1. WEST VIRGINIA MEDICAID BEHAVIORAL HEALTHCARE Single Point of Data Submission to APS and MCOs Integrated Resource Group, Inc. d/b/a

2. Single Point of Data Submission

4. CareConnection® Data Set / EDI File  No structural changes  No changes to allowed values with the exception of MCO- specific instructions for completion of:  CASE_DISCUSSION_TEXT_FIELD (Tier: Core)  TREATMENT_PLAN_SUMMARY_OTHER (Tier: Outpatient) PROVIDER TO APS DATA SETS / FILES

5. Single Point of Data Submission Service Request Data Set / EDI File  File length remains same  Existing Filler Positions Used: MCO Defined & Required:  MEMBER_PREGNANT  PLACE_SERVICE  PCP_COMMUNICATION  FREQUENCY_UNIT_USE  REQUESTED_UNIT APS Defined & Required:  COVERAGE_INDICATOR PROVIDER TO APS DATA SETS / FILES

6. Single Point of Data Submission PROVIDER TO APS SERVICE REQUEST COVERAGE_INDICATOR The Coverage_Indicator is an APS Mandatory Field, which the Provider completes indicating the desired recipient of the data being submitted for a member when seeking prior authorization for a Medicaid service. Allowed Values: 01 UniCare 02 The Health Plan 03 CareLink 04 APS Healthcare

7. Single Point of Data Submission PROVIDER TO APS SERVICE REQUEST FILE Is the member pregnant? Member_Pregnant 1 = Yes 2 = No 3 = Unknown Place of ServicePlace_Service See Place_Service Listing (45 Allowed Values) Has there been PCP Communication ? PCP_Communication 1 = Yes 2 = No

8. Single Point of Data Submission PROVIDER TO APS SERVICE REQUEST FILE Frequency of Appointments/ Visits Frequency_ Unit_Use 01 = Daily 02 = Twice per Week 03 = 3 Times per Week 04 = Weekly 05 = Biweekly 06 = Monthly 07 = Quarterly 08 = Semiannually 09 = Annually 10 = PRN or Other The Number of Units/Events/ Visits being Requested. Requested_ Units Units should be stated consistent with coding as set forth in BMS fee schedules

9. Single Point of Data Submission SERVICE REQUEST: PLACE OF SERVICE 01 = Pharmacy 03 = School 04 = Homeless Shelter 05 = Indian Health Service Free-Standing Facility 06 = Indian Health Service Provider-Based Facility 07 = Tribal 638 Free-Standing Facility 08 = Tribal 638 Provided-Based Facility 09 = Prison/Correctional Facility 11 = Office 12 = Home 13 = Assisted Living Facility 14 = Group Home 15 = Mobile Unit 16 = Temporary Lodging 17 = Walk-in Retail Health Clinic 20 = Urgent Care Facility

10. Single Point of Data Submission SERVICE REQUEST: PLACE OF SERVICE 21 = Inpatient Hospital 22 = Outpatient Hospital 23 = Emergency Room - Hospital 24 = Ambulatory Surgical Center 25 = Birthing Center 26 = Military Treatment Center 31 = Skilled Nursing Facility 32 = Nursing Facility 33 = Custodial Care Facility 34 = Hospice 41 = Ambulance - Land 42 = Ambulance - Air or Water 49 = Independent Clinic 50 = FQHC 51 = Inpatient Psychiatric Facility

11. Single Point of Data Submission SERVICE REQUEST: PLACE OF SERVICE 52 = Psychiatric Facility - Partial Hospitalization 53 = Community Mental Health Center 54 = Intermediate Care Facility/Mentally Retarded 55 = Residential Substance Abuse Treatment Facility 56 = Psychiatric Residential Treatment Center 57 = Non-Residential Substance Abuse TX Facility 60 = Mass Immunization Center 61 = Comprehensive Inpatient Rehabilitation Facility 62 = Comprehensive Outpatient Rehabilitation Facility 65 = End-Stage Renal Disease Treatment Facility 71 = Public Health Clinic 72 = Rural Health Clinic 81 = Independent Laboratory 99 = Other Place of Service

12. Single Point of Data Submission PROVIDER TO APS SERVICE REQUEST FILE FIELD #APS FIELD NAMELENGTHSTARTEND 1agency_id101 2consumer_id11 21 3Service_Code52226 4Service_Code_Modifier_122728 5Service_Code_Modifier_222930 6Filler23132 7APS_Service_Code_Modifer23334 8Service_Start_Date103544 9Prov_Medicaid_Code114555 10Agency_Trans_Id105665 11Provider_NPI106675 12Taxonomy107685 13Coverage_Indicator28687 14Member_Pregnant188 15Place_Service28990 16PCP_Communication29192 17Frequency_Unit_Use29394 18Requested_Units59599 19Filler36100135

13. Single Point of Data Submission