1. Molina Spring Workshops 2018

2. Enterprise Health Solutions (EHS) Processing Platform
West Virginia Family Health Plan (WVFH) transitioned to the EHS claims processing platform on 1/1/18. The system transition will provide you with improved service and responsiveness by integrating resources and expertise into a single point.
This upgrade, to an innovative and efficient system, will allow for timely, accurate payments and combined operations functionality.
EHS updates are available on our website at
If you have any questions about these changes, please call us at
to speak directly with Provider Services.

3. Navinet Enhancements The following transaction are now available:
Eligibility and Benefits
Claims Status Inquiry
Allowance Inquiry
Cash Management
EOB/Remittance
Enhanced Provider Features
Enhanced Provider Features transactions feature:
Provider Directory
NIA RadMD Authorizations
Claims Investigations (no change from current process)
Authorizations for J-codes ONLY
* Availability may vary depending on your office type

4. Allowance Inquiry
Allowance Inquiry allows you enter in the criteria to allow you to determine a Base Reimbursement* per Code/Modifier
* Plan Design Coinsurance, Deductibles, & Limitations & Exclusions may affect actual rate paid

5. EOB and Remittance: Search
This feature allows you to search by Billing Provider in 2 week increments. 6 months of history is kept in this section, too!
Click in Billing Provider box to display the available selections. Next choose your beginning and ending date (no more than 14 days a time)

6. EOB and Remittance: Search Results
Search results not only allow you to view by Statement Date, Provider #, Check #, & Check Amount, but you can also Download the PDF to save, print, or .

7. Appeal Request / Claim Dispute
Step #1: Select New Request/Dispute
Step #2: Choose your type of request

8. What will change for Providers?
Member ID Cards
Addresses (effective 1/1/2018)
Medicaid General Correspondence: P.O. Box , Camp Hill, PA
Medicaid Claims: P.O. Box , Camp Hill, PA
Medicaid Checks: P.O. Box , Camp Hill, PA

9. New Explanation of Payment (EOP)
Claim Denial Reason/Adjustment reason
Patient Information – including benefit and member type information
Claim Information – billed services
Basic payment information – pricing detail, member cost share, etc.

10. WVFH Key Contact Claim Information
Timely filing criteria: 365 calendar days after Date of Service, 180 days from primary payment or denial of claim
EPSDT’s for data reporting we prefer 60 days from the date of service
Timely filing for denied authorization appeals is 90 days
Timely filing for denied claim appeals is 180 days
Include current practitioner information, such as your NPI Number on electronic claims
Include current member information, such as WVFH Member ID number
WVFH accepts electronic claims through Emdeon and Relay Health
CPID and Payer ID 45276

11. Consumer Assessment of Healthcare Providers and Systems (CAHPS)
CAHPS measures a member’s experience with their:
Providers
Health Plan
Overall Health Care
Measures involving providers:
Getting Needed Care
Getting Care Quickly
Coordination of Care
Shared Decision Making
Health Promotion and Education
Rating of Personal Doctor
Rating of Specialist

12. Consumer Assessment of Healthcare Providers and Systems (CAHPS)
What can providers do?
Continue to provide excellent care
Review WVFH’s Accessibility Standards
Work with your patient to make decisions about their health care
Request that your patient keep you updated on care they receive from other providers
Educate members on how to prevent illness and how they can be healthy

13. Consumer Assessment of Healthcare Providers and Systems (CAHPS)
Other measures providers can impact
Advising smokers & tobacco users to quit
Discuss smoking cessation strategies with your patients
Refer them to the Quitline
Flu vaccination
Recommend that your patients receive a vaccine every year
Educate on the benefits of the flu vaccine
Correct misconceptions about the vaccine

14. MEDICATIONS TO REQUIRE MEDICAL PRIOR AUTHORIZATION EFFECTIVE MARCH 5TH, 2018
The prior authorization* process will apply to all West Virginia Family Health members.
NaviNet is the most efficient means to request authorization for using autofill functionality.
If you have trouble completing an authorization or have an issue with accessing NaviNet, contact your Provider Account Liaison.
J1300
J1561
J1745
J9355
J1322
J1566
J9042
J3490
J1459
J1568
J9228
J3590
J1556
J1569
J9271
J9999
J1557
J1572
J9299
J1599
J9305
HCPCS codes requiring
authorization on or
After 3/5/18
*Outpatient services only. Authorization requests for the following medication classes / medications should be directed to the WV Rational Drug Therapy Program: Hemophilia, Spinraza, and Hepatitis C

15. WVFH Key Contact Claim Information
WVFH Subcontractors
Behavioral Health
Beacon
Vision
Davis Vision –
In network claims must file electronically
Dental
United Concordia Dental (UCD) /Scion –
Member Services, Dental Referrals and Authorizations
Radiology
NIA –
Authorization – Diagnostic Imaging contact
Nurse Line (24/7 availability)
For more information regarding Medical, Vision, and Dental contacts and mailing addresses,
visit us online at

16. Behavioral Health Beacon
John Marks - Program Director Sheila Kelly - Case Manager
Electronic BH Payer ID:
Member Information, Claims, Authorizations –
Contact Beacon to assist with registering for eServices access
Visit Beacon online at

17. NaviNet Is The First Point of Contact
Provider Resources
NaviNet Is The First Point of Contact
Provider Services – phone claim review request fax line Jason Landers – President Jean Kranz - Director, Medicaid Operations
Lisa Shaffer - Senior Provider Contract Analyst
Kim Hammond - Manager Provider Relations
Website –
Provider Manual, Directory (Audit Record), Bulletins, Policy & Procedures

18. Provider Account Liaison’s Territories

19. WVFH Disease and Case Management
Disease & Case Management - Providers and Member Referrals Welcome!
Call WVFH at to reach our Case Management Department, Monday through Friday 8:30 am to 4:30 pm
Case Managers work with members who have multiple chronic conditions, high coordination risk, frequent hospitalizations, high ED utilization, complex/special needs, high risk maternity needs, and/or transition management needs. Case managers focus on care coordination, collaboration, education, addressing care gaps, and patient self-management.
Disease Management programs are aimed at improving the health outcomes for our members with COPD, Asthma, Cardiac Disease, and Diabetes.

20. WVFH Disease and Case Management
Growing Up/EPSDT program is focused on identifying children’s health problems early and to keep checking to be sure those children stay healthy.
Mom Matters® program offers support to pregnant members including ongoing care monitoring, evaluation, education and tailored interventions through pregnancy and up to one year post delivery.
Wellness Coaches are available for targeted member inventions including a Nutritionist, Certified Diabetes Educator, and a Rehabilitative Coach.

21. WVFH Value Added Services and Wellness Rewards
2018 Wellness & Reward Incentives (Value Adds) for Member and Provider
Diabetics ages who have completed the following three exams: HbA1C blood test, nephrology exam, and diabetic eye exam – $50 Member
Preventive dental care during pregnancy and 6 weeks postpartum
Smoking Cessation Quit Line ( ) for members who are trying to quit smoking
Phone Service – Free cell phone with text, data, and voice
Maternity to Post Partum - Member $150 potential + Provider Incentive $200 PRSI
DHHR notification by month 5 of pregnancy – $50 member reward
Well visit – Adults and children - Member $25 annually
Dental exam for 2-3 year old children – $25 Member
24 Hour Nurse Line ( )

22. West Virginia Family Health Thanks You All For Coming!
Questions?