Important Notifications

Important Information for “Pregnancy Only” Members

In keeping with the compliance of the Affordable Care Act (ACA), Magnolia “Pregnancy Only” members will now receive full benefits effective January 1, 2014.  Prior to this change, “Pregnancy Only” members did not receive dental, vision or behavioral health benefits.  They will now receive these benefits.

IMPORTANT:  Information about billing for 17 Alpha Hydroxyprogesterone

Please click on the link below for information about 17 Alpha Hydroxyprogesterone.

Billing for 17P (PDF)

Important Information about billing Makena

Billing Instructions for Makena (PDF)

Makena PA Form (PDF)

Conversion to CMS 1500 version 02/12

Effective:  January 6, 2014

The National Uniform Claim Committee (NUCC) has approved the conversion to the 02/12 version of the CMS 1500 form.  This change is being made to accommodate the additional reporting needs related to the implementation of ICD-10.

Magnolia Health Plan will follow the implementation of this form as recommended by the NUCC.  Specifically:

  • January 6, 2014 – March 31, 2014:  Magnolia Health Plan will accept the current version of the CMS 1500 form (version 08/05) AND will accept the new version of the CMS 1500 form (version 02/12).
  • April 1, 2014:  Magnolia Health Plan will ONLY accept the 02/12 version of the CMS 1500 form.

The above is date of submission sensitive and not date of service sensitive.  For example, if a claim has a date of service of March 17, 2014 and is submitted on or after April 1, 2014, the claim must be submitted on the 02/12 version.

While there are a number of changes from the 08/05 version to the 02/12 version, the notable change is that box 21 has added 8 additional lines for diagnosis codes.   

For more information regarding conversion to the 02/12 version, please visit NUCC at http://www.nucc.org/index.php?option=com_content&view=article&id=186&Itemid=138

 

Cardiac Imaging Program

On January 1, 2014, Magnolia Health Plan will be expanding their outpatient cardiac imaging program. The cardiac imaging program is developed to assist physicians in the timely management of patients with possible cardiac disease. This is in conjunction with an advanced imaging program

Why are Cardiac Procedures included?

The primary objective of including cardiac procedures in Magnolia Health Plan radiology management program is to promote the optimal use of diagnostic modalities in the assessment and treatment of cardiac diseases.  Ultimately, the program is designed to improve health care quality by minimizing radiation exposure and by using the most efficient and least invasive testing options available.

Program Components

  • Evidence-based clinical guidelines and proprietary algorithms to support clinically appropriate diagnostic options for each patient
  • Consultations with cardiologists related to elective cardiac diagnostic imaging when peer-to-peer review is required
  • Quality assessment of imaging providers to ensure the highest technical and professional standards

How the program works

In addition to the outpatient CCTA services currently managed under the NIA program, prior authorization will be required for the following non-emergent outpatient cardiac procedures:

  • Nuclear Cardiology/MPI
  • Stress Echocardiography
  • Echocardiography (Transthoracic and Transesophageal Echocardiography)

We are confident that this new program will have a positive impact on the quality of care rendered to your patients, and we look forward to working with you to deliver positive outcomes to our community. We would be happy to discuss the program further. Please contact Charmaine Gaymon, NIA Manager- Provider Relations at 410-953-2615 or email at: csgaymon@magellanhealth.com.

Quick Reference Guide for Ordering Physicians (PDF)

Quick Reference Guide for Imaging Facilities (PDF)

2013 Claims Utilization Review Matrix (PDF)

 

CLIA Notice to Providers

Effective January 6, 2014, providers billing CLIA services to Magnolia Health Plan must include a valid and appropriate CLIA number (i.e., either a CLIA Certification Number or CLIA Certificate of Waiver number, as applicable) with the claim, as follows: 

  • For paper claims, a valid and appropriate CLIA number must be included in Box 23 of the CMS-1500 form.
  • For EDI claims, if a single claim is submitted for those laboratory services for which CLIA certification or waiver is required, report the CLIA certification or waiver number in: X12N 837 (HIPAA version) loop 2300, REF02. REF01 = X4. If a claim is submitted with both laboratory services for which CLIA certification or waiver is required and non-CLIA covered laboratory test, in the 2400 loop for the appropriate line report the CLIA certification or waiver number in: X12N 837. (HIPAA version) loop 2400, REF02. REF01 = X4.  For additional information regarding submission of paper claims or EDI claims, please see the enclosed document. You can also refer to the HIPAA 837P Transaction Companion Guide found on our website at:  WWW.MAGNOLIAHEALTHPLAN.COM

**CLIA number is required in either loop 2300 or loop 2400 as indicated above, but will NOT be a requiremet to populate both loops.**

CLIA Notice to Providers

CLIA Billing Instructions

Congress established the Clinical Laboratory Improvement Amendments (CLIA) in 1988 to promote the accuracy, reliability and timeliness of patient test results, regardless of where the test was performed.

CLIA requires every laboratory, provider or facility that handles human test samples be certified by the Department of Health and Human Services (DHHS).  Certain basic tests may be performed under a Certificate of Waiver, but CLIA Certification is required for more complex procedures (such basic and complex procedures to be collectively referred to herein as “CLIA services”). Both the Certificate of Waiver and the CLIA Certification programs are administered by CMS.

 

If a valid and appropriate CLIA number is NOT included with the claim as provided above, the entire claim will not be considered a clean claim and will be rejected as incomplete.  This process is consistent with the procedure followed by CMS and is applicable to all products offered by Magnolia Health Plan.

 

 

 

ATTENTION:  OB Providers

Please click on the link below to access information that will be most important as we move forward in caring for Magnolia members.

ATTENTION OB PROVIDERS

Modifiers for Therapy CPT Codes

These codes are always therapy services, regardless of who performs them.  They always require therapy modifiers.

GP for PT

GO for OT

GN for SLP

CPT Codes: 92506, 92507, 92508, 92526, 92597, 92605, 92606, 92607, 92608, 92609, 96125, 97001, 97002, 97003, 97004, 97010, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97530, 97533, 97535, 97537, 97542, 97750, 97755, 97760, 97761, 97762, 97799

 

Medical Record Review

Magnolia Health Plan is in our first year of Medical Record Review (MRR) for Healthcare Effectiveness Data and Information Set (HEDIS).  HEDIS is a standardized set of performance measurements developed by the National Committee for Quality Assurance (NCQA) to evaluate consumer health care.

How this will affect you:

  • RecordFlow is the contracted MRR for Magnolia Health Plan.
  • RecordFlow is in the process of sending out a fax packet to your office for medical record retrieval.
  • For any questions, your office should call RecordFlow at (800) 698-1690 or Lynn Mitchell, QI Manager for Magnolia Health Plan, at (866) 912-6285 ext. 66834.
  • If you need to fax medical records, RecordFlow’s fax number is (855) 757-3630.
  • Timeframe for MRR retrieval is February through May 2013.

What is HEDIS?

  • Designed to allow consumers to compare health plan performance to other plans and to national or regional benchmarks.
  • One component of NCQA’s accreditation process.
  • Measures are related to many significant public health issues, such as diabetes, asthma, cancer and heart disease, as well as preventive services.
  • Data collection pertains to any enrolled Magnolia member.  Medicaid guidelines require completion of HEDIS data collection annually to meet contract requirements.

New Provider Orientations

Magnolia will be conducting new provider orientations over the next few weeks.  Please review the chart below for locations and times.

To register for an orientation:

Be sure to include number of attendees.

Date: Location: Address: Time:
2/22/2013 North MS Medical Center 830 S. Gloster Street 1st Session:  10AM – 11:30AM
  Education Center Auditorium Tupelo, MS  38801 2nd Session:  1PM – 3PM
       
3/13/2013 Jackson Medical Mall 350 W. Woodrow Wilson 1st Session:  10AM – 11:30AM
  Community Meeting Room Jackson, MS  39213 2nd Session:  1PM – 3PM

 

How to correctly bill for Evaluation and Management/Preventive Medicine Services

The placement of the 25 modifier on the Evaluation and Management/Preventive Medicine procedure codes 99381-99395 will allow payment of the visit and the immunization administration service.  However, the 25 modifier should only be reported on a claim when there is identifiably a significant, separately EM/Preventive Medicine Service performed by the professional healthcare provider on the same day of the procedure or other service, as substantiated by documentation in the patient’s medical record.

Claims submitted beginning with dates of service January 1, 2013 which resulted in a denial for NCCI Contra Edit 6562 may be voided by the provider and resubmitted using the 25 modifier with strict adherence to the description cited in the most current American Medical Association CPT codebook.

Magnolia Health Plan’s Affirmative Statement about Incentives

Magnolia Health Plan’s (Magnolia) decisions regarding the provision of health care services are based solely on appropriateness of care and services and the existence of coverage.

Magnolia does not:

  • Employ incentives to encourage barriers to care and services
  • Specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service care
  • Provide incentives for utilization review decision makers that result in underutilization

 

Intrauterine/Implants Contraceptive type of devices are covered by Magnolia per the DOM Administrative Code Part 221 Family Planning Services and paid per Administrative Code Part 209 DME.

Part 221 Family Planning Services covered contraceptive devices include:

  • Insertion and removal of contraceptive intrauterine devices
  • Insertion and removal of contraceptive implants
  • Diaphragm or cervical cap fitting with instruction
  • Vaginal rings

Requirements and billing for Intrauterine/Implants Contraceptive:

Items that do not have a fee or MSRP may be priced at the provider’s cost plus 20%

  • Provider must attach a copy of a current invoice indicating the cost to the provider for the item dispensed and a statement that there is no MSRP available for the item.
  • If the provider purchases from the manufacturer, a manufacturer’s invoice must be provided.
  • If the provider purchases from a distributor and not directly from the manufacturer, the invoice from the distributor must be provided.
  • Quotes, price lists, catalog pages, computer printouts or any form of documentation other than an invoice are not acceptable for this pricing solution.
  • The invoice must not be older than 1 year prior to the date of the request.  Exceptions to the 1 year requirement may be approved only for unusual circumstances.

Upcoming PaySpan Webinars

Wednesday, February 13th, 2013 – 2PM EASTERN TIME

https://payspan.webex.com/payspan/onstage/g.php?t=a&d=746515630

 

Wednesday, February 20th, 2013  – 2PM EASTERN TIME

https://payspan.webex.com/payspan/onstage/g.php?t=p&d=740419307

New Provider Orientations

Magnolia will be conducting new provider orientations over the next few weeks.  Please review the chart below for locations and times.

To register for an orientation, please click here.  Click on the “Provider” Tab.   In the “subject” line, please enter “other” and in the “message” box, please enter the location you will be attending and number of participates.

Date: Location: Address: Time:
1/31/2013 Handsboro Community   Center 1890 Switzer Road 1st Session:  10AM – 12PM
  Banquet Room Gulfport, MS  39507 2nd Session:  1PM – 3PM
       
2/1/2013 North MS Medical   Center 830 S. Gloster Street 1st Session:  10AM – 11:30AM
  Education Center Auditorium Tupelo, MS  38801 2nd Session:  1PM – 3PM
       
2/15/2013 Jackson Medical Mall 350 W. Woodrow   Wilson 1st Session:  10AM – 11:30AM
  Community Meeting Room Jackson, MS  39213 2nd Session:  1PM – 3PM
       

 

Health Employer Data Information Set (HEDIS)

As state and federal governments move toward a healthcare industry that is driven by quality, HEDIS rates are becoming more and more important, not only to Magnolia, but to its providers as well.  Please click on the links below to access the HEDIS Quick Reference Guides.

HEDIS Quick Reference Guide Adult (PDF)

HEDIS Quick Reference Guide Women (PDF)

HEDIS Quick Reference Guide Pediatric (PDF)

Important Claims Information

As a reminder, providers have 45 days to make corrections to a submitted claim from the date of the EOP.  Please refer to page 5 in the Claims Filing Manual.

Magnolia only accepts the red and white CMS 1500 (8/05) and CMS 1450 (UB-04) paper claims forms.  Other claim form types will be rejected and returned to the provider.

The preferred methold for submitting claims to Magnolia is electronically.  Please refer to the EDI section of our website to learn more about submitting claims electronically.

 

NurseWise Triage Report

Triage reports are a brief summary of a member call to the NurseWise line and the call was deemed as a medical/triage call. NurseWise is one of the benefits that members receive from Magnolia Health Plan.  NurseWise is a 24/7/365 health information line staffed with Registered Nurses.

In an effort to communicate with providers and make them aware of what is going on with their patients, triage reports will be sent out on patients who were given instructions to see their PCP within 4 – 24 hours and/or members who were advised to seek urgent/emergent care for their medical condition.  Included on the triage report are questions asked of the member and what their response was.

Magnolia follows up with outreach calls to all members who have a triage report created.

Click the link below for an example of the triage report.

NurseWise Triage Report (PDF)

 

Attention:  Magnolia OB/GYN Providers

Modifier TH identifies “obstetrical treatment/services, prenatal and postpartum” and must be reported with each code for antepartum visits and deliveries and postpartum care. 

When billing 62319 (Epidurals), the TH modifier must be listed first and the 59 modifier listed second. 

The following chart is being provided as a reference for providers:

 

CPT Code

Billing Instructions

99201 – TH Bill  for  dates  of  service on    and after  10/01/03 only if  appropriate   to  bill   antepartum visit 1 or 2 or 3. Bill one code per visit.
99202 – TH Bill  for  dates  of  service on    and after  10/01/03 only if  appropriate   to  bill   antepartum visit 1 or 2 or 3. Bill one code per visit.
99203 – TH Bill  for  dates  of  service on    and after  10/01/03 only if  appropriate   to  bill   antepartum visit 1 or 2 or 3. Bill one code per visit.
99204 – TH Bill  for  dates  of  service on    and after  10/01/03 only if  appropriate   to  bill   antepartum visit 1 or 2 or 3. Bill one code per visit.
99205 – TH Bill  for  dates  of  service on    and after  10/01/03 only if  appropriate   to  bill   antepartum visit 1 or 2 or 3. Bill one code per visit.
99211 – TH Bill  for  dates  of  service on    and after  10/01/03 only if  appropriate   to  bill   antepartum visit 1 or 2 or 3. Bill one code per visit.
99212 – TH Bill  for  dates  of  service on    and after  10/01/03 only if  appropriate   to  bill   antepartum visit 1 or 2 or 3. Bill one code per visit.
99213 – TH Bill  for  dates  of  service on    and after  10/01/03 only if  appropriate   to  bill   antepartum visit 1 or 2 or 3. Bill one code per visit.
99214 – TH Bill  for  dates  of  service on    and after  10/01/03 only if  appropriate   to  bill   antepartum visit 1 or 2 or 3. Bill one code per visit.
99215 – TH Bill  for  dates  of  service on    and after  10/01/03 only if  appropriate   to  bill   antepartum visit 1 or 2 or 3. Bill one code per visit.
59400 – TH Closed
59409 – TH Bill for dates of service on and after 10/01/03 only if physician performs the delivery with no other services.
59410 – TH Bill for dates of   service on and   after 10/01/03.
59425 – TH Bill for dates of service on and after 10/01/03 for each antepartum visit 4, 5 or 6.
59426 – TH Bill for dates of service on and after 10/01/03 for each antepartum visit 7 and over.
59430 – TH Bill for dates of service on and after 10/01/03 when the physician   did not perform the delivery and is billing only for inpatient and office postpartum   visits.
59510 – TH Closed
59514 – TH Bill for dates of service on and after 10/01/03 only if physician performs the   delivery with no   other services.
59515 – TH Bill for dates of   service on and   after 10/01/03.
59610 – TH Closed
59612 – TH Bill for dates of service on and after 10/01/03 only if physician performs the   delivery with no other services.
59614 – TH Bill for dates of   service on and   after 10/01/03.
59618 – TH Closed
59620 – TH Bill for dates of service on and after 10/01/03 only if Physician performs the delivery with no   other services.
59622 – TH Bill for dates of   service on and after 10/01/03.

 

Submitting Claims with Correct Member ID Number

Some Magnolia network providers have submitted claims with members’ Magnolia identification (ID) numbers which contain additional alpha and/or numeric characters which are not part of the member’s ID number (i.e., 123456789P, C123456789).

For all Magnolia claims submission purposes, additional alpha and/or numeric characters in the member ID field will cause the claim to be unclean. Magnolia Member ID numbers should only contain nine (9) numeric characters and is the same ID number provided by Mississippi Medicaid. If you submit claims which have more characters than the member’s Magnolia ID number, the claim is not considered to be a “clean” claim and may cause your claim may be rejected or result in slower processing of the claim as we try to identify the member.

OB/GYN Frequently Asked Questions

How long is the postpartum period in which Magnolia Health Plan (Magnolia) will cover pregnant women after delivery? 

  • Medicaid defines postpartum services as services inclusive of both hospital and office visits following vaginal and cesarean section deliveries. Eligible pregnant women continue to be eligible for postpartum medical assistance for a sixty (60) day period beginning on the last day of her pregnancy and for any remaining days in the month in which the sixtieth (60th) day falls.

If the member’s primary insurance carrier denies maternity coverage, will the provider still have to file the primary each time for the denial and then file Magnolia for secondary? 

  • Magnolia will still require the Primary EOB denial. Provider will need to bill the primary insurance each time, get the denial letter and attach that denial EOP to the claim being submitted to Magnolia.

What if I am not contracted with Magnolia and my patient is a Magnolia member? 

  • As long as you have a Mississippi Medicaid ID number, you can continue to see the Magnolia member.
  • You will need to fill out a Prior Authorization (PA) Form and send into Magnolia. Click Here for the Prior Authorization Form.  The PA Form will need to span the length of the pregnancy.  All visits and delivery will be approved.
  • Click Here to request a Contract Request Form to become a Participating Provider with Magnolia.

Will Magnolia cover code 58563 Endometrial Ablation (Novasure)?

  • Yes, will need to have a Sterilization Consent Form signed.  Click Here to access the Sterilization Consent Form.

Will Magnolia cover code 58565 (Essure) Hysteroscopic Placement of Micro-Inserts in the Fallopian Tubes as a form of permanent sterilization?

  • Yes, will need to have a Sterilization Consent Form signed.  Clink Here to access the Sterilization Consent Form.

If a patient presents to Labor and Delivery and believes she is in labor and is evaluated with a non-stress test but does not stay the sufficient length of time to be billed as Observation Care under the APC rules, how should this be billed by the hospital?

  • If the services are less than 8 hours, the services will be considered other diagnostic services and should be billed with appropriate revenue codes and procedure codes.
  • If the services are between 8 – 23 hours, bill as Revenue Code for Observation.

 

 

Upcoming PaySpan Webinars

 

  • The PaySpan Provider Portal training includes regular webinar content, great for anyone who needs an overview of the new provider portal.
  • The new Denial Management training will cover how to search for denials using PaySpan and also how to use Denial Detector.
  • The new Mailbox Management session will cover how to activate, manage and use PaySpan mailboxes.

Register today to attend a FREE webinar about the new PaySpan Provider Portal!

To hear the audio of these webinars, call 1-866-951-1151 and enter Conference Room ID# 1254662.

 

Denial Management using PaySpan

Tuesday, September 25th NOON EASTERN TIME

https://www2.gotomeeting.com/register/687350210

PaySpan Provider Portal Training

Wednesday, September 26th 2PM EASTERN TIME

https://www2.gotomeeting.com/register/706391410

 

Denial Management using PaySpan

Tuesday, October 16th 2PM EASTERN TIME

https://www2.gotomeeting.com/register/485841242

 

PaySpan Provider Portal Training

Tuesday, October 23rd 2PM EASTERN TIME

https://www2.gotomeeting.com/register/297348642

 

Mailbox Management using PaySpan

Tuesday, October 30th 2PM EASTERN TIME

https://www2.gotomeeting.com/register/833455082

 

 

 

Cenpatico Contracting Information

As you may already be aware, MississippiCAN has carved in outpatient behavioral health benefits effective December 1, 2012.  In order to provide behavioral health services to Magnolia members as a participating provider, behavioral health providers must contract and complete credentialing with our behavioral health partner, Cenpatico.  Cenpatico is responsible for the management and claims payment of Magnolia’s covered behavioral health benefits.  Please contact Kristen Arnold, Network Implementations Manager, by email at karnold@cenpatico.com or by phone at 512-406-7231 to request a contracting packet.

 

Updates to Provider Secure Portal

Effective September 14, 2012, enhancements to the Magnolia Health Plan provider secure portal have been implemented.

These enhancements will give you:

  • Greater control of registration and user account access
  • Provide more detailed information regarding claims payment and prior authorization requests
  • Provider notification regarding prescribed devices and prescriptions

If you have any questions regarding these enhancements, please reach out to your provider relations representative.

The link below will show you some screenshots of the portal enhancements.

Provider Secure Portal Enhancements

 

Correct Way for Hospitals to bill Orthotic/Prosthetic Devices

The correct way for hospitals to bill orthotic/prosthetic devices is under revenue code 0274.

Only DME providers are allowed reimbursement for the “L” code.

Pre-Authorization Tool now available to Providers

Our convenient code look up tool will instantly let you know if you need a pre-authorization for a specific procedure, medication or revenue code.

Please click on the link below to access this new tool.

http://www.magnoliahealthplan.com/for-providers/pre-auth

Mississippi Division of Medicaid (DOM) Provider Workshops:

The Division of Medicaid, Coordinated Care, in conjunction with Magnolia Health Plan and UnitedHealthcare, will conduct MississippiCAN Provider Workshops from September 5,2012 through October 2, 2012.  It is very important for you to attend these workshops as the following topics will be covered:

  • Expansion of the MississippiCAN Program beginning December, 2012
  • New Categories of Eligibility (Some are now Mandatory)
  • Provider Enrollment and Service Limits
  • Prior Authorizations and Claims Submissions
  • Pharmacy
  • Covered and Non-Covered Services for MississippiCAN

Please open the link below for information about the upcoming DOM workshops.

DOM Provider Workshops (PDF)

Providers issuing refund checks to Magnolia

Magnolia can only accept checks in the following payee names:

  • Magnolia Health Plan
  • Magnolia Health Plan, Inc.
  • Magnolia Refund
  • Magnolia MississippiCAN (MSCAN)
  • MississippiCAN (MSCAN) Magnolia
  • Centene Corporation

If the check is made payable any other way, it has to be returned to the provider and the provider will have to void the check and reissue.

 

 

Attn:  Physical, Occupational, & Speech Therapy Providers

Dear Physical, Occupational, & Speech Therapy Providers,

Please accept my sincere thanks for the care that you provide to the members of Magnolia Health Plan.  We are grateful for your service.

Effective 8/1/2012 we will require a copy of the Individualized Education Program for any child who is receiving therapy for any type of developmental delay to be submitted with any request for therapy.  This is done so that we can assure that there is no duplication of services.  Also much of this therapy is provided through the Early Periodic Screening Diagnostic and Treatment (EPSDT) program.  Therefore effective 8/1/2012, our Utilization Management department will look to see if a child has had his/her EPSDT Screening exam.  Therapy can not be approved if the child has not had the EPSDT exam.

Again thank you for the care that you provider to Magnolia members and if you have any questions do not hesitate to contact us at (866) 912-6285 or call your provider representative.

Sincerely,

Jason B. Dees, D.O. FAAFP

Chief Medical Director

Provider Bulletin regarding transition of Home Care Services

Dear Provider:

Magnolia Health Plan (Magnolia) is pleased to announce that effective August 1, 2012, we have partnered with Univita Health, Inc. (Univita) to provide home care services[1] (durable medical equipment, home health services, home-based therapies, and home infusion services) for Magnolia members. Magnolia’s decision to partner with Univita is based on an extensive review of their demonstrated record of service excellence in providing these services in several regions of the country.

If you currently are a contracted provider with CareCentrix, Inc. (CareCentrix) for home care services, please continue working with CareCentrix through July 31, 2012 for assistance with all dates of service through July 31, 2012.

During the transition period from March 31, 2012 through July 31, 2012, Magnolia and Univita will be working with you to transition the care of Magnolia members from CareCentrix to Univita. Univita representatives will be contacting you for contracting, education, and assistance purposes during this transition period. We strongly encourage you to contract promptly with Univita, should you choose to do so.

Should you have any questions, you may contact us in the following ways:

Magnolia Provider Services Team                                                                    866-912-6285

Kisa Briceno, Director of Contracting                                                               601-863-0720

Joy Payne, Director of Provider Relations                                                       601-863-0717

David Willard, Vice President, Network Development & Contracting                     601-863-0813

We look forward to a seamless transition from CareCentrix to Univita and to your continued support of and care for Magnolia members. Please do not hesitate to contact us if we may be of assistance.

Sincerely,

David Willard, RN

Vice President, Network Development & Contracting

Magnolia Health Plan

dwillard@centene.com

 

[1] Orthotics & prosthetics (O&P) will not be contracted through Univita but will be contracted directly with Magnolia effective August 1, 2012; Magnolia’s contracting team will outreach directly to O&P providers outside of this transition of services from CareCentrix to Univita.

Attention:  Therapy Providers

In an effort to improve our prior authorization process for therapy services, we have developed a prior authorization form specifically for therapy. A copy of this form is attached and you may begin using this form immediately.  This form has items that are necessary for us to approve services.  If a child is age 3 or over, a copy of the child’s IEP must be sent with the request for therapy.   Additionally, all requests for therapy must include documentation that a home exercise program has been established in the evaluation.  Any continuation of therapy request must contain information about a patient’s adherence to the original therapy plan as well as the progress made with therapy goals.

Prior Authorization Form Therapy (PDF)

Attention:  Pain Management Providers

After review of our current prior authorization processes, our prior authorization forms, discussion with many pain management providers, and review of the medical literature we are pleased to share with you some changes we are making.  First and foremost, we have developed a specific Pain Management Prior Authorization Form that we hope will make things easier for you and your staff.  Secondly, we have clarified our general requirements for invasive pain management procedures.  In order for any invasive procedure to be authorized all of these items should be documented and submitted with the request for procedure.  These items include full documentation of the location, quality, severity, duration, context and modifying factors of the pain including how the pain interferes with activities of daily living along with appropriate documentation of the physical exam.  Documentation of a complete medical history must also be included that details use of or contraindication to non-steroidal anti-inflammatory drugs and previous physical therapy treatment.  Only one image-guided modality or procedure will be authorized at a time.  We hope this improves the process for prior authorization for you, your staff, and our patients.

You may begin using this prior authorization form immediately.

Prior Authorization Form Pain Management (PDF)

 

Important Notice from Opticare

Attention:  Magnolia Health Plan Providers

 

Effective April 2012, the following requirements for the dispensing of aspheric lenses will be enforced:

Aspheric lenses (V2410, V2430, and V2499) will only be considered medically necessary for prescriptions greater than ±4.00 diopters.

Medical necessity documentation (i.e., eyeglasses prescription, medical record with documented refraction) and a copy of the laboratory lens invoice must be submitted with the claim to be considered for reimbursement.

Paper claims:  Supporting documentation may be submitted with the CMS-1500 for claims submitted by paper.

Electronic or Web claims:  Supporting documentation may be submitted by fax for claims submitted electronically or through OptiCare’s Eye Health Manager.  The Fax Cover Sheet for Claim Attachments is available on the Provider Forms page of www.opticare.com and must be included with the supporting documentation.

Claims submitted without the required documentation will be denied.

Denials for CPT Codes 75572 – 75574

CPT codes 75572 – 75574 have been opened for reimbursement effective 1/1/2010.  Claims billed with these codes which denied for Edit 0439 – PROCEDURE NOT A BENEFIT FOR DATE OF SERVICE will be reprocessed for dates of service 1/1/2010 – 8/11/2011.  The mass adjustments will begin the week of 02/13/2012.  If you have any questions, please contact your provider representative or the Division of Medicaid.

Prior Authorizations for Plastic Surgeons

Office visits/consults (including follow-up after procedures) with plastic surgeons do not require prior authorization for par providers.  Surgery would still require prior authorization as with all other outpatient surgical procedures.

Vaccines for Children Update

The Division of Medicaid (DOM) claims processing procedures were recently modified to be in compliance with the 2009 Code Update AMA change in regards to the billing rules for immunization codes 90471 and 90473.  The AMA ruling indicated only one or the other code can be billed on a single date of service.  The recent NCCI mutually exclusive ruling also mandates certain codes cannot be billed together by the same physician on the same beneficiary on the same date of service.

DOM claims processing system will evaluate all claims by the same physician on the same beneficiary on the same date of service.  If a claim is found which indicates one of the codes has been paid, the current claim will be denied.

DOM claims processing procedures were also modified to become in compliance with the 2011 Code Update AMA change in regards to the billing rules for immunization codes 90460 and 90461 on the same date.  Both codes can now be billed on a single date of service.

Hospice Prior Authorization Medical Necessity Changes:

Effective August 15, 2011, the required documentation to support medical necessity for hospice admissions will change.  Our current guidelines only require the physician certification signed by the attending physician and the hospice medical director to be submitted for prior authorization.  Effective August 15, 2011, Magnolia Health Plan will require in addition to the physician certification, a patient election form, a history and physical by the attending physician with the terminal diagnosis listed.  All hospice prior authorizations will be evaluated for medical necessity using the medical necessity criteria developed by the Louisiana Mississippi Hospice and Palliative Care Organization.

Prior Authorizations and Filing Claims Effective 4/1/11

Magnolia Network Providers: Submitting Claims for Payment

CHCs: Submitting Claims with Correct Place of Service Code