not required.

Please download the attached PDF for complete information about the training sessions.

Effective December 3, 2012, WVMI will begin using the InterQual 2012 Interim Updated Criteria.

Due to the array of concerns, questions, and requests for additional training options, in respect to the implementation of WV Medicaid Prior Authorizations into CareConnection® (C3 Provider Portal), APS in conjunction with subcontractor WVMI, will DELAY the October 1, 2012, implementation of direct data entry (DDE) for prior authorizations into the electronic system.

To adequately address the providers’ concerns that have been brought to our attention, the dental trainings scheduled for Thursday, September 27, 2012, 9:30 a.m. and 1:30 p.m., will both be rescheduled for a later date, yet to be determined.

Effectiv October, 1, Dentists, home health, and hospice Providers will be permitted to input WV Medicaid Prior Authorization Requests electronically—this method is commonly referred to as DDE (direct data entry).  The following three memos cointain more information:

Welcome Announcement for Dentists
Welcome Announcement for HH
Welcome Announcement for Hospice


 

The new Private Duty Nursing Manual can now be accessed at the following link:

http://www.dhhr.wv.gov/bms/Documents/Chapter532PDNS.pdf

Greetings WV Medicaid Private Duty Nursing Providers!

APS Healthcare, the prime Utilization Management Contractor (UMC), for prior authorization of West Virginia Medicaid Medical and Behavioral Health services, in conjunction with subcontractor WVMI, would like to inform you of the following important information:

• Effective September 17, 2012, Private Duty Nursing Providers will be permitted to input WV Medicaid Prior Authorization Requests electronically—this method is commonly referred to as DDE (direct data entry)—on the APS CareConnection® (C3) web-portal. Faxed requests will also be accepted and processed. The updated Prior Authorization Request Forms for C3 will be made available to providers just before the “go-live” date.
• Either means of submission, DDE or Fax, will require each Molina enrolled WV Medicaid Provider/Group to register/enroll independently online at the C3 Self-Enrollment Portal. You may begin C3 registration/enrollment at any time by accessing the following web-portal: https://c3wv.apshealthcare.com.

• Regardless of submission method, all determinations for prior authorization requests will be available exclusively online. Verbal and/or faxed confirmations will be phased out upon the “go-live” date referenced above.
• Private Duty Nursing services will be reviewed by West Virginia Medical Institute (WVMI) under the existing BMS
  Manual and criteria.
• Two web-training sessions have been scheduled and devised to assist with the self-enrollment process, as well as with technical assistance in regards to DDE and determination retrieval. Registration for the sessions listed below is not required. 

Greetings WV Medicaid Vision Providers!

APS Healthcare, the prime Utilization Management Contractor (UMC), for prior authorization of West Virginia Medicaid Medical and Behavioral Health services, in conjunction with subcontractor WVMI, would like to inform you of the following important information:

• Effective September 17, 2012, Vision Providers will be permitted to input WV Medicaid Prior Authorization Requests -FOR OUTPATIENT NON-SURGICAL SERVICES (CODES: 92019, 92065, 92326) ONLY -electronically—this method is commonly referred to as DDE (direct data entry)—on the APS CareConnection® (C3) web-portal. Faxed
  requests will also be accepted and processed. The updated Prior Authorization Request Forms for C3 will be made available to providers just before the “go-live” date.
• Either means of submission, DDE or Fax, will require each Molina enrolled WV Medicaid Provider/Group to register/enroll independently online at the C3 Self-Enrollment Portal. You may begin C3 registration/enrollment at any time by accessing the following web-portal: https://c3wv.apshealthcare.com.

• Regardless of submission method, all determinations for prior authorization requests will be available exclusively online. Verbal and/or faxed confirmations will be phased out upon the “go-live” date referenced abo
• Vision services will be reviewed by West Virginia Medical Institute (WVMI) under the existing BMS Manual and criteria.
• Two web-training sessions have been scheduled and devised to assist with the self-enrollment process, as well as with technical assistance in regards to DDE and determination retrieval. Registration for the sessions listed below is not required.

• Upon registering you should read the CareConnection® Overview & Enrollment Guide and or Self-Registration Process Instructions (Please contact APS Healthcare by telephone or email to obtain a copy of these materials. Our contact information is listed below.)
• After reading the guide, you must print, sign, and fax a hard-copy of the required Provider Portal Signature Page (See attachment Section R on page 26)
• Successfully link all “WV Medicaid Molina Enrolled Providers” to your registered organization
• Receive full access to the production site via email from APS Healthcare
• Access the WV Medical CareConnection User Guide, prior to “going-live” at the following URL: http://www.wvmi.org/Medicaid-Documents/PriorAuthTraining/WV-C3-Provider-Portal-Manual-For-Providers-v-10-22.aspx 

In preparation for the pending release (currently scheduled for late September/early October) of the updated Occupational/Physical Therapy Services Chapter (515), changes have been made to the APS C3 direct data entry provider portal screens as well as the hardcopy fax forms devised for PT/OT prior authorization requests. However, until Chapter 515 is released, you may continue to use the application/means of submission that are currently in place at your location—meaning if you are currently utilizing the WVMI form or C3 DDE/Forms, please carry on until further notice.

Please remember that self-enrollment is required to utilize C3 (DDE or Fax)—you may access this electronic process at any juncture: https://c3wv.apshealthcare.com/

For in-the-moment assistance, in regards to these changes, self-enrollment, training sessions, or prior authorizations in general, please feel free to direct your questions, comments, or concerns to APS Healthcare. You may contact us by phone: 1-800-346-8272, or by email: wvmedicalservices@apshealthcare.com.

We look forward to working with each of you and will help in any way possible to ensure a smooth transition process.

The Bureau for Medical Services Office of Facility Based and Residential Care is revising the following CPT (procedure codes) reimbursement methodology.

The codes below will no longer be reimbursed after 11/01/2012 in any outpatient facility setting.

Please remove the following CPT Codes from Outpatient Hospital and Ambulatory Surgical Center contracts:

On  AUGUST 2, 2012 a number of  updates, changes and corrections to the APS Medical CareConnection® (C3) Direct Data Entry (DDE) system utilized for West Virginia Medicaid Medical Prior Authorization requests will be available—this will impact both the provider portal https://providerportal.apshealthcare.com and the registered organization’s administrative portal https://c3wv.apshealthcare.com.
 
The changes are organized into GENERAL changes that affect all providers currently using C3 and changes SPECIFIC to current provider groups that utilize C3. Those providers are: 

• Acute Inpatient providers and physicians requesting inpatient admissions for WV Medicaid members
• Medical Rehabilitation<21 providers
• Cardiac and Pulmonary Rehabilitation providers
• Speech and Audiology and Chiropractic providers
• PT/OT providers currently using the C3 system MAY CONTINUE to use the WVMI legacy system until a firm implementation date is established by BMS for release of the updated manual (see below for specific details) 

NOTE: If your provider type is not listed then there are no specific changes for your group.
 
The following GENERAL changes will be implemented for ALL submitting provider types:

• Performance upgrades (to improve speed);
• Notes/attachments not saving;
• Server error messages on searches and after performing other functions;
• Actions/buttons becoming disabled after certain actions were performed;
• Reconsideration requests for PROVIDERS are now limited to 2: Peer-to-Peer and Reconsideration—if reconsideration is initially requested peer-to-peer becomes unavailable;
• After Member Search all member coverages are displayed-provider must select the Medicaid ID they wish to create the request under AND which will be contained in the prior authorization sent to Molina. Medicaid Id’s beginning with “19” are for BHHF Charity Care and are not for medical requests- if a “19’ number is selected in error it will be closed and a message will be sent to the provider on the Summary and Submit page indicated the request must be resubmitted with the appropriate Medicaid ID. The provider should note the date the original request was submitted and that the “19” number was selected in error to avoid denial for out of timelines;
• For retrospective request the choice: unknown eligibility at time of admission has been removed;
• Organization Manager functions becoming unavailable in some cases with the introduction of the Provider Portal

The following changes will be implemented for SPEECH AND AUDIOLOGY providers ONLY:

• For members under age<21 a question has been added regarding whether the member has an IEP;
• Addition related to certificate of medical necessity.

The following changes will be implemented for PT/OT providers ONLY:

IMPORTANT NOTICE: C3 has now been configured to accept requests related to the NEW PT/OT manual. FOR THIS REASON beginning August 1, 2012 it will be necessary to utilize the WVMI legacy system OR ONLY CHOOSE ESTABLISHED PATIENT in C3. The WVMI legacy system is configured to the CURRENT manual and APS has configured the C3 environment to accommodate many of the requirements of the NEW PT/OT manual. At this time it appears that this manual will go into effect in mid-September 2012. Until the manual becomes effective PER BMS APPROVAL prior authorizations issued for PT/OT in C3 will not successfully post at Molina if ESTABLISHED PATIENT IS NOT SELECTED. 
 
The subsequent items listed are some of the features that are now in the C3 environment (or will be added through the month of August) to accommodate the NEW MANUAL—CHAPTER 515: COVERED SERVICES, LIMITATIONS, AND EXCLUSIONS FOROCCUPATIONAL/PHYSICAL THERAPY SERVICES:

• Return to a single authorization for multiple therapy codes (as in the current WVMI system)
• A reduced data set for initial services provided to members which now require authorization (PA required from 1st therapy service)
• Auto-adjudication of the initial ten sessions of all therapy services
• Ability to request all services required for the calendar year per the treatment plan (subsequent to the initial submission)
• APS will provide training to PT/OT providers prior to the release of the manual focusing solely on the C3 system.
• Because there are so many changes there will be no transition from the WVMI system to C3—on a specific date (to be announced) providers will no longer be able to use the WVMI system and must use C3.
• Training dates will be announced as soon as the manual effective date is released.

We would like to remind you that after ANY maintenance/update is performed to the C3 system, it requires you to clear cookies/cache and then to refresh. PLEASE REMEMBER TO CLEAR COOKIES/CACHE BEFORE YOU BEGIN WORK ON AUGUST 2, 2012. To do this, you will first need to log out of C3; then go to Tools and select Internet Options, then Delete Cache and Browser History. After completing those commands, please log back into C3 and click control F5 (or CTRL and your refresh button). This will ensure proper functionality of the system after an upgrade, as without clearing the cache and history you may inherit the older version of C3 and experience unexpected system errors.
 
Please disseminate this message to all C3 web-users/providers that will be affected by the upgrade, as not all that utilize the system or deal with Prior Authorization (PA) requests have supplied correspondence emails. With that said, we ask that if your organization has any personnel (C3 web-user or not) or third party branches involved in the PA process that are not on the APS Email Notification List, please dispatch those email addresses to wvmedicalservices@apshealthcare.com so that they may be added and are kept “in the know” for all WV Medicaid Medical Prior Authorization announcements.
 
In close, APS will be available to directly assist and address your questions and C3 technical needs. You may call 1.800.346.8272 or email wvmedicalservices@apshealthcare.com

The Bureau for Medical Services Office of Facility Based and Residential Care is revising  CPT (procedure codes) reimbursement methodology.  Review this document for complete details.

Effective Monday, August 6, 2012, WVMI will begin using the 2012 update of the InterQual criteria, where InterQual criteria has been used ( i.e., Inpatient Hospital Admissions, Outpatient Surgery, DME, and Imaging).

Beginning Monday, June 25, 2012, there will be a new URL address that all providers will use to access C3. It is:
https://providerportal.apshealthcare.com.  It will not be available for use until June 25, 2012.  

• Effective June 25, 2012, Cardiac and Pulmonary Providers will be permitted to input WV Medicaid Prior Authorization Requests electronically—this method is commonly referred to as DDE (direct data entry)—on the APS CareConnection® (C3) web-portal. Faxed requests will also be accepted and processed. The updated Prior Authorization Request Forms for C3 will be made available to providers just before the “go-live” date.
• Either means of submission, DDE or Fax, will require each Molina enrolled WV Medicaid Provider/Group to register/enroll independently online at the C3 Self-Enrollment Portal. You may begin C3 registration/enrollment at any time by accessing the following web-portal: https://c3wv.apshealthcare.com.

Providers are asked to self-enroll on the C3 system prior to June 25, 2012, to avoid any interruption in services. 

• Regardless of submission method, all determinations for prior authorization requests will be available exclusively online. Verbal and/or faxed confirmations will be phased out upon the “go-live” date referenced above.
• Cardiac and Pulmonary Rehabilitation services will be reviewed by West Virginia Medical Institute (WVMI) under the existing BMS Manual and criteria.
• Two web-training sessions have been scheduled and devised to assist with the self-enrollment process, as well as with technical assistance in regards to DDE and determination retrieval. Registration for the sessions listed below is not required.

Beginning June 4, 2012, APS Healthcare, Inc. and its’ subcontractor WVMI (the current Utilization Management Contractor (UMC) for the Bureau for Medical Services) will be covering all Out-of-Network requests that have previously been handled by BMS.

A few reminders about out-of-network requests for services for WV Medicaid members:

• ALL Out-of-Network services requested for WV Medicaid members require prior authorization by the Utilization Management Contractor (UMC) or the Bureau for Medical Services (BMS) before services are provided.
• Out-of-Network services must be requested by an enrolled West Virginia Medicaid provider with required documentation of medical necessity AND justification of why requested service(s) cannot be obtained from an in-network provider.
• Out-of-Network services, with the exception of confirmed emergent situations, shall not be authorized or reimbursed when the requested service is available in West Virginia.
• The treating Out-of-Network physician and facility must enroll as a West Virginia provider to be eligible for reimbursement, accept West Virginia Medicaid’s reimbursement as payment in full, and attach a copy of the approval form to the BMS’ Fiscal Agent billing form for payment consideration OR bill under the authorization number granted by
  the UMC if the request is entered into their systems.
• As in all cases, prior authorization does not guarantee payment.

Any Out-of-Network request for a review area already in the APS Medical CareConnection® (e.g. acute inpatient services), will be requested using the APS C3 Medical UM CareConnection® application or corresponding fax request forms and selecting the Out-of-Network selection for the servicing provider. Any Out-of-Network requests handled by WVMI in their legacy system will continue to be handled in the same manner as they have always been
(e.g. Imaging).

For requests that have historically been directed to BMS—BMS will forward the request to APS or direct the caller to fax the request for Out-of-Network service and all supporting documentation to APS.

To decrease the time necessary to address these requests they may now be:

• Faxed Confidentially: 1.866.209.9632, or
• Emailed Securely: wvmedicalservices@apshealthcare.com

Faxes and E-mails should be labeled Out-of-Network Request.

Providers with questions about Out-of-Network requests may contact APS at:
Email: wvmedicalservices@apshealthcare.com
Telephone: 1-800-346-8272
Fax: 1.866.209.9632

In cases where the Prior Authorization cannot be communicated to the Out-of-Network provider by APS or WVMI through their system, this form approving the service will be completed, signed by the APS nurse,
and sent back to the provider by APS (fax or secure email) and call tracking will be initiated with Molina if necessary (Out-of-Network provider is not enrolled or is termed).

It is the responsibility of the provider to enroll in WV Medicaid- the PA number cannot be sent and the claim cannot be paid, even when a service has been authorized, if the provider is not enrolled in WV Medicaid.

In those instances where the prior authorization cannot be communicated directly to Molina upon provider enrollment, the Out-of-Network service provider will be directed to attach the completed form to their claim. If a denial of service is rendered by the UMC all appropriate notifications will be sent.

Greetings WV Medicaid Providers Submitting Prior Authorization Requests!

APS Healthcare would like to first take the opportunity to thank you for your patience and feedback regarding the APS CareConnection® (C3) system for WV Medicaid Prior Authorizations. We hope you are becoming more familiar with navigating the system. With that being said, we would like to provide some additional important information about the C3 system, which will help reduce your number of administrative closures and resubmissions. This will improve the efficiency in receiving your determinations.

We would like to reiterate the importance of your computers’ compatibility with the APS CareConnection® system. It has come to our attention that if every user is not working on a computer that has IE8, (Internet Explorer 8), this can produce some problems with submitting your requests. Instructions on how to make your computers compatible with our system are available by clicking here. (Please note, following these instructions does not impair your computer system, and does not bother your other programs that are on the computer). Please make sure that all users of our system have access to these instructions. This will help prevent requests from being what we call “stuck in cyberspace”. This is when a request has been submitted, but stays in Pending status, and never goes to queue to be reviewed.

Another important thing to remember is that you have to have patience when submitting a request. Please remember to wait until everything is populated on the Summary and Submit page, BEFORE clicking the Submit button. Clicking Submit before being able to see the information on the page could be another contributing factor to “stuck” requests. Also, waiting for the entered information will allow you the opportunity to review the request, to make sure dates and all information are correct, and to make sure you didn’t leave anything off that might be pertinent to the review.

Next, we would like to inform you about timelines for sending in additional clinical information, whether it be faxed, or mailed additional information, for any case, to WVMI. In order for your requests to be processed in a timely, efficient manner, WVMI needs to receive information in a timely manner. If you enter requests via the CareConnection® system, and want to fax the clinical information to WVMI, the faxed information needs to be received by WVMI within 2 business days from the submission of the request. If you enter a reconsideration request into the system, and mail the additional clinical information, WVMI needs to receive this information within 5 business days. If the information is not received within the allotted timeframe, your request will be closed administratively, and you will have to re-submit your request, which could cause you to miss the 72 business hour timeline, for a timely submission. Leniency will NOT be given in these cases!

APS would like to stress that it is the provider’s responsibility, and is IMPERATIVE that the provider check each member’s eligibility. Although, both APS and WVMI, check for sufficient coverage, we are only responsible for determining whether or not a procedure meets medical necessity. This is especially important for PT, OT, Speech, and Audiology because your authorizations run to the end of the calendar year; however, this DOES NOT mean that each member’s eligibility runs through to the end of the year. That is the provider’s responsibility to check. 

It is also the provider’s responsibility to check for determinations of their requests, via the CareConnection® system. WVMI and APS will not give authorizations over the phone. APS will, however, continue to assist you by teaching you how to find your determination. The instructions for this are available by clicking here.

Finally, please make sure you are entering the correct dates on requests. We want to clarify that when submitting Acute Inpatient or Inpatient Rehab <21 requests, please make sure the Authorization Start Date and the Admission Date are the SAME date! When submitting therapy requests, (PT, OT, Speech, Audiology), if you have more than one procedure to get authorized, the Authorization Start Date should be the Start Date for the earliest service. You do not need to enter the date the request was entered because that date will automatically populate once the request is submitted. APS has to submit an IT request ticket to our Corporate Data Management team in order to have the dates changed, and this delays your ability to seek reimbursement for services rendered. So, in order to help us help you more efficiently, let’s please be sure to enter the correct dates on the requests.

If anyone is still in need of assistance and/or training with the APS CareConnection® system, please let us know. We can set up times to do trainings via webinars for your facility, or when time permits, we can work with you by phone and help you enter a request step by step, if you would prefer.

Thank you for time attention to the above matters. As always, we are here to help you in any way possible, so please feel free to contact us with any questions, comments, or concerns you may have by calling: 1-800-346-8272, or by emailing: wvmedicalservices@apshealthcare.com.
 

CPT codes 76942, 77002, 77003, 77012 and 77021 describe radiologic guidance for needle placement by different modalities.  Beginning 3-1-2012, WV Medicaid will allow one unit of service per day for any of these codes regardless of the number of needle placements performed.  Prior authorization for over the service limit may be obtained through our Utilization Management Contractor. Requests for these codes must be submitted to WVMI for service start dates on or after 3-1-2012. To request further information or address questions about this change to APS Healthcare, Inc, at wvmedicalservices.@apshealthcare.com.

If you are a WV Medicaid enrolled Speech Therapy and Audiology provider who refers and/or provides services to West Virginia Medicaid members that require prior authorization AND completes the prior authorization requests to the Utilization Management Contractor, you must Self Register/Enroll prior to Monday, January 30, 2012. The registration process is available now at https://c3wv.apshealthcare.com. All other providers are encouraged to not enroll until three weeks prior to their released/scheduled implementation date.

Based on provider feedback the Bureau for Medical Services has agreed to modify the scheduled December 12, 2011 implementation of the direct data entry system APS Medical CareConnection® for physical and occupational therapy services. The training and Production sites WILL be available on December 12, 2011 BUT WVMI will continue to accept physical and occupational therapy requests on their existing system until further notice. Physical and Occupational Therapy service providers may utilize the training site to familiarize their practices with the new system. Any provider who wishes to utilize the new system to request services may do so beginning December 12, 2011 but should contact APS at 1-800-346-8272 OR e-mail them at wvmedicalservices@apshealthcare.com to let them know your plan to “go-live” in the system.


Progress will be evaluated and a date in which providers MUST utilize the new system will be released by January 16, 2012. APS will continue to offer technical training on the system during the next several weeks and additional training sessions will be posted on the APS (apshealthcare.com) and WVMI (WVMI.org) websites. APS will continue to offer training and technical assistance to providers to facilitate a smooth transition to the new system. Physical and Occupational Therapy services providers who need assistance can make special arrangements for training or technical assistance by contacting us at 1-800-346-8272 OR by e-mailing us at wvmedicalservices@apshealthcare.com.

APS Healthcare in conjunction with WVMI would like to inform you of some very important upcoming information.

The scheduled Go-Live date for PT/OT prior authorization requests in the new C3 direct data entry system is December 12, 2011. Here is important information about registration and training.

How to Self-Enroll/Register on the C3 Production Site (https://c3wv.apshealthcare.com)
 

Providers are required to register in the C3 system prior to Go-Live. 

• You must read the CareConnection® Overview & Enrollment Guide (also access the intro letter). 
• After reading the guide, you must print, sign, and fax a hard-copy of the required Provider Portal Signature Page (Located in the attachment in Section R on page 26)
• You must successfully enroll and link all “WV Medicaid Molina Enrolled Providers” by NPI to your registered organization
• You must have one training submission remitted (details for this prerequisite will be provided the week of December 5, 2011)
• You must receive the “Go-Live” Memorandum via email from APS Healthcare after fulfilling all required registration processes. This memo will be granting your organization with full access to the production site. Without this memorandum your organization’s prior authorizations will not be processed.

Outpatient Physical and Occupation therapy services will be reviewed under the existing BMS Manuals and criteria. Changes and trainings regarding the new manual will be forthcoming and training updates will be provided at the time the new manual is finalized.

Training Webinars
 

APS in conjunction with WVMI will be hosting training Webinars.  The first week's will be training for the registration process only.

The next week’s webinars will be a quick overview of registration, but will be mostly technical training, showing how to submit a prior authorization request in our system.  Here are related documents with dates and instructions.

• Training Sessions
• Webex Instructions

In closing, if you have any questions or need assistance, please call APS Healthcare at 1-800-346-8272 or email wvmedicalservices@apshealthcare.com

We look forward to working with each of you and will help you in any way possible to ensure a smooth transitions process.

IMPORTANT: Many inpatient providers are still not registered and many have not tested. Please review the information below to prepare for October 31, 2011. You cannot simply begin to use the site on October 31, 2011- you must take the actions below to ensure a successful transition!

The APS Medical CareConnection® DDE System Production URL (C3wv.apshealthcare.com) will be available to make requests and implementation will begin October 31, 2011.

APS' West Virginia C3 Provider Portal Manual For Providers is now available.  To access it, click here.  You may access it by clicking on this link.  For future reference, you can find it anytime in the training resources library on the prior authorization page.

APS has announced the following dates and login information for Medical CareConnection DDE System training.

Webinars are scheduled for October 25 at 11:00 a.m. and October 27 at 2:30 p.m.  For complete information and login information, download the Webinar document from APS.

APS has issued a memo titled, "Implementation Go-Live for APS Medical CareConnection® DDE System."  Download the memo here or read the text of it below.

First and foremost thanks to all of you who have attended webinars, tested, and spoken with us about your needs related to implementation. We have evaluated the progress to date and will implement the following plan for “go-live”:

Based on provider feedback the Bureau for Medical Services has agreed to delay the scheduled October 17, 2011 implementation of the direct data entry system APS Medical CareConnection® for inpatient hospital services and inpatient rehabilitation <21 services. The site WILL NOT go-live on October 17, 2011 AND WVMI will continue to accept inpatient requests on their existing system until further notice. A training site will be prepared for providers who have registered with APS to allow for testing the week of October 17-21 2011.

Effective October 31, 2011, at noon, WVMI will no longer be able to accept phone reviews, for acute care (inpatient) hospital admissions, unless the case is medically urgent., as well as all inpatient rehab <21 cases.

Medically urgent is defined as:

• A delay could seriously jeopardize the life or health of the consumer or,
• The ability of the consumer to regain maximum function or,
• In the opinion of a physician with knowledge of the consumer’s medical condition, would subject the consumer to severe pain that cannot be adequately managed without the care or treatment that is the subject of the case.

Download the files for more information.

• APS Medical Care Connection Intro Letter
• October Webinar Information
• Self Registration Enrollment User Guide
• Timelines for Provider Registration

Utilization Management System Presentation and FAQs Available

APS Healthcare has made available a copy of its training presentation and frequently asked questions related to the Utilization Management system.  Click the links to download.

As you may be aware IRG d/b/a APS Healthcare, Inc. (APS) is now the primary Utilization Management Contractor (UMC) for prior authorization of Medicaid medical and behavioral health services.

In order to improve the efficiency and timeliness of processing medical prior authorization requests, APS has developed web-based complete CareConnection (C3) software system for the direct data entry of West Virginia Medicaid prior authorization requests. We are pleased to announce that initial training will be conducted to introduce medical providers to the features of this system.

Retrospective Review is avaiable for the following.

• Retrospective review is available following weekends or holidays or at times when the Utilization Management Contractor review process is unavailable.

Molina Medicaid Services has issued a letter to provide you an additional reminder that the changes for the Bureau for Medical Services (BMS), Dental Services Manual will be effective 4/1/2011. The letter lists the following specific changes.

Effective April 1, 2011, the UMC forms and prior authorization requirements contained in Chapter 505 Dental Services manual effective 11/1/10 will be in place. Previous UMC forms will not be accepted after April 1, 2011 and all services requiring prior authorization in the updated manual will now be subject to review by WVMI.

Effective 10/08/10, phone reviews will only be accepted for medically urgent nebulizer requests for children 3 years of age or under. If you have any questions, please contact Stacy Holstine, Project Manager, at 1-800-642-8686, ext. 3279, or Melissa Nichols, Support Staff Supervisor, at ext. 3233.

Effective Tuesday, August 2, 2011, WVMI will utilize the 2011 update of the InterQual criteria, where InterQual criteria has been used, i.e., Inpatient Hospital Admissions, Outpatient surgery, DME, and Imaging.

All Behavioral Health Review for WV Medicaid is now being handled by APS Healthcare. You may contact APS’ clinical review line at 1-800-378-0284 or 304-346-6732.