March 2023

Provider-Patient Relationship Tips

Patient‐Provider engagement is a priority for the VillageCareMAX provider network. VillageCareMAX is committed to supporting our providers in delivering the highest quality care and experience.

The CAHPS surveys ask patients about their experiences with their providers; both PCPs and specialists.

The information below contains advice to help guide the patient‐provider experience.

Appointments:

·        Maintain access and availability standards.

·        Offer convenient appointment times.

·        Consider offering telemedicine appointments.

·        Notify patients early if long wait times are expected.

·        Do your best to see your patients within 15 minutes of their appointment time. Patients are asked if the person they came to see saw them within 15minutes.

·        Immediately schedule follow‐up appointments to ensure continuity of care.

·        Assist members with scheduling appointments with specialists.

·        Share health records with patients’ other providers to keep everyone informed.

Patient Interaction:

·        Review the patient’s medical record prior to entering the room. Patients are asked if their

doctor knew their medical history.

·        Ensure the patient is comfortable; this will help them open up and share their concerns.

·        Use language the patient can understand when reviewing test results and explain how these

test results relate to their current health.

·        Be sure patients understand their treatment regimen.

·        Ask patients about their treatment goals and assess treatment options against those goals.

·        Ask patients about other doctors and specialist they have seen

·        Discuss urinary continence and treatment options for incontinence.

·        Discuss tobacco use and cessation treatment options, when applicable.

·        Encourage patients to get a flu vaccine for the flu season.

·        Use the VillageCareMAX Gaps in Care reports to identify clinical services needed.

Medication Review:

·        Review patient medications during office or telehealth visits and emphasize the importance of

adhering to these medications.

·        Prescribe an extended days’ supply of 90‐day fills whenever possible to support adherence.

·        Reconcile medications post hospital discharge.

Public Health Emergency (PHE) 1135 Waivers: Updated Guidance for Providers

On February 9, the Department of Health and Human Services (HHS) announced the Public Health Emergency (PHE) for COVID-19 will end on May, 11, 2023. COVID-19 remains a significant priority for the Biden-Harris Administration and over the next several months, the Centers for Medicare & Medicaid Services (CMS) will work to ensure a smooth transition. During the PHE, CMS has used a combination of emergency authority waivers, regulations, enforcement discretion, and sub-regulatory guidance to ensure easier access to care during the PHE for health care providers and their beneficiaries.

Some of the flexibilities that were created during the pandemic were recently expanded by the Consolidated Appropriations Act, 2023. Others, while critical during our initial responses to COVID-19, are no longer needed. CMS has made further updates to our CMS Emergencies Page with useful information for providers – specifically around major telehealth and individual waivers – that were initiated during the Public Health Emergency (PHE).

Please reference the following guidance in response to the PHE ending May 11, 2023:

Provider-specific fact sheets about COVID-19 Public Health Emergency (PHE) waivers and flexibilities: https://www.cms.gov/coronavirus-waivers

CMS COVID-19 Waivers and Flexibilities for Providers include:

•        Physicians and Other Clinicians 

•        Hospitals and CAHs (including Swing Beds, DPUs), ASCs and CMHCs

•        Teaching Hospitals, Teaching Physicians and Medical Residents

•        Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities)

•        Home Health Agencies 

•        Hospice

•        Inpatient Rehabilitation Facilities

•        Long Term Care Hospitals & Extended Neoplastic Disease Care Hospitals

•        Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)

•        Laboratories

•        Medicare Shared Savings Program

•        Durable Medical Equipment, Prosthetics, Orthotics and Supplies

•        Medicare Advantage and Part D Plans

•        Ambulances

•        End Stage Renal Disease (ESRD) Facilities

•        Participants in the Medicare Diabetes Prevention Program

•        Intermediate Care Facility for Individuals with Intellectual Disabilities

Department of Health & Human Services Fact Sheet: https://www.hhs.gov/about/news/2023/02/09/fact-sheet-covid-19-public-health-emergency-transition-roadmap.html

Pharmacy Corner

Our Pharmacy department provides important updates through its Pharmacy Corner newsletter, available on the Providers page of our website. Read this month about Medication Adherence, Comprehensive Medication Review (CMR) Billing Codes, Real Time Benefit Check program, Choice 90 Program, Refill Reminder Program, and Formulary.

The newsletter can be accessed by visiting:

www.villagecaremax.org/prescription-drug-benefit#Pharmacy_Corner

Risk Adjustment Coding Corner

A Medicare Annual Wellness Visit (AWV) is an opportunity to promote quality, proactive, cost-effective care. 

Who can perform an AWV: A physician, PA, NP, certified clinical nurse specialist or a medical professional under the direct supervision of a physician (including health educators, registered dietitians and other licensed practitioners) can perform AWVs.

AWV documentation

Document all diagnoses and conditions to accurately reflect severity of illness and risk of high-cost care to the appropriate specificity.

AWV coding 

An ICD-10 Z code is the first diagnosis code to list for wellness exams to ensure that member financial responsibility is $0.

• Z00.00 — encounter for general adult medical examination without abnormal findings

• Z00.01 — encounter for general adult medical examination with abnormal findings

The CPT® codes used to report AWV services are:*

• G0402 — Welcome to Medicare visit

• G0438 — initial visit**

• G0439 — subsequent visit (no lifetime limits)

• G0468 — FQHC distinction for billing an AWV visit 

 **Additional services ordered during an AWV may be applied toward the patient’s deductible and/or be subject to coinsurance. Before performing additional services, discuss them

with the patient to verify that the patient understands their financial responsibilities.

More information

https://www.medicare.gov/coverage/yearly-wellness-visits

•  *CPT® is a registered trademark of the American Medical Association.

Provider Quick Reference Information

Click the following link to access the VIllageCareMAX Provider Manual and Quick Reference Guides on the VillageCareMAX website: https://www.villagecaremax.org/provider-manual/

Please refer to below grid for your account manager’s contact info, and if any questions or you need to confirm who your account manager is, please contact our team at ProviderRelations@villagecare.org. 

Provider Relations Account Manager Contact Info:

Behavioral Health Services Update

Beacon Health Options is now Carelon Behavioral Health.

As of January 1, 2023, VillageCareMAX has partnered with Carelon Behavioral Health (formally known as Beacon Health Options) to administer MAP and DSNP behavioral Health benefits. All Utilization Management (UM), Care Management (CM), Provider Relations (PR), Claims processing, and Call Center Operations related to behavioral health will be managed by Carelon Behavioral Health.

For inquiries around behavioral health services for VillageCareMAX MAP and DSNP members or to become a participating behavioral health provider in the Carelon network, please contact Carelon directly at 800-397-1630 or online at www.carelonbehavioralhealth.com/providers. 

Any claims relating to covered Behavioral Health services must be submitted to Carelon for payment

Important Information for Carelon Behavioral Health:

•        Phone #: (800) 397-1630

•        Join Carelon Behavioral Health: www.carelonbehavioralhealth.com/providers/join-our-network

•        Availity is the multi-payer portal for submitting the following transactions:

·        Claim Submissions (Direct Data Entry Professional and Facility Claims) applications or EDI using the Availity EDI Gateway

·        Eligibility & Benefits

·        Claim Status

For more information regarding claims submissions and eligibility, benefits and claim status please click here: https://s21151.pcdn.co/wp-content/uploads/2.18.22-Availity-Transition_Updated-Provider-FAQ_FINAL.pdf

Nursing Homes

Revenue Codes for Medicaid Covered Services

Please refer to below grid to ensure your billing systems are updated with the standardized Revenue codes for Medicaid covered days. Please click the following link for more information from NYS DOH:

https://www.health.ny.gov/facilities/long_term_care/reimbursement/nhr/benchmark/jun2015_benchmark_letter.htm

Current IRS W-9 Forms

VillageCareMAX Requires all Providers to submit current IRS-W-9 Forms. Failure to do so may result in claims related issues including, but not limited to, the pending and denial of claims. The IRS W-9 Forms must also be submitted if the Provider's Taxpayer Identification Number (TIN) information changes.

A current Form W-9 is required to ensure that VillageCareMAX Identifies the correct provider for payment and complies with IRS rules.

Please submit a current W-9 to ProviderRelations@VillageCare.org or via fax (718) 517-2698 if this has not previously been sent.