“Reaching across Arizona to provide comprehensive quality health care for those in need” Our...

“Reaching across Arizona to provide comprehensive quality health care for those in need”

Our first care is your health care Arizona Health Care Cost Containment System

AHCCCS Update Meeting – Systems Update – April 2014



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Cost Sharing (Copays) Minor changes implemented 1/1/14 – No longer assigning

mandatory copay levels 40 and 45 and elimination of copays for well visit codes; Minor changes to Policy 431

Addition modifications under evaluation and planned for 10/1/2014: Populations currently subject to mandatory and optional (nominal)

copayments; Populations exempt from copayments; Amounts for applicable copayments; And services for which copayment apply are planned.



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Data Exchange/Blind Spots AHCCCS will manage an ongoing exchange of encounter

and claims data to Contractors in order to eliminate “blind spots” for services provided to a member shared by multiple programs (In compliance with Federal privacy regulations)

Contractors should use this information to develop short- and long-term strategies to improve care coordination

Ongoing – provide at least quarterly; First 1/4ly report for January – March 2014 will be run and distributed in April


Data Exchange/Blind Spots (cont.) Planned additions to the Data Exchange include the

integration of - Medicare Paid Claims Data (Part D; D-SNP; Medicare FFS) – In progress

Technical Workgroup for this project held on 2/5/14; reviewed layout, questions, and exchange matrix

Addition of a requirement for 3 year history for all Acute and RBHA contractors who did not already receive them for a GSA or in whole; in progress


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DRG’s On schedule for 10/1/2014 (based upon Dates of Discharge)

Implementation DRG Project Webpage – “AHCCCS Transition to DRG-

based Payment” http://azahcccs.gov/commercial/ProviderBilling/DRGBasedPayments.aspx

Proposed Final Rule currently available for public comment/review http://www.azahcccs.gov/reporting/Downloads/ProposedStateRules/NOPRDRG03072014.pdf


DRG’s (cont.) Technical Workgroup Formed for this project; Meeting on a

regular basis; Meeting materials and key action items/discussion available at http://www.azahcccs.gov/commercial/EDIresources/EDITechnicalWorkgroups.aspx

Next Workgroup meeting Wednesday, April 16th 3 Key Forms of Project Documentation –

AHCCCS Policy Document AHCCCS Rule AHCCCS DRG Calculator


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DRG’s (cont.) Finalizing all Policy decisions which will be shared with all

Contractors as a component of the DRG Technical Workgroup

Call with 3M last week to finalize key decisions; confirm final DRG Calculator and respond to project survey

Testing 3M APR-DRG software Contractors will be provided with and will be required to

successfully execute a defined set of test scenarios


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DRG’s (cont.) Contractor monthly project Milestone Reporting began in

February, 2014 Status Summary developed for publication to the web DRG Effective Date – October 1, 2014 (IP Dates of

Discharge)


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DRG’s (cont.) Current DRG Project Milestones:

Complete Requirements and Design - In Progress - March 2014 Complete Coding – In Progress - May 2014 Internal Testing Begins - May 2014 Internal Testing Ends - July 2014 External Testing Begins (all plans/providers/ATR) - June 2014 System Implementation - September 2014 External Testing Ends (No earlier than) - September 2014


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ICD-10 The AHCCCS ICD10 Project impacted by Federal

Legislation; waiting for specific direction from CMS as to timeframes and implementation requirement; more details and updates to come pending receipt of this direction

No impact to APR-DRG project timeframes

Our first care is your health care Arizona Health

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ICD-10 (cont.) Current AHCCCS ICD10 Project Milestones

Requirements and Design Reference System - Completed Coding Reference Systems - Completed Requirements and Design All Other Systems – Completed Internal Testing Reference System - Completed Coding All other System Areas – Completed System Implementation Reference System – Completed Initial Reference Table Loads – Completed (validation of

key policy impacts completed this week to be send out ASAP)


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ICD-10 (cont.) ICD10 Reference Table Extracts for Contractors –

Distribute this week Internal Testing All Other Systems – In Progress External Testing Began - January 2014 (with incremental begin

dates as noted below) 837 Submissions (Claims/Encounters) - January 15th 2014 – In

Progress/supported ongoing Claims/Encounters Editing and Results Reporting (End to End) –

March 15th 2014 – In Progress/supported ongoing Reports – June 1st 2014 ICD10/DRG Integrated End to End – June 1st 2014


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ICD-10 (cont.) System Implementation - September 2014 ICD10 Effective Date TBD (Professional and Outpatient

dates of service; Inpatient dates of discharge) External Testing Ends No earlier than September 2014 Status Summary developed for publication to the web Contractor Milestone Reporting and Tracking ongoing

(began in June 2013); “Thanks to all for your timely submissions”


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ICD-10 (cont.) Contractors will be provided with and will be required to

successfully execute a defined set of test scenarios likely during and in conjunction with the ICD10/DRG Integrated End to End testing timeframe

Webpage - http://azahcccs.gov/commercial/EDIresources/ICD10.aspx


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FQHC/RHC FQHC/RHC Payment Alignment

MCO’s will need to pay FQHC/RHC unique PPS rates for each “visit” (separate service not with same discipline)

Timeline October 1, 2014 implementation Provider registration letter and spreadsheet (will go out by May 2014,

due by 8/15/14) Testing window for plans and providers (late July 2014 – early

August 2014)


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FQHC/RHC (cont.) AHCCCS Proposal for FQHC/RHC Processing

AHCCCS will establish a unique provider type for FQHCs and a unique provider type for RHCs; Provider types 29 and C2

AHCCCS is requesting that all FQHCs and RHCs register and obtain a unique AHCCCS Provider ID under these applicable provider types

To facilitate this registration and AHCCCS claims processing, AHCCCS is requesting that FQHCs or RHCs have a unique NPI (not already associated with any other active AHCCCS Provider ID) to be on file and utilized for related claims submissions

AHCCCS will provide a streamlined approach for provider registration


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FQHC/RHC (cont.) FQHC and RHC claims will identify the unique NPI of the FQHC or

RHC as the service/rendering provider FQHCs and RHCs can be reimbursed on same day for each “unique”

visit, i.e. a separate service not within same discipline (e.g. dental and medical); no change from the current process

FQHCs and RHCs will bill AHCCCS and its Contractors for each “unique” visit utilizing appropriate CPT Evaluation and Management codes and including all related services for the visit utilizing a 1500 claim format (standard practice for most facilities)

FQHCs and RHCs will be paid an all inclusive "visit" rate per visit that will serve a full reimbursement for the individual visit regardless of other related services for the visit


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FQHC/RHC (cont.) Visit payments will be paid associated with the billed E&M “visit”

codes and any other related services will be valued at $0.00 AHCCCS will implement a unique Provider specific fee schedule

(equivalent to the PPS rate) for each FQHC and RHC where visit E&M codes will reflect the appropriate per visit rate effective for the date of service and in which all other related service codes will reflect a rate of $0.00 (due to bundling under the per visit rate as noted above)

Current FQHC Pharmacy (340B) billing will remain as is under the Pharmacy provider type, etc... and will not be impacted by this change


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FQHC/RHC (cont.) AHCCCS will continue to have a quarterly payment and reconciliation

process but the amounts that are part of the quarterly payments will be updated to reflect that health plans will be paying considerably more to avoid recoupments as part of the reconciliation


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PCP Rate Parity Payment of new claims, and 4 month window for retro

processing concluded 11/30/2013 AHCCCS is working with individual contractors to ensure

that all encounters eligible for the PCP Rate Parity have been appropriately identified and reprocessed

AHCCCS will make quarterly cost-settlement payments to the Contractor based upon adjudicated/approved encounter data.

Contractors will be required to refund payments to AHCCCS for any reduced claim payments in the event that a provider is subsequently “decertified” for enhanced payments


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PCP Rate Parity (cont.) Contractors will receive an initial limited data (i.e. one

month) cost-settlement report to allow for an initial test ASAP

First full cost-settlement report for PCP Rate Parity qualified encounters adjudicated/approved between 8/1/2013 and 12/31/2013 is in progress for distribution to Contractors no later than the week or April 21st

Please note, all valuation by AHCCCS reflects appropriate rates in effect for the encounter date of service (i.e. dates of service 1/1/14 and after will reflect the 1/1/14 PCP rates, etc…)


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Security Audit Reminder - First audit will be due June 1, 2014 Minor clarifications made to published policy in response to

additional Contractor feedback made and distributed in January


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AHCCCS >99 Encounter Lines AHCCCS 999 UB Lines HIPAA compliance changes

proposed for 1/1/2015 Will fully remediate the PMMIS system to expand the CRN

by 1 additional digit


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Other Implemented new Maricopa RBHA and Integrated SMI

Contractor 4/1/14


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