Spring 2020 Edition
Get More Information Online
We would like to remind you about important information available on our website (www.chpw.org). If you have any questions about accessing our website or would like to get more information or paper copies of any of the following items, contact our Customer Service team at 1-800-440-1561 (TTY Relay: Dial 711), Monday through Friday, 8 a.m. – 5 p.m.
You can view and/or download information about the following topics on the website:
- Our Quality Improvement Program including goals, processes, and outcomes as related to care and service.
- The process to refer members to Case Management.
- The process to refer members to Population Health Management.
- Our Population Health Management programs, including how to use the services and how we work with a practitioner’s patients in the program.
- Our adopted clinical practice guidelines.
- Our medical necessity criteria, including how to obtain or view a copy. Information about the availability of staff to answer questions about Utilization Management (UM) issues.
- The toll-free number to contact staff regarding UM issues.
- The availability of TDD/TTY services for hearing impaired members who need these special telephone lines.
- Information about how members may obtain language assistance to discuss UM issues.
- Our policy prohibiting financial incentives for UM decision-makers. Our pharmaceutical management procedures.
- A description of the process to review information submitted to support a practitioner’s credentialing application, correct erroneous information and, upon request, to be informed of the status of the credentialing or recredentialing application.
- Our member rights and responsibilities statement. Our Provider Manual.
CHPW has a COVID-19 specific FAQ and Bulletin that is updated regularly with policies, billing information, resources and CHPW specific programs. This information can be accessed on the website or email firstname.lastname@example.org to be added to the mailing list. Some highlights from these bulletins include:
- Medicaid Billing – CHPW is following HCA guidance on billing that can be found on their COVID-19 Information website.
- Medicare Cost-Share – During the COVID-19 outbreak, CHPW is waiving Medicare member cost-sharing (copays, deductibles and coinsurance) for covered services for COVID-19 related tests and treatments. This applies regardless of where services take place including, but not limited to, telehealth, primary care physician visits, specialty physician visits, hospital stays, labs, home health, and ambulance services.
- Telehealth – CHPW has been coordinating with the Behavioral Health Institute to develop and coordinate training and support statewide for telehealth for behavioral health providers. The new website contains resources and information on training, including the reoccurring, twice a week telehealth trainings. Find additional information and resources for the changing landscape of telehealth delivery, including billing, privacy rules and implementation support in the provider bulletin.
Payment for Opioid Treatment Programs Services Effective January 1, 2020
Beginning January 1, 2020, for dually eligible beneficiaries who receive Opioid Treatment Programs (OTP) services through Medicaid, Medicare will become the primary payer for OTP services.
- “Dual-eligible beneficiaries” means people enrolled in both Medicare and Medicaid, including members of CHPW’s Special Needs Plan 014.
- Medicare will pay for OTP through bundled payments for opioid use disorder (OUD) treatment services.
- OUD services include toxicology testing, medication-assisted treatment (MAT), and counseling.
Per the Centers for Medicare & Medicaid Services (CMS), Medicaid must pay for OTP services “delivered to these beneficiaries by OTP providers who are not yet enrolled in Medicare but are enrolled in Medicaid, to the extent the service is covered in the state plan.”
Medicare allows providers to retroactively (retro) enroll back to 30 days prior to the date of the decision that the provider is qualified. The provider can then bill for dates of service (DOS) effective back to the 30 days.
New HCPCS G codes will be used for reimbursement by Medicare.
Please refer to the following CMS resources for more information:
- Opioid Treatment Program (general information about OTP)
- CY2020 Final Payment Rates for Opioid Treatment Program (OTP) CMS-1715F (for specific HCPCS G codes)
- Opioid Treatment Program Providers, a list of providers enrolled in Medicare under the Opioid Treatment Program
Medicare-enrolled providers should notify the Washington State Health Care Authority (HCA) upon approval of Medicare enrollment.
If providers have the capacity to do so, they may complete a self-audit, review their own claims, and submit adjustments or voids after Medicare has made payment. Providers who self-audit and send a check as an adjustment should include supporting documentation indicating the claim(s) to which the check is applicable.
Providers will now submit claims to CHPW (or the applicable Managed Care Organization) along with the Medicare Explanation of Benefits (EOB) per the standard Coordination of Benefits (COB) process. This includes claims that are within the 30-day retro enrollment timeframe.
CHPW will continue to pay OTP claims after January 1, 2020 for dual-eligible members. We will not impose system edits to automatically deny such claims because Medicare is now the primary payer for OTP services. CHPW will pay the G codes if we receive a Medicare EOB with the claim. If not, and a provider bills CHPW using the H codes, CHPW will process the claim as the primary payer and not deny for an EOB. When a provider becomes enrolled with Medicare, the provider will bill only G codes for these services and CHPW will pay as secondary.
If you have questions about the changes for payment of OTP/OUD services, please contact our Customer Service Department at:
CHPW Washington Apple Health Integrated Managed Care (IMC) Customer Service: 1 (800) 440-1561 (Toll Free) Monday through Friday, 8am to 5pm CHPW Medicare Advantage Customer Service: 1 (800) 942-0247 (Toll Free) 7 days/week, 8am to 8pm
Medicare Advantage Dental Codes
CHPW would like to clarify the categories and ranges of dental codes that we cover for our Medicare Advantage plans. Please note that dental benefits and coverage vary by plan.
- Preventive dental benefit: D0100-D0330, D1000-D1999
- Comprehensive dental benefit:
- Diagnostic dental: D0340-D0999
- Restorative dental: D2000-D2999
- Endodontic dental: D3000-D3999
- Periodontics dental: D4000-D4999
- Prosthodontic dental: D5000-D5999
- Implant dental: D6000-D6199
- Prosthodontic “fixed” dental: D6200-D6999
- Oral/maxillofacial dental: D7000-D7999
- Orthodontic dental: D8000-D8999
If you have any questions, please contact Customer Service at 1-800-942-0247.
Apple Health (Medicaid) Facility Readmissions
A readmission is when a CHPW Apple Health (Medicaid) member (patient) is discharged from and admitted to the same hospital or facility for similar or related conditions within zero to two (0-2) calendar days of discharge. CHPW considers all such readmissions as a continuation of the initial treatment.
CHPW does not reimburse inpatient hospitals for related readmissions billed as separate episodes of care or reimburse for multiple claims in those circumstances. Instead, CHPW combines reimbursement when the readmissions occurred within zero to two (0-2) calendar days of discharge of the prior admission.
If CHPW determines that one of the following criteria applies, the readmission(s) must be combined with the prior admission:
- Clinically related readmissions; or
- Planned readmissions or leaves of absence; or
- Related services for one episode of care; or
- Related services billed as two (or multiple) separate inpatient episodes of care; or
- The member is readmitted to the same hospital or an affiliated hospital and the readmission is for the same or related diagnostic related group (DRG) as the prior admission.
If any the above criteria apply, CHPW will deny the claim and instruct the facility to bill the entire inpatient stay as one claim. If the provider already submitted the initial admission claim, CHPW will instruct the provider to submit a corrected claim combining the stays, using type of bill (TOB) 117 (Replacement of Prior Claim).
In addition to the above, CHPW follows the Apple Health contract requirements, titled Fourteen-Day Readmission Review Program , for identification, post payment review, and reporting of potentially preventable readmissions.
Pharmacy & Therapeutics Committee
New policies for Daraprim and Continuous Glucose Monitoring Systems (CGMS) were approved by CHPW P&T Committee. See our formulary below: https://www.chpw.org/for-members/pharmacy/apple-health-formulary
Zero Copays for Visits for Management of Certain Chronic Diseases for All Our Medicare Members:
An important part of managing chronic conditions is having dedicated follow up clinic visits to address those conditions. The copays can be prohibitive for many patients.
CHPW has long believed it is contradictory to encourage members to seek treatment to address chronic illness while still requiring copays and coinsurance that often serve as barriers to care. To decrease barriers to appropriate follow-up, we are reducing the copay to zero for visits to address the following conditions:
Chronic obstructive pulmonary disease (COPD): The copay will be zero for visits to primary care and pulmonology for a primary diagnosis related to COPD. Copays for Oxygen DME will also be zero for members with COPD.
Diabetes: The copay will be zero for visits to PCP, endocrinology, ophthalmology or optometry for a primary diagnosis related to Diabetes (or diabetic retinal exam).
Heart failure: The copay will be zero for visits to PCP and cardiology with a primary diagnosis related to Heart Failure.
Clinical Coverage Criteria Updates for November 2019-February 2020
CHPW regularly updates its Clinical Criteria. The criteria summary of changes can be found here: https://www.chpw.org/resources/UM_documents/Pharmacy_Clinical_Coverage_Criteria/Cinical-Coverage-Criteria-Policies.pdf
Provider and Staff Training Programs
CHPW is committed to provide training and education to our Providers and their Staff. We are dedicated to develop your knowledge and understanding through a variety of mandatory and optional training programs.
To access our online training programs, go to our website at www.chpw.org. From the home page, select “For Providers” and from the menu, select Orientation, Training and Education.
If you prefer an in-person training session, or if you have any questions regarding our training programs, please contact our Provider Relations Department at Provider.Relations@CHPW.org
Reporting Changes in Provider Information
All CHPW providers must give notice to CHPW at least 60 days in advance of any provider changes including, but not limited to:
- Tax identification
- NPI number (individual and/or group)
- Billing (vendor) address
- Office phone and fax numbers
- Service location address updates
- Provider additions (include provider effective date)
- Provider terminations (include provider termination date)
- Clinic/facility location additions/changes (if applicable, include effective and termination dates for your clinics and/or facility)
Advance notice for changes will provide CHPW ample time to update all systems, notify members, and prevent claims payment delays. Provider and group changes should be reported to CHPW by completing a Provider Add Change Term Form and/or Clinic and Group Add Change Term Form (available on the Provider Forms and Tools page of our website). Simply complete and submit the online form or email your completed form to Provider.Changes@chpw.org.
For new providers requiring credentialing, please submit a full credentialing application to Provider.Credentialing@chpw.org.
For Delegated Credentialing provider groups, please refer to and follow your delegated credentialing agreement. Delegated Credentialing provider groups should submit provider updates via email to DelegatedCredentialing@chpw.org.
We welcome your feedback and future topic ideas.
Email us at: Provider.Relations@chpw.org
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