Web Announcement 598

Progesterone Reimbursement Notification

Effective May 15, 2013, progesterone (Depo-Provera®) 400 mg injection will no longer be required to meet non-preferred criteria for reimbursement. Please continue to submit claims normally for this product.

Web Announcement 597

Enhancement to Online Prior Authorization Search Using Service Date

An enhancement has been made to the online prior authorization system to assist providers in searching for prior authorizations (PAs) on file. Previously, a provider needed to know the specific start date of a PA to search using the “Service Date.” With this current enhancement, a search will find a match against a PA on file if the “Service Date” entered by the provider is greater than or equal to the PA start date and less than or equal to the PA end date.

For example, if a PA has a start date of 05/01/2013 and an end date of 05/31/2013, a match will occur if any date in May of 2013 is entered.

Given the broadened matching criteria, a maximum number of match results will be enforced. If search criteria return more than this maximum number of results, the following error will be returned:

• Error: This search has exceeded the maximum number of results. Please add or update your search criteria so that fewer authorizations are returned.

Tip: If you receive the maximum number of results message, you can add “Member Information” (recipient ID or recipient information: first name, last name and birth date) to the search to limit the results. Another option to limit the search results is to include the servicing “Provider ID.”

Review the attached full Announcement 597 to view screenshots showing the authorization pages.

Web Announcement 596

Attention Provider Types 20, 24, 28 and 77: Prior Authorization Reminder for Psychotropic Drugs

Per Nevada Medicaid policy, prior authorizations are required for all psychotropic medications for recipients under the age of 18 years. Prior authorizations are also required for all agents used for the treatment of Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD) for children and adults. Refer to Medicaid Services Manual (MSM) Chapter 1200 for further information on pharmaceutical coverage and limitations.

Web Announcement 595

Ordering, Prescribing or Referring (OPR) Providers Required to Enroll in Medicaid

With the implementation of the Patient Protection and Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) requires all ordering, prescribing and referring physicians to be enrolled in the state Medicaid program (§455.410 Enrollment and Screening of Providers). Traditionally, most providers have enrolled in the Nevada Medicaid program to furnish covered services to Medicaid recipients and to submit claims for such services. However, the Affordable Care Act (ACA) now requires physicians or other eligible practitioners to enroll in the Medicaid program to order, prescribe and refer items or services for Medicaid recipients, even when they do not submit claims to Medicaid.

Ordering, prescribing or referring (OPR) providers do not bill Nevada Medicaid for services rendered, but may order, prescribe or refer services/supplies for Medicaid recipients. For Medicaid to reimburse for services or medical supplies resulting from a practitioner's order, prescription or referral, the OPR provider must be enrolled in Medicaid. Enrolling as an OPR provider is appropriate for practitioners who:

• May occasionally see an individual who is a Medicaid recipient who needs additional services or supplies that will be covered by the Medicaid program
• Do not want to be enrolled as another Nevada Medicaid provider type
• Do not plan to submit claims for payment of services rendered

This new requirement does not apply to orders, prescriptions or referrals for individuals enrolled in a Medicaid Managed Care Organization (MCO). It is applicable only to the Nevada Fee for Service (FFS) Medicaid program. Furthermore, the CMS Final Rule mandates that if items or services are ordered, prescribed or referred by a resident or intern, the claim must identify the teaching physician as the ordering or referring supplier and the teaching physician must be identified on the claim by his or her legal name and National Provider Identifier (NPI), and he or she must be an enrolled provider.

Physicians or other eligible professionals who are already enrolled in Medicaid as participating providers and who submit claims to Medicaid are not required to enroll separately as OPR providers.

It is important for OPR providers to understand the implications of failing to enroll in Medicaid. If you are an OPR provider, the physicians, other practitioners and facilities who actually render services to Medicaid recipients based on your order, prescription or referral, will not be paid for such items or services unless you enroll in Medicaid and your NPI is included on the claim submitted to Medicaid by the rendering provider (42 CFR 455.440).

Please note that this extends to pharmacy Point of Sale (POS) systems as well. The POS system will deny, at the time of the pharmacy transaction, any claims submitted for a Medicaid recipient with a prescriber who is not enrolled as a Medicaid provider.

Web Announcement 594

Update for PTs 20, 24 and 74 Regarding Obstetrical Delivery Claims: Resubmitted Claims Have Been Processed

Previously recouped claims for obstetrical delivery only services that provider types 20, 24 and 74 resubmitted to HP Enterprise Services by the April 1, 2013, deadline have been processed. The adjudication of the processed claims will appear on providers’ remittance advices (RAs) dated May 10, 2013.

For previous communications to providers regarding claims for obstetrical delivery only, please see Web Announcement 562, Web Announcement 563, Web Announcement 575 and Web Announcement 581.

Web Announcement 593

Updated Initial Enrollment and Re-Enrollment Applications Must Be Used

Updated Provider Initial Enrollment Applications and Provider Re-Enrollment Applications were published on the Provider Enrollment webpage on April 12, 2013. Effective June 1, 2013, only the applications dated April 12, 2013, or later will be accepted by HP Enterprise Services (HPES). Refer to the date shown in the lower left corner of each page of the applications. Previously published applications will not be accepted on or after June 1.

Application instructions are attached to each application. In addition, all providers are encouraged to review the new Provider Enrollment Information Booklet, which includes general instructions, frequently asked questions (FAQs), the list of provider types and specialties, and information for out-of-state providers.

Web Announcement 592

Provider Training in May Includes an ICD-10 Overview

The table below lists the provider workshops that will be presented by the HP Enterprise Services (HPES) training team in May.

The new ICD-10 Overview workshop will explain what ICD-10 is, when it will be required and where to find future updates.

Please review the dates, times and topics below and register now by using the 2013 Provider Training Registration Form (FA-41). All times indicated are Pacific Time (PT). For questions, contact the HPES Training Department at NevadaProviderTraining@hp.com or (877) 638-3472, option 2, then option 0, then option 4.