GATEWAY HEALTH PLAN®
US Steel Tower, Floor 41, 600 Grant Street, Pittsburgh, PA 15219
HOSPITAL NEWSFLASH
Inside This Issue:
DIVA
REMINDER - NEWBORN ENROLLMENT
BONE DENSITY AND DEXA SCANS
HIPAA 5010 AND ICD-10 STRATEGY AND TIMELINE
PENNSYLVANIA MEDICAID INPATIENT HOSPTIAL PAYMENT METHODOLOGY
PENNSYLVANIA MEDICAID RE-ADMISSION TIMEFRAME POLICY CHANGE
IMPORTANT INFORMATION
DIVA
DIVA… Your DIGITAL VOICE ASSISTANT!
As part of our Going Green efforts here at Gateway we announced in the December 2010 Provider Update plans to discontinue printing and mailing the newsletter in 2011. The newsletter will be accessible on our website. We’ve received positive feedback to this news and suggestions from our providers and Gateway staff on other opportunities to help the environment, and Go Green. To further reduce our impact on the environment Gateway will discontinue printing and distributing paper Referral Forms and require providers to use DIVA – Gateway’s Automated Telephone Referral System instead. This change will go into effect July 1, 2011 for our OB/GYN providers and October 1, 2011 for our Primary Care Physicians. Additional information on this change will be forthcoming. Training will be provided by your Provider Relations Representative who will share with you the many benefits of using DIVA.
If you are not a DIVA user already you don’t have to wait until the implementation dates to begin. Give it a try by calling 1-800-642-3515!
If you have not entered a referral in DIVA, we suggest that you use the detailed Referral Entry instructions printed in the Gateway at a Glance for Medicaid Providersor you can view a DIVA video tutorial at http://www.gatewayhealthplan.com/aboutus/diva.aspx. You’ll quickly find that it only takes seconds to generate a DIVA referral versus the minutes it takes to manually write one. In addition, you can enter multiple referrals during the same call without having to hang up or re-enter your practice information. We are convinced that you will find DIVA a faster and more economical alternative to paper.
Gateway understands that there may be instances when a provider is unable to use DIVA. A downloadable version of the PCP and OB/GYN Referral Form is available at www.GatewayHealthPlan.com. Each time a form is downloaded it is given a unique referral number. For claims payment purposes each referral you issue requires a NEW form to be downloaded and printed; just print, complete and mail to the address on the form.
REMINDER – NEWBORN ENROLLMENT
Per DPW Systems Notice - #SYS-2011-008, please be sure you are using the MA-112 form to notify the County Assistance Office when a baby is born to a Gateway Member. This will help in getting the newborn added to Medical Assistance and Gateway coverage sooner.
BONE DENSITY AND DEXA SCANS
Effective 1/1/11 the NIA prior-authorization requirement for Bone Mineral Density or Bone Densitometry tests has been lifted for both our Medicaid and Medicare Assured® lines of business. PCPs and specialists can refer a member for the test with just a script.
HIPAA 5010 AND ICD-10 STRATEGY AND TIMELINE
The 5010 version of the HIPAA electronic transactions is required in order to support the transfer to ICD-10 diagnosis code and ICD-10 procedure code data on claims and remittances.
Currently, Gateway has completed internal testing of the 5010 maps and loading of test scenarios in its claims system. External testing with Gateway’s three EDI clearinghouses/direct submitters has been initiated to ensure version 5010 format and data compliance. Contact your Practice Management System vendor and/or EDI vendor/clearinghouse to confirm preparedness for January 1, 2012.
As of January 1, 2012, version 4010 transactions will be accepted for dates of service prior to 1/1/2012. Only version 5010 transactions will be accepted for dates of service on or after 1/1/2012.
Prior to January 1, 2013, Gateway will begin ICD-10 testing with its 3 clearinghouses/direct submitters. Contact your Practice Management System vendor and/or EDI vendor/clearinghouse to confirm preparedness for ICD-10 implementation.
Gateway will continue to provide updates and further details as these initiatives progress.
PENNSYLVANIA MEDICAID INPATIENT HOSPITAL PAYMENT METHODOLOGY
Gateway Health Plan® Position Summary
Pennsylvania Medicaid Inpatient Hospital Payment Methodology
As of March 15, 2011
On July 9, 2010, the Pennsylvania (PA) legislature passed Act 49 of 2010. Act 49 allowed for the creation of a Hospital Quality Care Assessment (QCA).
The QCA was designed to provide funding for the Medical Assistance (MA) Fee-For-Service
(FFS) Program and for hospitals for Fiscal Years (FYs) 2010 to 2013.
During those FYs, the Pennsylvania Department of Public Welfare (DPW) will make enhanced capitation payments to Managed Care Organizations (MCOs) exclusively for the purpose of the MCOs making supplemental payments to hospitals.
The MCOs supplemental payments to hospitals are in place of increased payments for inpatient acute care services resulting from the department's implementation of All Patient Refined-Diagnosis Related Group (APR-DRG) payments.
Further, under Act 49, MCOs are not obligated to make other additional payments to hospitals that exceed the enhanced capitation received from DPW, and are required to make the supplemental payments to hospitals only after they have received the enhanced capitation payments from DPW.
During the next two weeks, DPW plans to reprocess HealthChoices capitation payments for the July 2010 – February 2011 program months. DPW anticipates that the MCOs will receive the funds by March 25, 2011. DPW will send each MCO a report on APR Adjustment payments and HAP will be supplied with a summary version of the report. DPW will provide a monthly report thereafter by the 25th of each month.
On March 4, 2011, DPW implemented APR-DRG Version 27 for MA enrolled acute care general hospitals that provide services in the FFS delivery system.
MCOs are not required to implement APR-DRGs neither through their contracts with DPW nor by the regulations that permitted DPW to implement APR-DRGs. The funding necessary to support the increased payments in the move to APR-DRGs was not provided to the MCOs. The funding to the MCOs is mandated solely for the supplemental payments to the hospitals.
Gateway Health Plan® (Gateway) will continue to follow DRG Grouper 23 and/or other inpatient payment methodology outlined in its hospital contracts. Hospitals must continue to submit the appropriately coded DRG on claims to Gateway.
In addition, while DPW will recognize only high cost outliers under APR-DRG, Gateway will continue to recognize both day and cost outliers under DRG Grouper 23.
Sources:
62 P.S. § 443.1, Medical assistance payments for institutional care
PA DPW Provider Quick Tips #102
PA DPW Hospital Quality Care Assessment, 12/10/2010; revised 01/28/201
PENNSYLVANIA MEDICAID RE-ADMISSION TIMEFRAME POLICY CHANGE
The Fiscal Year 2011-2012 State Budges contains a payment policy change in re-admission guidelines from 14 days to 30 days. This change will be in effect for all inpatient stays with a discharge date of 7/1/11 or later.