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WellCare Provider Training MLTSS 2014


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Title: WellCare Provider Training MLTSS 2014

WellCare Provider Training MLTSS 2014
Topics For MLTSS Provider Training
  • What is Managed Long Term Services and Support
  • Services under MLTSS
  • How to qualify for MLTSS
  • Member Eligibility
  • Timely Claims Submission
  • Claims Submission Requirements/Paper Claims
  • Electronic Claims Submissions/Prompt Payment
  • Coordination of Benefits/Hold Harmless Dual
  • Credentialing
  • Claims Appeals/Appeals/Grievances
  • Nursing Facilities/Assisted Living
  • Prior Authorization
  • HIPPA Electronic Transactions and Code Sets
  • Authorization Required for Long Term Care

What is Managed Long Term Services and Support
  • Managed Long Term Services and Supports (MLTSS)
    refers to the delivery of long-term services and
    supports through New Jersey Medicaid's NJ
    FamilyCare managed care program.  MLTSS is
    designed to expand home and community-based
    services, promote community inclusion and ensure
    quality and efficiency.
  • Principles for Managed Long Term Services
  • MLTSS overall goal is to provide quality
    long-term services and supports to individuals of
    all ages in the most integrated setting
    appropriate to their needs.
  • . Home and Community-Based Services is the
    preferred service delivery method for people
    receiving Managed Long Term Services and Supports
  • Person-centered service options should be
    available so that individuals of all ages who use
    MLTSS are enabled to live in the community, in
    their own homes if possible
  • Criteria for community living should
    include privacy autonomy respect personal
    preference cultural differences dignity
    safety choice and control within the residential
    setting integration with the greater community
    independent advocacy when appropriate and
    personal control over moving to, remaining in or
    leaving the setting and
  • Consumer Choice selecting providers and living
    settings is the priority if MLTSS
  • People of all ages have the right to choose
    and, if they wish, direct their care plan
  • MLTSS works with individuals to ensure that
    quality of life is as important as quality of
  • MLTSS will work to maintain or improve the
    health and functional state of seniors and people
    with disabilities.

Services under MLTSS includes
  • Personal Care
  • Respite
  • Care Management
  • Home and Vehicle Modifications
  • Home Delivered Meals
  • Personal Emergency Response Systems
  • Mental Health and Addiction Services
  • Assisted Living
  • Community Residential Services
  • Nursing Home Care
  • Behavioral Health
  • participants in the Medicaid waiver programs
    listed below will be automatically enrolled in
    the Managed Long Term Services and Supports
    (MLTSS) program through their current Medicaid
    managed care organization (MCO), also known as a
    health plan
  • Global Options for Long-Term Care (GO) AIDS
    Community Care Alternatives Program (ACCAP)
    Community Resources for People with Disabilities
    (CRPD) or, Traumatic Brain Injury (TBI) Waiver

How to qualify for MLTSS
  • Global Options for Long-Term Care (GO) AIDS
    Community Care Alternatives Program (ACCAP)
    Community Resources for People with Disabilities
    (CRPD) or, Traumatic Brain Injury (TBI) Waiver
    are automatically enrolled on July 1st 2014
  • A person also can qualify for Managed Long Term
    Services and Supports (MLTSS) by meeting these
    established Medicaid requirements
  • Financial Requirements - These include monthly
    income, as well as total liquid assets. For more
    detailed information on Medicaid financial
    eligibility, click here.
  • Clinical Requirements - A person meets the
    qualifications for nursing home level of care,
    which means that the person requires assistance
    with activities of daily living such as bathing,
    toileting and mobility.
  • Age and/or Disability Requirements - These
    involve age requirements whereby one must be 65
    years or older and/or disability requirements
    whereby one must be under 65 years of age and
    determined to be blind or disabled by the Social
    Security Administration or the State of New

Member Eligibility

  • A members
    eligibility status can change at any time.
    Therefore, all providers should consider
    requesting and copying a members identification
    card, along with additional proof of
    identification such as a photo ID, and filing
    them in the patients medical record.
  • Providers may do one of the following to verify
  • Access the secure, online Provider Portal of the
    WellCare website at www.wellcare.com
  • Access WellCares interactive voice response
    (IVR) system and/or contact the WellCare
    Provider Service Department.
  • You will need your Provider ID number to access
    member eligibility through the avenues listed
  • Molina Medicaid/Family Care Solutions at
    800-776-6334 (you must have a Medicaid/Family
    Care provider number to use this provider line).
  • Medicaid/Family Care FFS Services Enrolled
    Providers can also visit NJMMIS website at
    www.NJMMIS.com and select link on the left side
    of the page (contact Webmaster) once on the
    webpage complete request for username and
    password and access eMEVS ( the electronic
    Medicaid/Family Care Eligibility Verification
    System) or call 800-776-6334.
  • REVS- You must be a Medicaid/Family Care Provider
    to have access to REVS TEL 800-676-6562 the
    advantage of using REVS is that you can also
    confirm if a member has Medciare Parts A and B
    and MCO.

Timely Claims Submission
  • Unless otherwise stated in the Provider
    Participation Agreement (Agreement), provider
    must submit claims (initial, corrected and
    voided) within six (6) months or 180 days from
    the Medicaid or primary insurance payment date,
    whichever is later) from the date of service.
    Unless prohibited by federal law or CMS, WellCare
    may deny payment for any claims that fail to meet
    WellCares submission requirements for Clean
    Claims or that are received after the time limit
    in the Agreement for filing Clean Claims. MCO
    will adjudicate MLTSS claims within 15 days of
    clean claim submission
  • If the beneficiary is dually eligible Medicare
    must be billed prior to Medicaid/Family Care if
    the service is covered by Medicare. Medicare
    balances may be billed to the Medicaid/Family
    Care MCO if the Medicare Benefit is exhausted.
  • If the beneficiary is not enrolled in a MCO, or
    the beneficiarys Medicaid/Family Care
    eligibility lapsed and service is a
    Medicaid/Family Care billable service the
    beneficairy may be covered by Medicaid/Family
    Care FFS
  • REMEMBER Medicaid/Family Care is the payer or
    last resort
  • The following items can be accepted as proof that
    a claim was submitted timely
  • A clearinghouse electronic acknowledgement
    indicating claim was electronically accepted by
    WellCare and
  • A providers electronic submission sheet with all
    the following identifiers, including patient
    name, provider name, date of service to match
    Explanation of Benefits (EOB)/claim(s) in
    question, prior submission bill dates and
    WellCare product name or line of business.
  • The following items are not acceptable as
    evidence of timely submission
  • Strategic National Implementation Process (SNIP)
    Rejection Letter and
  • A copy of the Providers billing screen.
    (Continue on next page)

Electronic Claims Submissions
  • WellCare accepts electronic claims submission
    through Electronic Data Interchange (EDI) as its
    preferred method of claims submission. All files
    submitted to WellCare must be in the ANSI ASC
    X12N format, version 5010. For more information
    on EDI implementation with WellCare, refer to the
    Wellcare Companion Guides which may be found on
    WellCares website.
  • Because most clearinghouses can exchange data
    with one another, providers should work with
    their existing clearinghouse, or a WellCare
    contracted clearinghouse, to establish EDI with
    WellCare. For a list of WellCare contracted
    clearinghouse(s),for information on the unique
    WellCare Payer Identification (Payer ID) numbers
    used to identify WellCare on electronic claims
    submissions, or to contact WellCares EDI team
  • EDI-Master_at_wellcare.com

Paper Claims Submissions Contd
  • The information must be aligned within the data
    fields and must be
  • Typed
  • In black ink
  • Large, dark font such as, PICA, ARIAL 10-, 11-or
    12-point type and
  • In capital letters.
  • The typed information must not have
  • Broken characters
  • Script, italics or stylized font
  • Red ink
  • Mini font or
  • Dot matrix font.

MLTSS time frames for claims processing
  • WellCare is required to adjudicate (pay or deny)
    claims (for MLTSS members) for MLTSS services
    such as assisted living providers, nursing
    facilities, special care nursing facilities, CRS
    providers, adult/pediatric medical day care
    providers, PCA and participant directed Vendor
    Fiscal/Employer Agent Financial Management
    Services (VF/EA FMS) claims within the following
  • 1. HIPAA compliant electronically submitted clean
    claims shall be processed within fifteen (15)
    calendar days of receipt
  • 2. Manually submitted clean claims shall be
    processed within thirty (30) calendar days of
    receipt and
  • 3. All claims shall be processed within
    forty-five (45) calendar days of receipt.

Coordination of Benefits (COB)
  • WellCare shall coordinate payment for
    Covered Services in accordance with the terms of
    a members benefit plan, applicable state and
    federal laws and CMS guidance. Providers shall
    bill primary insurers for items and services they
    provide to a member before they submit claims for
    the same items or services to WellCare. Any
    balance due after receipt of payment from the
    primary payer should be submitted to WellCare for
    consideration and the claim must include
    information verifying the payment amount received
    from the primary plan as well as a copy of the
    Explanation of Benefits (EOB). WellCare may
    recoup payments for items or services provided to
    a member where other insurers are determined to
    be responsible for such items and services to the
    extent permitted by applicable laws. Providers
    shall follow WellCare policies and procedures
    regarding subrogation activity.

Balance Billing
  • Providers shall accept payment from WellCare for
    Covered Services provided to WellCare members in
    accordance with the reimbursement terms outlined
    in the Agreement. Payment made to providers
    constitutes payment in full by WellCare for
    covered benefits, with the exception of member
    expenses. For Covered Services, providers shall
    not balance bill members any amount in excess of
    the contracted amount in the Agreement. An
    adjustment in payment as a result of WellCares
    claims policies and/or procedures does not
    indicate that the service provided is a
    non-covered service, and members are to be held
    harmless for Covered Services. For more
    information on balance billing, refer to the
    Provider Manual.
  • Hold Members Harmless
  • Those dual eligible members whose Medicare
    Part A and B member expenses are identified and
    paid for at the amounts provided for by DMAHS
    (Medicaid) shall not be billed for such Medicare
    Part A and B member expenses, regardless of
    whether the amount a provider receives is less
    than the allowed Medicare amount or provider
    charges are reduced due to limitations on
    additional reimbursement provided by DMAHS.
    Providers shall accept WellCares payment as
    payment in full or will bill New Jersey Medicaid
    if WellCare has not assumed the Agencys
    financial responsibility under an agreement
    between WellCare and the Agency. For more
    information on holding harmless dual eligible
    members, refer to Medicaid Provider General

Credentialing Process Highlights
  • Please take note of the following credentialing
    process highlights
  • Primary source verifications are obtained in
    accordance with the state and federal regulatory
    agencies, accreditation, and WellCare policy and
    procedure requirements and include a query to the
    National Practitioner Data Bank
  • Physicians, allied health professionals, and
    ancillary facilities/health care delivery
    organizations are required to be credentialed in
    order to be network providers of services to
    WellCare members.
  • Satisfactory site inspection evaluations are
    required to be performed in accordance with
    state, federal, state and accreditation
  • WellCare will complete credentialing activities
    and notify providers within 90 days of receiving
    a completed application. The notification to the
    provider will inform them as to whether they are
    credentialed, whether additional time to complete
    the credentialing process is needed, or that
    additional providers are not needed at the time.
    When additional information is needed t o
    complete a provider application, WellCare will
    make the request from the provider as soon as
    possible, and no later than 90 days from the
    receipt of the application. WellCare will also
    communicate with providers within these
    timeframes throughout the provider
    re-credentialing process.

Claims Appeals
  • Provider Claim appeals must be submitted within
    90 days of the most recent adverse determination
    on a claim or claim appeal. (see provider manual)
    During all stage of the appeal process or Fair
    Hearing services will continue if all the
    requirements below apply.
  • The appeal is filed on time
  • The appeal involves a course of treatment that
    was authorized
  • The services were ordered by an authorized
    network provider
  • The written request to continue services is
    received within 10 days if the date of initial
    denial letter ( this only applies to
    Medicaid/Family Care Fair Hearings) Mail or fax
    medical appeals with supporting documentation to
  • WellCare Health Plans, Inc.
  • Fax 1-866-201-0657
  • Attn Appeals Department
  • PO Box 313683
  • Tampa, FL 33631-3368
  • A beneficiary or provider on behalf of a
    beneficiary (with beneficiary written consent)
    can request a Fair Hearing at any time during the
    appeals process. The Medicaid/Family Care Fair
    Hearing Dept. can be reached at 609-588-2655 or
    609-588-2656, or via mail or fax to Department
    of Human Services Medicaid/Family Care Fair
    Hearing Dept. 7 Quakerbridge Rd. Mercerville NJ,
    08619 Fax 609-588-7343

  • Member grievances may be filed verbally by
    contacting Customer Service or submitted via fax
    or mail.
  • Providers may also file a grievance on behalf of
    the member with the members written consent.
  • Mail or fax member grievances to
  • WellCare Health Plans, Inc.
  • Fax 1-866-388-1769
  • Attn Grievance Department
  • PO Box 31384 Tampa, FL 33631-3384

  • MLTSS Any Willing Provider status for NF, SCNF,
    AL and CRS will be for a two year period from the
    date that the service comes into MLTSS, dependent
    upon available appropriation in each Fiscal Year.
    For NF, SCNF, AL and CRS that would mean that Any
    Willing Provider status expires on June 30, 2016.
  • Nursing Facility Level of Care (NF LOC)--The
    designation given to individuals who meet
    clinical eligibility for MLTSS services. This is
    assessed using the NJ Choice Assessment System
    and findings are validated by OCCO, in accordance
    with N.J.A.C. 885.
  • Nursing Facility Services(NF) shall be a
    covered benefit for Medicaid/NJ FamilyCare A, and
    the MCO shall be financially responsible for all
    nursing facility services for NJ FamilyCare A
    enrollees from the date the enrollee enters the
    nursing facility to the date of discharge.
    Special Care Nursing Facilities (SCNF) residents
    currently receiving NJ FamilyCare through
    Fee-for-Service will convert to managed care on
    July 1, 2016.
  • Short term nursing facility stays are available
    for MLTSS Members receiving HCBS who require
    temporary placement in a nursing facility due to
    temporary illness, serious injury, wound care, or
    the absence of the primary caregiver and there is
    a reasonable expectation that the member will be
    discharged back to the community within 180 days.
  • If, prior to the end of the 180 day period (post
    admission date) it is determined that the member
    will not be discharged from the nursing facility,
    the member shall be determined as custodial. The
    member is automatically converted to custodial
    status in the nursing facility if the member is
    in the nursing facility beyond 180 days.
  • Current custodial nursing home residents on
    Medicaid will remain in a fee-for-service
    environment. Medicaid beneficiaries living in
    Special Care Nursing Facilities (SCNFs) as of
    July 1, 2014 will remain in the fee-for-service
    environment for two years. 
  • Any individual who is newly eligible for Medicaid
    and living in a nursing home after July 1, 2014
    will have his/her care managed by a NJ FamilyCare
    MCO through the MLTSS program. Individuals who
    enter a SCNF after July 1, 2014 will have their
    acute and primary health care services and their
    nursing home care managed by a NJ FamilyCare MCO
    through the MLTSS program
  • OCCO is responsible for issuing the final
    approval or denial letter to the Member.
  • In the event the Member does not meet NF LOC OCCO
    will explain to the Member the reason(s) for
    denial, provide counseling on alternative HCBS
    and issue a determination letter which shall
    include the Members right to appeal and how to
    apply for a Medicaid fair hearing.
  • .

  • MLTSS Members residing in an Assisted Living (AL)
    or in an Adult Family Care (AFC) setting may have
    a cost share as calculated by the County Welfare
    Agency and are responsible to pay the provider of
    services the cost share. This is in addition to
    the Room and Board charge established by the
  • MLTSS Members living in Assisted Living (AL) or
    in an Adult Family Care (AFC) setting, whose
    income is only derived from Supplemental Security
    Income (SSI), will not have a cost share. They
    will be required to pay the Room and Board charge
    established by the state
  • Assisted Living For individuals who are placed
    in an assisted living residence the Care Manager
    shall discuss room and board payments and any
    potential patient pay liability the Member may
    incur. Since New Jersey Medicaid does not cover
    room and board in a community alternative
    residential setting, this must be paid by the
    Member or other source (such as the Members
    family) directly to the facility. The State shall
    notify the Contractor annually of the room and
    board amount which shall be collected from the
    resident by the provider. In addition, the Care
    Manager shall discuss any patient payment
    liability for cost of care with the Member. The
    patient liability for cost of care is the portion
    of the cost of care that ALR, CPCH or AFC
    residents must pay based on their available
    income as calculated by the CWA. The State shall
    notify the Contractor of any applicable patient
    payment liability via the 834 eligibility/enrollme
    nt file. The Contractor shall delegate collection
    of both the room and board and patient payment
    liability for the cost of care to the provider.
    The Contractor shall pay the facility net of the
    applicable patient liability amount.

Prior Authorization
  • MLTSS Prior authorization guidelines to note are
  • Prior authorization decisions for non-emergency
    services shall be made within 10 days. With
    complete medical information Wellcare responds to
    more than 90 of requests within three business
  • Within 72 hours of the request, you may log into
    the website www.wellcare.com for update.
  • Prior authorization Denials and limitations must
    be provided in writing in accordance with the
    Health Claims Authorization Processing and
    Payment Act, P.L. 2005, c.352.
  • The prior authorization request should include
    the diagnosis to be treated and the CPT code
    describing the anticipated procedure. If the
    procedure performed and billed is different from
    that on the request, but within the same family
    of services, a revised authorization is not
  • An authorization may be given for a series of
    visits or services related to an episode of care.
    The authorization request should outline the plan
    of care including the frequency and total number
    of visits requested and t he expected duration of

  • Adult Companion Services
  • Adult Day Health Care
  • Assisted Living Services
  • PCA
  • Pediatric Medical Day Care
  • CSR
  • Chore Services
  • Consumable Medical Supplies
  • Behavioral Management ( TBI)
  • Environmental Accessibility Adaptation Services
  • Family Training Services
  • .

  • Homemaker Services
  • Personal Emergency Response Systems
  • Respite Care Services
  • Occupational Therapy
  • Physical Therapy .
  • Respiratory Therapy
  • Speech Therapy
  • Nursing Facility
  • Assisted Living
  • Behavioral Health

Critical Incident Reporting - MCO Requirements
  • In all MLTSS provider contracts, the Contractor
    shall require full adherence to the mandatory
    training and reporting requirements applicable to
    Adult Protective Services, office of
    Institutionalized Elderly, Department of Children
    and Families and the Division of Disability
    Services including but not limited to
  • N.J.A.C. 839-9.4
  • N.J.A.C. 836-5.10(A)
  • N.J.A.C. 843F-3.3
  • N.J.A.C. 843J-3.4
  • N.J.S.A. 5227D-409
  • N.J.A.C. 857

Critical incidents shall include but not be
limited to the following incidents
  1. Unexpected death of a member
  2. Missing person or unable to contact
  3. Suspected or evidenced physical or mental abuse
    (including seclusion and restraints, both
    physical and chemical)
  4. Theft with law enforcement involvement
  5. Law enforcement contact
  6. Severe injury or fall resulting in the need of
    medical treatment
  7. Medical or psychiatric emergency, including
    suicide attempt
  8. Medication error
  9. Inappropriate or unprofessional conduct by a
    provider involving the member
  10. Sexual abuse and/or suspected sexual abuse and
    abuse and neglect, including self-neglect, and/or
    suspected abuse and neglect

Timeframes for incident reporting
  • Contracted MLTSS providers and their staff are
    required to report, respond to and document
    critical incidents as specified by the contractor
    as follows
  • The maximum timeframe for reporting an incident
    to WellCare shall be 24 hours, the report might
    be submitted verbally, in which case the
    agency/person/entity making the initial report
    shall submit a follow-up written report within 48
  • Suspected abuse, neglect, and exploitation must
    be reported immediately
  • WellCare is required to report to DMAHS any death
    and any incident that could significantly impact
    the health or safety of a member within 24 hours
    of detection or notification
  • Timeframe for submitting reports shall be as soon
    as possible, may be based on the severity of the
    incident (see 2,3) but shall not exceed more
    than 30 calendar days from the day of the incident

CIR and MLTSS Self-Direction
  • Consider whether incidents involving members who
    self direct are tagged and tracked separate from
    the traditional systems
  • Definitions of critical incidents may need to
    differ for individuals who are self directing and
    those in the traditional agency model
  • Important to determine whether reported incident
    has a direct correlation to the fact that the
    individual was self directing and make sure
    appropriate staff are apprised of this
  • Ensuring critical incident reporting is
    challenging when services are self directed and
    provided in the members home or family home,
    additional considerations include
  • Relying on redundant systems such as
    grievance/complaint reporting to identify
  • Sensitizing care managers/support brokers on how
    to elicit serious risk issues when visiting with
  • Providing hotlines for members to call to report
  • Analyzing incident data related to self direction
    to detect trends
  • Direct service workers and providers of goods and
    services become mandatory reporters

  • Forms and Documents newjersey.wellcare.com/provi
  •  Quick Reference Quick Reference Guides
  •  Clinical Practice Guidelines
  •  Clinical Coverage Guidelines
  •  WellCare Companion Guide newjersey.wellcare.com
  •  Provider Training newjersey.wellcare.com/Provid
  • EDI team EDI-Master_at_wellcare.com
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