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Prior Authorization for Drug Claims and Modifier JW If you are billing a drug that requires prior authorization (PA), the PA must be approved for the drug, without

modifier JW.

If the entire vial is not administered, please bill one line with the drug and units administered (PA required [as

applicable by code] and no modifier used). Bill another line, on the same claim, with the drug and units left in

the vial. (Must use modifier JW and PA is not required for this line).

If the entire vial is administered, bill one line with the drug and units administered (PA required [as applicable

by code] and no modifier used) only.

For additional information, please see https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/HospitalOutpatientPPS/Downloads/JW-Modifier-FAQs.pdf and https://www.cms.gov/Regulations-

and-Guidance/Guidance/Manuals/downloads/clm104c17.pdf.

Discontinuing Use of L1 Modifier Effective for claims with dates of service 1/1/17 and after, L1 modifier will no longer need to be attached to

laboratory codes on outpatient claims. CMS is discontinuing the use of the L1 modifier and will be packaging

most lab tests, with a few exceptions, if they appear on a claim with other hospital outpatient services. DVHA

will be aligning with CMS by also discontinuing the use of the L1 modifier as of January 1, 2017.

Closed for New Year’s Day Holiday The DVHA and Hewlett Packard Enterprise offices will be closed Monday, January 2, 2017 in observance of

the New Year’s Day holiday.

Server Maintenance - January 8, 2017 The Provider Web Portal server maintenance is scheduled from midnight to 8:00AM on Sunday, January 8,

2017. During this time, all Provider Web Services will be unavailable. Providers wishing to check eligibility,

receive other insurance information or determine if service limits have been reached are advised to use the

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automated Voice Response System (VRS). The VRS can be accessed by dialing 802.878.7871, option 1 and

then option 1 again.

Delay in Provider Enrollment Application Processing Due to the implementation of the Affordable Care Act, we have seen a significant increase in the number of

provider enrollments for VT Medicaid. This growth in application volume has caused a delay in our processing

time. We are making every attempt to enroll providers as quickly as possible. We have developed a plan that

will improve the processing time such that by the end of January 2017, we will be processing all applications

within approximately 18 weeks. We appreciate your continued understanding while we work through this

backlog of applications.

Providers can check their end dates with the Provider Look-Up on the VT Medicaid website.

For additional information, including if you have extenuating circumstances and need to be enrolled sooner,

please visit: http://vtmedicaid.com/assets/provEnroll/EnrollmentProcessingDelay.pdf.

PERM Audit Helpful Suggestions We have received notice that several providers have been notified to submit additional medical

documentation for their PERM sampled claims. If you are selected for the PERM audit, be sure to review and

submit all medical record documentation requested in the CMS contractor’s, CNI Advantage, initial request.

Providers selected in quarters 1, 2 and 3 - requests to submit medical documentation is underway. Quarter 4

sample claims were recently selected and those providers will be notified in the near future.

Providers are also reminded that our time limit for documentation submission differs from CNI Advantage. See

our PERM website (http://dvha.vermont.gov/for-providers/payment-error-rate-measurement-perm/view) for

more information.

Prescriber Customer Service Satisfaction Survey Change Healthcare, the PBM for Vermont Medicaid is conducting a Prescriber Customer Satisfaction Survey

now through January 31, 2017. You can take the survey by either populating this link

https://www.surveymonkey.com/r/Prescriber_Customer_Satisfaction_Survey into your web browser, or by

going to the Department of Vermont Health Access (DVHA) website at http://dvha.vermont.gov/for-

providers/pharmacy and clicking on the Survey monkey link. To have the link or paper copy sent to you via

email or postal mail please contact Laurie Brady at 844-679-5363 or lbrady@changehealthcare.com.

Pharmacy Customer Service Satisfaction Survey Change Healthcare, the PBM for Vermont Medicaid is conducting a Pharmacy Customer Satisfaction Survey

now through January 31, 2017. You can take the survey by either populating this link

https://www.surveymonkey.com/r/Pharmacy_Customer-Satisfaction_Survey into your web browser, or by

going to the Department of Vermont Health Access (DVHA) website at http://dvha.vermont.gov/for-

providers/pharmacy and clicking on the Survey monkey link. To have the link or paper copy sent to you via

email or postal mail please contact Laurie Brady at 844-679-5363 or lbrady@changehealthcare.com.

Closed for Christmas Holiday The DVHA and Hewlett Packard Enterprise offices will be closed Monday, December 26, 2016 in observance

of the Christmas holiday.

Electronic RAs Available Longer Based on feedback from our annual Provider Survey, HPE is excited to announce that electronic Remittance

Advice files available online have been expanded from four RA files to eight. While you will not be able to see

older RAs once they have rolled off the system (as they do now), providers will be able to access them longer.

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We still recommend that providers access these files on a weekly basis and securely save a local copy for

accounting and auditing purposes.

Assistant Surgeon Modifiers Effective date of service 12/1/2016, DVHA will deny claims for payment that have more than one assistant

surgeon modifier. Each of the assistant surgeon modifiers (currently AS, 80, 81, and 82) are to be used for

specific providers and situations. Please refer to your current coding manuals for more information. The

combination of two or more of these modifiers is invalid, and claims will be denied.

HCPCS Code V5266 - Hearing Aid Battery Vermont Medicaid Rule 4.213 specifies that hearing aid batteries are limited to a maximum of six (6) batteries

per 30 days per beneficiary.

The correct billing of HCPCS code V5266 is one billed unit equals one battery. For example, when a package

of six (6) batteries is dispensed, the billed units would be six (6).

Server Maintenance - December 11, 2016 The Provider Web Portal server maintenance is scheduled from midnight to 8:00AM on Sunday, December

11, 2016. During this time, all Provider Web Services will be unavailable. Providers wishing to check eligibility,

receive other insurance information or determine if service limits have been reached are advised to use the

automated Voice Response System (VRS). The VRS can be accessed by dialing 802.878.7871, option 1 and

then option 1 again.

GMO Labeling Law and Infant Formula Update The US Federal Law requiring food manufacturers to label products containing bioengineered ingredients

preempts the Vermont GMO labeling law. Some infant formulas were briefly unavailable to WIC families but

are now back on retail shelves in Vermont and can again be prescribed when medically indicated.

The Vermont WIC program continues to promote and support breastfeeding as the optimal feeding method for

infants. When exclusive breastfeeding is not possible, WIC helps families by providing supplemental formula.

WIC requires Medical Documentation, including ICD-10 diagnosis, in order to provide medical formulas. For

your reference, the medical documentation form can be found at:

http://www.healthvermont.gov/wic/providers.aspx

We appreciate your ongoing support for the WIC program. If you have questions, please email:

WIC@Vermont.gov

PERM Time Limit on Record Submission Providers have contacted VT Medicaid expressing concerns that the CNI Advantage PERM Federal Notice

Letter states a time limit to submit required medical records that differs from what VT Medicaid is

communicating.

Vermont Medicaid providers have 30 days from the day they receive the federal letter to submit all records

requested by CNI Advantage (or 7 days if additional records are requested by CNI Advantage). Participation

is required and there is a 10% withhold on all VT Medicaid providers that do not submit required records

within the above timeframe (until the issue is resolved).

For additional information, please visit: http://dvha.vermont.gov/for-providers/payment-error-rate-

measurement-perm/view or email questions to VTPERM@hpe.com

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Interrupted Psychiatric Stays and Rapid Readmissions Providers are reminded that it is required to indicate an interruption in psychiatric stay by a transfer to a

medical floor in the same facility by using Occurrence Span Code 74 with the date span the individual was on

the medical floor. In addition, providers must use Value Code 75 and the number of days the patient was

inpatient prior to the rapid readmissions on claims when the patient is admitted within 3 days of discharge

from the same or another facility. Claims must be held for 3 days to ensure a readmission does not occur.

Please see the Applied Behavior Analysis, Mental Health and Substance Abuse Services Supplement at

http://vtmedicaid.com/#/manuals for additional information.

New Buprenorphine Billing Codes for HUBs Effective date of service 12/01/2016, HUB locations will be required to bill using the following new codes in

order to comply with proper billing practices: J0571, J0572, J0573, J0574 and J0575.

These new codes will need to replace the pre-existing code for Unclassified Drugs (J3490). Providers are still

required to list the NDCs for the specific drug administered on the claim.

Please see the separate mailing from ADAP with complete instructions for billing Buprenorphine and

Suboxone services, sent in November.

Closed for Thanksgiving Holiday The DVHA and Hewlett Packard Enterprise offices will be closed Thursday, November 24, 2016 and Friday,

November 25, 2016 in observance of the Thanksgiving holiday.

Electronic Remittance Advice Retention Providers that utilize our electronic remittance advice (RA) service are reminded that they have four (4) weeks

to save a local copy for their records. It is the expectation that providers are checking their electronic RAs on

a weekly basis and retaining local copies for accounting and audit purposes. If your office is using a

contracted billing service, you may consider providing them access to your electronic RAs. If you need help to

save your electronic RAs locally or to learn about allowing your billing service access, please contact our EDI

Coordinator at 802-879-4450, option 3.

Closed for Veteran’s Day Holiday The DVHA and Hewlett Packard Enterprise offices will be closed Friday, November 11, 2016 in observance of

Veteran’s Day.

Server Maintenance - November 13, 2016 The Provider Web Portal server maintenance is scheduled from midnight to 8:00AM on Sunday, November

13, 2016. During this time, all Provider Web Services will be unavailable. Providers wishing to check eligibility,

receive other insurance information or determine if service limits have been reached are advised to use the

automated Voice Response System (VRS). The VRS can be accessed by dialing 802.878.7871, option 1 and

then option 1 again.

Timed Codes Providers are reminded that for proper billing of all time-based procedure codes, please refer to the guideline

section of your current coding manual. For VT Medicaid physical, occupational, and speech therapy services,

please see additional clarification in our therapy guidelines, available at http://dvha.vermont.gov/for-

providers/clinical-coverage-guidelines

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Use of an Assistive Technology Professional in the Evaluation of Complex Rehab

Wheelchairs Providers of complex rehab wheelchairs are reminded that CMS has a requirement for direct, in-person

involvement by an Assistive Technology Professional (ATP) in wheelchair selection for a patient. An ATP

cannot review and sign off on the work of an individual who is not an ATP. The ATP must submit a document

that clearly demonstrates their in-person presence at the clinical evaluation. The wheelchairs that require ATP

assessment are: Group 2 power wheelchairs with single or multiple power options, all Group 3, Group 4 and

Group 5 power wheelchairs, power assist devices, ultra-lightweight manual wheelchairs, and tilt-in-space

manual wheelchairs.

Session Length Reminder An internal audit has revealed that many therapy providers are billing in excess of 4-units of timed codes per

session. According to the Physical, Occupational and Speech Therapy guidelines document, located

http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines, a maximum of 4-units of timed therapy

procedure codes that state “15 minutes” are allowed per treatment session. The 4-unit maximum is the

combined total of timed units, not a per-procedure code limit. Evaluation, re-evaluation and other non-timed

codes are not subject to the limit and may be billed in addition to the 4 timed codes during a single session.

The code for “wheelchair management, direct one-on-one patient contact, each 15 minutes” is an exception,

and is excluded from the 4-unit limit.

Prior Authorization Forms for Providers DVHA reviews and updates all Prior Authorization (PA) forms on a regular basis. Please make sure you are

submitting your requests utilizing the most current version. The links below are where the most current PA

forms for Clinical and Dental are located: http://dvha.vermont.gov/for-providers/clinical-prior-authorization-

forms and http://dvha.vermont.gov/for-providers/dental-prior-authorization-forms

Server Maintenance - October 9, 2016 The Provider Web Portal server maintenance is scheduled from midnight to 8:00AM on Sunday, October 9,

2016. During this time, all Provider Web Services will be unavailable. Providers wishing to check eligibility,

receive other insurance information or determine if service limits have been reached are advised to use the

automated Voice Response System (VRS). The VRS can be accessed by dialing 802.878.7871, option 1 and

then option 1 again.

DVHA Time Limit Requirements for PERM Audit Submissions Providers are reminded that DVHA has established time limit requirements that differ from CMS.

Once you receive the PERM Federal Letter, providers have 30 days from the date of notification from CNI

Advantage, LLC to submit required medical records and documents to CNI Advantage LLC. If additional

information is requested by CNI Advantage, LLC, providers have 7 days from the date of notification to submit

the medical records and documents.

Provider participation is required. DVHA will enforce a 10% withhold on all Vermont Medicaid payments for all

providers that do not submit the required documentation in the timeframe outlined above until the issue is

resolved.

Enrollment with Vermont Medicaid Due to the Title 42 Code of Federal Regulations (CFR) §§455.410 and §455.450 that require all providers,

whether new or existing, be screened, we are experiencing a delay in processing New Enrollments. To date,

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we have revalidated about 9000 of 14,000 currently participating providers. Over the last 6 months, we have

enrolled 784 new providers into our Medicaid Program. We anticipate being in full compliance with (CFR)

§§455.410 and §455.450 for our existing providers by 09/25/2016. Your participation with VT Medicaid is

important to us. At this time, we are processing complete applications within about a 20 week time frame. To

address the backlog, we have hired additional staff to meet the demand and speed up the process and are in

hopes of improving the turnaround time in the next few months. It is important you submit complete

applications as incomplete applications are returned.

If you have extenuating circumstances that will hinder the care to our members, please contact Suellen

Bottiggi at 802-871-3187 or suellen.bottiggi@vermont.gov. Thank you for your understanding and patience.

Temporary Provider Representative Coverage Changes Effective immediately, the following temporary changes have been made to the areas of coverage for our

provider representatives.

- Spring Maynard (802-857-2956): UVMMC, DHMC, Addison, Rutland, Bennington, Windham,

Orange and Windsor counties.

- Margaret Murray (802-857-2963): Caledonia, Essex, Orleans, Chittenden, Franklin, Grand Isle,

Lamoille and Washington counties.

- All out of state providers should contact the Call Center (802-878-7871) for any inquiries.

A detailed map, including Provider Representative Contact and territory information is available at:

http://www.vtmedicaid.com/#/manuals

Server Maintenance - September 11, 2016 The Provider Web Portal server maintenance is scheduled from midnight to 8:00AM on Sunday, September

11, 2016. During this time, all Provider Web Services will be unavailable. Providers wishing to check eligibility,

receive other insurance information or determine if service limits have been reached are advised to use the

automated Voice Response System (VRS). The VRS can be accessed by dialing 802.878.7871, option 1 and

then option 1 again.

PERM FAQ Updated As we progress through the Payment Error Rate Measurement (PERM) audit cycle, we have been receiving

questions from the provider community. We have updated the Frequently Asked Questions document

(http://dvha.vermont.gov/for-providers/payment-error-rate-measurement-perm/view) to include medical

documentation expectations, clarification around the DVHA Time Limit Requirements and answers to other

questions we have received.

If you have questions not covered in the FAQ, please email VTPERM@hpe.com or call our Provider Help

Desk at 1-800-925-1706 (toll-free in-state) or 1-802-878-7871 (out-of-state).

Provider Help Desk Inquiry Time Limit Preliminary results from the current Provider Survey has shown that many providers in our community had

concerns surrounding the 5 minute limit on Help Desk calls instituted in June 2015. Effective immediately, the

limit has been removed from calls to the Help Desk. To keep Call Center wait times to a minimum, we

encourage providers to use the Web Portal and Voice Recognition System for eligibility inquiries, when

appropriate. These services are best utilized when your office has the beneficiary’s unique ID number. If you

are not using these automated options, please contact our Provider Call Center for instructions to sign up.

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Reminder: Modifier PO - Off-Campus Outpatient Department PO is an outpatient modifier to be used on facility claims when the services are furnished at an off-campus

provider-based outpatient department. Corresponding physician claims should be utilizing the correct

outpatient place of service code also identifying that the services were furnished at an off-campus outpatient

department.

PO modifier is for outpatient use only and should not be billed on physician claims.

Reminder: Modifier L1 - Outpatient Clinical Laboratory L1 is an outpatient modifier to be used on the 13x bill type when non-referred clinical lab tests are eligible for

separate payment under the following two exceptions:

1. A hospital collects specimen and furnishes only the outpatient labs on a given date of service

-OR-

2. A hospital conducts outpatient lab tests that are clinically unrelated to other hospital outpatient services

furnished the same day. “Unrelated” means the laboratory test is ordered by a different practitioner than the

practitioner who ordered the other hospital outpatient services, for a different diagnosis.

A third exception is allowed for non-patient (referred) clinical lab specimens. Providers are to continue billing

these outpatient lab tests separately on a type of bill 14x; do not use the L1 modifier.

L1 modifier is for outpatient use only and should not be billed on physician claims.

Cardiac Imaging Effective date of service 10/01/2016, prior authorization will need to be requested from eviCore healthcare

(MedSolutions Inc.) for: Nuclear Stress Tests, Myocardial Perfusion Images, Stress Echocardiograms and

Echocardiography Studies. eviCore will accept authorization requests for services beginning September 19,

2016.

Services performed without authorization will be denied for payment and you may not seek reimbursement

from members.

Services performed in conjunction with an inpatient stay, 23-hour observation, or emergency room visit are

not subject to authorization requirements. A guidance letter from eviCore healthcare regarding the prior

authorization process is available here: http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines

Voice Response System and Web Portal for Eligibility Verification Requests Want to obtain member eligibility status quickly and efficiently? We offer two automated ways to verify

eligibility. The Voice Response System (VRS) service is available 24 hours a day, 7 days a week and can

often be quicker than calling into our Provider Help Desk. To use, please call 802-878-7871, option 1, and

then option 1 again.

Providers may also choose to use the VT Medicaid Web Portal by going to www.vtmedicaid.com/#/, navigate

to “Transactions” and choose the appropriate log in. You may sign up for this service on the portal. For any

issues with the web portal, please contact the EDI Coordinator at: 802 879 4450 Option 3. You may also find

additional information, in Section 7 of the Appendix or Section 4.1.2 of the Provider Manual.

New Timely Filing Reconsideration Request Forms Providers with timely filing reconsideration requests should use the new forms available on the Vermont

Medicaid website (www.vtmedicaid.com/#/forms). Providers with a single claim request, please use the

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Timely Filing Reconsideration Form - Single Claim. For those with more than one claim, the Timely Filing

Reconsideration Form - Multiple Claims should be used. Instructions on how to complete each form are

located within each editable PDF.

Effective date of receipt 09/01/2016, Hewlett Packard Enterprise will return requests that are either not on the

new forms or new forms that are not properly completed.

Server Maintenance - August 14, 2016 The Provider Web Portal server maintenance is scheduled from midnight to 8:00AM on Sunday, August 14,

2016. During this time, all Provider Web Services will be unavailable. Providers wishing to check eligibility,

receive other insurance information or determine if service limits have been reached are advised to use the

automated Voice Response System (VRS). The VRS can be accessed by dialing 802.878.7871, option 1 and

then option 1 again.

2015 Provider Annual Survey Hewlett Packard Enterprise invites all Vermont Medicaid providers to participate in the Provider Annual

Survey for calendar year 2015. We want to hear your thoughts on the assistance that Provider Services

delivers to the Vermont Medicaid provider community.

Please visit https://www.surveymonkey.com/r/2015HPEProvSurvey and complete the survey. Providers with

no internet access may request a paper copy by contacting the Provider Help Desk at 802-878-7871 (out-of-

state) or 800-925-1706 (in-state).

The deadline for all surveys is August 31, 2016.

Enrollment of Dental Hygienists The Department of Vermont Health Access (DVHA) will begin accepting applications from independently

billing Dental Hygienists to become enrolled as Vermont Medicaid providers. A letter should be expected (if

not already received) in the coming weeks to those dental hygienists eligible to enroll.

In order to enroll, a Dental Hygienist must meet all licensing requirements set forth by the State of Vermont. A

complete list of Provider Enrollment forms can be accessed at http://vtmedicaid.com/#/provEnrollAppPackets.

Questions about the enrollment process may be directed to HPE at 1-800-925-1706, option 4.

PERM Notice: Clarification on DVHA Time Limit Requirement Providers have contacted us expressing concerns that CNI Advantage LLC has not contacted them regarding

their claim(s) for the PERM audit. We are aware of this delay and are in contact with CMS. The 30 day

timeline for Vermont Medicaid providers selected for the audit begins when you receive a letter of notification

from CNI Advantage LLC, not with the letter you receive from Vermont Medicaid.

Please visit http://dvha.vermont.gov/for-providers/payment-error-rate-measurement-perm for additional PERM

related information.

Reminder: 340B Providers and UD Modifier 340B providers are reminded as of date of receipt June 1, 2016, the modifier “UD” must be included with the

J-Codes on the Prior Authorization (PA) request form. When a drug is administered under DVHA’s 340B Drug

Program, the following fields must be completed on the PA request form: 1) The check box adjacent to

“Please check box if this drug is provided under the DVHA’s 340B Drug Program” must be clearly marked -

AND- 2) The J-Code provided in the field “Drug Request” must be followed by the modifier “UD”

Provider requests to add the modifier retrospectively are no longer be accepted. DVHA staff will no longer add

the modifier. Failure to include the “UD” modifier when appropriate will result in denial of the PA request

and/or the resulting claim.

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Please email VT340B@hpe.com with any questions you may have.

Durable Medical Equipment Date Span Effective date of receipt on or after August 1, 2016, any claim for a DME rented item which does not contain

the appropriate date span of the rental will be denied. The billed date of service on the claim must be the date

that the item was dispensed /delivered to the member. When the billings are for monthly DME rentals, the

dates of service should span the rental month. For additional information and guidance, please reference the

Vermont Medicaid Provider Manual located at: http://www.vtmedicaid.com/#/manuals

Reminder: Providers with Billing Services During an internal audit, the Department of Vermont Health Access (DVHA) found that several billing services,

hired by Vermont Medicaid providers, submitted claims incorrectly that resulted in improper payments. Please

remember that, as the provider of services, you are solely responsible for the accuracy of claims submitted.

This policy is outlined in the provider enrollment agreement that you have signed.

Reminder: Provider-Based Billing Policy Providers are reminded that effective for claims with dates of service 7/1/2016 and after, DVHA will no longer

reimburse for the 51x clinic revenue code series. These revenue codes (510-519) indicate clinic charges for

providing diagnostic, preventative, curative, rehabilitative, and education services to ambulatory patients.

For additional information, please reference the Provider Manual located at http://vtmedicaid.com/#/manuals

Retracted: Short Acting Opiates On June 29, 2016, the Department of Vermont Health Access sent out a letter to Vermont Medicaid providers

stating that as of July 5, 2016 initial prescriptions for all short acting opiates will be limited to a 10-day supply

under Medicaid. This letter was based on an internal miscommunication and is hereby retracted. Please be

advised that the previously issued banner on this subject published on the July 1, 2016 Provider Remittance

Advice should be disregarded. To review entire notification please go to http://dvha.vermont.gov/for-

providers/opiate-rx-limits-retraction.pdf

Reminder: Vermont Medicaid Portal Changes Providers should expect to see changes to the Vermont Medicaid website soon. As mentioned in the May 20,

2016 Banner, providers will enjoy new search features and filters for our Banner publication. Publications,

manuals, PES Software, forms and other downloads that were located under “Downloads” and “Information”

on the current site will be found under the “Information” menu on the new site. All documents associated with

Provider Enrollment will be located under the “Provider Enrollment” menu. For Web and Transaction Services,

you will click login under the menu “Transactions” on the new website. Providers will also be alerted to known

issues, office closures and server maintenance right from the home page.

CPT Codes 59425 & 59426 - Max Unit Change Effective date of service 08/01/2016, CPT Codes 59425 and 59426 will be limited to one (1) unit each. For

specific billing guidance, please see section 10.3.39 Obstetrical Care of the Provider Manual at

http://vtmedicaid.com/#/manuals

Prior Authorization Requirements for CPT Codes Effective date of service August 1, 2016, the following CPT codes (and any applicable/appropriate modifiers)

will require prior authorization:

- 19330

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- 20910

- 21208

- 30465 and 30520

- 67950, 67961, and 67966

Please refer to the fee schedule at http://dvha.vermont.gov/for-providers/claims-processing-1 for additional

information.

Reminder - Vaccine Administration Codes Providers are reminded that per Correct Coding Practices all vaccine administration fees must be supported

with a vaccine code, even when there is no amount to be reimbursed. Lack of CPT vaccine code will result in

claim denial, effective immediately.

Providers who have not done so, have until 07/31/2016 to submit vaccine claims from 10/01/2015 and after. If

the claim is older than 6 months, it needs to be submitted on paper and sent “Attn: Vaccine Claims”. All claims

submitted for vaccine administration without a vaccine code will be recouped after 07/31/2016.

For additional information, please visit: https://www.aap.org/en-

us/Documents/coding_faq_immunization_administration.pdf

Initial Prescriptions for All Short Acting Opiates On June 29, 2016, the Department of Vermont Health Access sent out a letter to Vermont Medicaid providers

stating that as of July 5, 2016 initial prescriptions for all short acting opiates will be limited to a 10-day supply

under Medicaid. This letter was based on an internal miscommunication and is hereby retracted. Please be

advised that a banner on this subject has already been issued with provider remittance advice and should be

disregarded.

The critical work of reducing the number of opioids prescribed in Vermont is complex and will require many

different modalities and the input from stakeholders across the state. DVHA is currently working with the

Department of Health on a number of initiatives, including those related to Act 173. An act relating to

combating opioid abuse in Vermont. Under the Act, the Commissioner of Health is directed to adopt rules

concerning the use of opioids to treat acute pain. Commissioner of Health, Dr. Chen, has been meeting with

health care providers to understand their experience and hear recommendations. On July 21, 2016, Dr. Chen

will convene the newly created Controlled Substances and Pain Management Advisory Council to receive

input and advice from the broad spectrum of the Council’s membership. Following that meeting, a proposed

rule will be posted on the Department of Health’s website and there will be a noticed public hearing and an

opportunity to comment in person, via email, letter, or phone. Rules will be adopted thereafter with a likely

effective date early in 2017. At that time, claims will be monitored to ensure adherence to the new regulation.

DVHA looks forward to working with its sister Department and the provider community to solve this

multifaceted problem.

Closed for Independence Day Holiday The DVHA and Hewlett Packard Enterprise offices will be closed Monday, July 4, 2016 in observance of

Independence Day.

Server Maintenance - July 10, 2016 The Provider Web Portal server maintenance is scheduled from midnight to 8:00AM on Sunday, July 10,

2016. During this time, all Provider Web Services will be unavailable. Providers wishing to check eligibility,

receive other insurance information or determine if service limits have been reached are advised to use the

automated Voice Response System (VRS). The VRS can be accessed by dialing 802.878.7871, option 1 and

then option 1 again.

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Prior Authorization Required for CPT Codes 92310-92312 Effective date of service August 1, 2016, CPT Codes 92310, 92311 and 92312 (with any appropriate

modifiers) will require prior authorization.

Reminder: HCPCS Codes E0951 and E0952 Providers are reminded that shoe holders have two code choices E0951 and E0952. Shoe holders will not be

accepted under HCPCS code K0108 per correct coding. Codes are a National Standard and may be updated

on a quarterly basis. Correct coding is the sole responsibility of the billing provider. DVHA is not authorized to

give code selection guidance.

Please see sections 3.3.1 Correct Coding Practices and 3.3.2 New, Revised and Deleted Codes of the

Provider Manual for further guidance.

VT Medicaid Provider Manual Applied Behavior Analysis, Mental Health and Substance

Abuse Services Supplement The Department of Vermont Health Access (DVHA) has completed an update to the Vermont Medicaid

Provider Manual Applied Behavior Analysis, Mental Health and Substance Abuse Services Supplement. This

supplement is meant to provide additional information regarding select mental health and substance-abuse

related services and is a supplement to, but does not replace, the Green Mountain Care Provider Manual.

Both the supplement and provider manual can be found at the following location:

http://vtmedicaid.com/#/manuals

CMS PERM Informational Webinars CMS is offering four provider-specific informational webinars (June 21, June 29, July 19 and July 27, 2016) for

providers seeking education about the PERM Audit and process. They will also focus on provider

responsibilities during a PERM review as well as recent trends, frequent mistakes and best practices. Please

visit the DVHA PERM site at http://dvha.vermont.gov/for-providers/payment-error-rate-measurement-

perm/view where the webinar links are posted for additional information.

Workshop for ACCS/ERC Providers and Billers HPE will be holding a workshop for ACCS (Assistive Community Care Services) and ERC (Enhanced

Residential Care) providers Thursday, June 23, 2016 from 10:00AM to 11:30AM at 312 Hurricane Lane, Suite

201, Williston, VT 05495 in the upstairs conference room. New billers as well as billers wanting a refresher

are encouraged to attend. Topics will include, but are not limited to: Top 10 Denials, Patient Share, Eligibility

and Resources Available on the VT Medicaid website. A member of the DVHA Coordination of Benefits staff

will be in attendance.

If you are interested in attending, please register with Margaret Murray by phone (802-857-2963) or by email

at Margaret.murray@hpe.com. Space is limited so please register ahead of time.

Server Maintenance - June 12, 2016 The Provider Web Portal server maintenance is scheduled from midnight to 8:00AM on Sunday, June 12,

2016. During this time, all Provider Web Services will be unavailable. Providers wishing to check eligibility,

receive other insurance information or determine if service limits have been reached are advised to use the

automated Voice Response System (VRS). The VRS can be accessed by dialing 802.878.7871, option 1 and

then option 1 again.

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Sleep Studies During an internal audit, we identified that several providers are incorrectly billing for sleep studies. If the

physician who interprets test results and writes the report does not own and operate the equipment to perform

the sleep study, physicians must bill only for the professional component with appropriate modifier. Facilities

must bill the technical component only with the appropriate modifier.

Failure to report services with the proper modifiers is in violation of Correct Coding and may result in penalties

under the False Claims Act.

As of 11/1/2015 sleep studies (current codes 95782, 95783, 95805, 95807, 95808, 95810, and 95811) require

prior authorization (PA). The requesting provider must identify by procedure code and modifier (if appropriate)

whether they will be performing the total procedure (which includes interpretation) or only the technical

component. VT Medicaid will not retroactively add modifiers to any PAs.

GY Modifier When applied correctly, the GY modifier identifies services provided to Medicare dual-eligible individuals that

are not covered as a part of a Medicare benefit package. The Department of Vermont Health Access expects

providers to comply with the National Correct Coding Initiative and to utilize the GY modifier accordingly.

Applied Behavior Analysis Clinical Practice Guidelines The Department of Vermont Health Access (DVHA) acting as the Vermont Medicaid Managed Care

Organization has adopted the Applied Behavior Analysis Clinical Practice Guidelines. The guidelines are

posted on the DVHA website: http://dvha.vermont.gov/for-providers/initiatives

HCPCS Code E0240 with NU Modifier No Longer Accepted Effective 07/01/2016, HCPCS code E0240, when billed with the NU modifier, will no longer be accepted.

Outpatient Procedure Code/Modifier Combinations Effective date of receipt 07/01/2016, improper procedure code/modifier combinations on Outpatient claims will

result in denial.

Elimination of Provider-Based Billing for Hospital-Owned Clinics Effective for claims with dates of service 7/1/2016 and after, DVHA will be eliminating Provider-Based billing

for hospital owned provider-based clinics. On-campus and off-campus hospital-based clinics that have

provider-based status under 42 C.F.R. § 413.65 will no longer be allowed to bill a separate and additional

“facility charge” in connection with clinic/office visit services performed by a physician or other medical

professional.

For more detailed information, including billing instructions, please visit: http://dvha.vermont.gov/global-

commitment-to-health/pbb-proposed-gcr.pdf

Coverage Changes Related to the Elimination of Provider-Based Billing Effective for claims with dates of service 7/1/2016 and after, the 51x clinic revenue code series along with

code G0463 (hospital outpatient clinic visit) will no longer be covered or reimbursed by DVHA. In addition,

E&M codes 99381-99397 (well visits) will no longer be reimbursed when billed on a UB-04 (facility) claim type,

and 99201-99205, 99211-99215 will remain non-reimbursable when billed on a UB-04 claim type as these

codes represent professional services provided in an office or clinic setting.

For more detailed information regarding the elimination of provider-based billing, please visit:

http://dvha.vermont.gov/global-commitment-to-health/pbb-proposed-gcr.pdf

New Vermont Medicaid Website In June 2016, providers should expect to see a new and improved Vermont Medicaid website.

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Providers will enjoy new search features and filters for our Banner publication. Publications, manuals, PES

Software, forms and other downloads that were located under “Downloads” and “Information” on the current

site will be found under the “Information” menu on the new site. All documents associated with Provider

Enrollment will be located under the “Provider Enrollment” menu. For Web and Transaction Services, you will

click login under the menu “Transactions” on the new website. Providers will also be alerted to known issues,

office closures and server maintenance right from the home page.

Members will find new search abilities for our provider look-up.

The Transaction Services portion of the site will function the same as today.

Closed for the Memorial Day Holiday The DVHA and Hewlett Packard Enterprise offices will be closed Monday, May 30, 2016 in observance of

Memorial Day.

HCPCS Codes G0478-G0483 with QW Modifier Effective for claims with dates of service on or after January 1, 2016, providers may bill HCPCS codes

G0478-G0483 with the QW modifier as appropriate. Providers with claims that previously denied for these

HCPCS codes and modifier combination may resubmit claims for reconsideration.

Provider Enrollment Application Processing Providers are notified 90-days prior to their enrollment end date that they need to revalidate with Vermont

Medicaid. Providers must submit a complete application packet 30-days before their enrollment end date to

avoid lapses in enrollment. Applications are processed in the order they are received.

PERM Audit: A+ Government Solutions is Now CNI Advantage, LLC In the banner notice published on April 15, 2016 and in the May 2016 Advisory article, it stated that A+

Government Solutions (A+ GS) would be contacting providers selected for the PERM Audit Sample. Please

note, CNI Advantage, LLC has replaced A+ GS as the record review PERM contractor. All PERM record

requests will come from CNI Advantage, LLC. We apologize for any confusion and thank you for your

continued support through this audit cycle.

Global Commitment Register and Public Notice/Comment Information The Vermont Global Commitment Register (GCR) is a database of policy changes to and clarifications of

existing Medicaid policy under Vermont's 1115 Global Commitment to Health waiver. Providers interested in

receiving notification of proposed and final policies, including opportunity for public comment, should email

AHS.MedicaidPolicy@vermont.gov and request to be added to the GCR distribution list.

GMO Labeling Law and Infant Formula In July 2016, Vermont will implement the GMO labeling law which includes infant formula. Infant formula manufacturer Mead Johnson indicated they have products with GMOs but will not be changing their labels to comply with the law and have decided to no longer have these products available retail in Vermont. The products affecting WIC families in Vermont are:

- Nutramigen - EnfaCare - Pregestimil

To help our WIC families manage this change, please consider similar Abbott products for management of your patient’s medical diagnosis:

- Alimentum is hypoallergenic and could substitute for Nutramigen - NeoSure is a 22 cal/oz formula for premature infants and could substitute for EnfaCare

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- Alimentum can be prescribed for fat malabsorption although only 33% of fat is MCT as opposed to 55% MCT in Pregestimil

Please email questions to Jackie Charnley at Jackie.Charnley@Vermont.gov

Outpatient Claim Modifiers Providers are expected to follow correct coding, including accurate reporting of modifiers, on all claims.

Outpatient claims are no exception. Please refer to the Vermont Medicaid Fee Schedule to determine if the

procedure code being reported requires a TC when done in the facility. Outpatient claims will be monitored,

post-payment, for non-compliance. Failure to report appropriate modifiers may not result in an incorrect

payment, but you could be subject to penalties under the False Claims Act.

Remember to include the appropriate modifier(s) when submitting prior authorization requests.

HCPCS Code A9276 Unit Update Effective date of service 06/01/2016, HCPCS code A9276 will be restricted to one (1) unit per day. When

billing multiple units, providers will need to bill a date range.

Dental Global Period Effective for dates of service on and after June 1, 2016, Vermont Medicaid is implementing a 10-day global

period for certain dental procedure codes. During the dental global period, any palliative treatment for pain is

considered included in the payment for the primary procedure for that tooth and will not be reimbursed

separately. For additional information, please see the Dental Supplement and the Dental Fee Schedule at:

http://vtmedicaid.com/#/manuals

Physician Authorization of IEP Medical School-Based Services Effective for dates of service on and after June 1, 2016, in order to comply with National Correct Coding,

there is a change to the code that physicians must use when authorizing medical school-based services in an

IEP. Please refer to the Addendum to the (Agency of Education’s) School-Based Health Services Program for

2015-2016 School Year, dated April 2016, for specific billing instructions.

http://education.vermont.gov/documents/edu-special-education-finance-medicaid-school-based-health-

services-addendum-april-2016.pdf

Long Acting-Reversible Contraceptives Provided in Hospital, Post-Partum Settings The Vermont Dept of Health is promoting Long Acting-Reversible Contraceptives (LARC) utilization as an

efficient means to prevent unplanned pregnancy.

When a LARC is provided in an inpatient hospital setting, post-partum, providers must submit claims utilizing

the appropriate code from each category listed in Section 9.14 of the Provider Manual at:

http://vtmedicaid.com/Downloads/manuals.html. The claim will adjudicate and a LARC add-on payment of

$200.00 will be made in addition to the DRG portion.

For hospitals that have paid claims for dates of discharge of January 1, 2016 or after, and a LARC was

provided, you will need to submit a replacement claim, to include the appropriate codes, as described above,

in order to be reimbursed for the LARC.

HCPCS Code G0477 with QW Modifier Effective for claims with dates of service on or after January 1, 2016, providers may bill HCPCS code G0477

with the QW modifier as appropriate. Providers with claims that previously denied for this HCPCS code and

modifier combination may resubmit claims for reconsideration.

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Server Maintenance - May 8, 2016 The Provider Web Portal server maintenance is scheduled from midnight to 8:00AM on Sunday, May 8, 2016.

During this time, all Provider Web Services will be unavailable. Providers wishing to check eligibility, receive

other insurance information or determine if service limits have been reached are advised to use the

automated Voice Response System (VRS). The VRS can be accessed by dialing 802.878.7871, option 1 and

then option 1 again.

Provider Representative Coverage Changes Effective immediately, the following changes have been made to the areas of coverage for our provider

representatives. Unless otherwise specified, hospitals and facilities are to use the representatives for their

county.

- Spring Maynard (802-857-2956): UVMMC, DHMC, Orange and Windsor Counties

- Mary Muir (802-857-2948): Out of State Providers, Caledonia, Essex and Orleans Counties

- Margaret Murray (802-857-2963): Chittenden, Franklin, Grand Isle, Lamoille and Washington Counties

- Nora Williams (802-857-2957): Addison, Bennington, Rutland and Windham Counties

A detailed map, including Provider Representative Contact information and territory, is available at:

http://vtmedicaid.com/#/manuals

EHRIP Awareness Survey The Department of Vermont Health Access is conducting a survey in order to gauge awareness of the

Vermont Medicaid Electronic Health Record Incentive Program (EHRIP) and Meaningful Use requirements.

As a practitioner (or a practice representative) who provides services to Medicaid beneficiaries, you may be

eligible to participate and receive payments from the Vermont Medicaid EHRIP. Learn more here:

http://healthdata.vermont.gov/ehrip/VermontMedicaidEhrIncentiveProgramAwarenessSurvey

Modifier 59 Effective date of service 06/01/2016, providers will no longer be allowed to use modifier 59 to append E/M

(Evaluation and Management) codes.

PERM Audit Reminder Providers are reminded that the FFY2016 Payment Error Rate Measurement (PERM) audit is underway.

DVHA will outreach to those providers selected in the sample prior to the A+ Government Solutions (A+ GS)

sending out their notice to obtain contact information to further aid the providers chosen. For additional

information please visit: http://dvha.vermont.gov/for-providers/

DVHA PERM Time Limit Requirements: Providers have 30 days from date of receipt of notice to submit

required medical records and adjoining documents to A+ GS. If additional information is needed, providers

have 7 days from the date of receipt of notice to send in the information to A+ GS.

Please note: DVHA will enforce a 10% withholding from all providers that do not submit the required medical

records and adjoining documents within 30 days or the additional documentation within 7 days.

Modifier Changes for CPT Codes 76641 and 76642 Effective date of receipt May 1, 2016, providers billing CPT codes 76641 and 76642 will be required to use an

appropriate modifier to clarify on which breast the ultrasound is performed.

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Cancer Screening Recommendations from VDH The following documents are now available to help clarify to members and providers the recommendations

from the Vermont Department of Health (VDH) on cancer screening:

Public Document: “Recommended Cancer Screening Schedule”

http://healthvermont.gov/prevent/cancer/documents/CancerScreening_Public.pdf

Provider Document: “Cancer Screening Recommendations”

http://healthvermont.gov/prevent/cancer/documents/CancerScreening_Providers.pdf

Please distribute the public document in your practice. If you have any questions or wish to order copies,

please contact Sharon Mallory in the VDH Cancer Prevention and Control Program at

Sharon.Mallory@vermont.gov.

New Ladies First Fee Schedule and Non-Covered Codes Effective date of service 05/01/2016, codes G0279, 77063, 99395, 99396 and 99397 will no longer be

covered by the Ladies First Program.

A new fee schedule, outlining the new 2016 reimbursable services along with codes no longer covered, is

currently available at: http://dvha.vermont.gov/for-providers/2vermont-ladies-first-2016-fee-schedule.pdf.

Server Maintenance - April 10, 2016 The Provider Web Portal server maintenance is scheduled from midnight to 8:00AM on Sunday, April 10,

2016. During this time, all Provider Web Services will be unavailable. Providers wishing to check eligibility,

receive other insurance information or determine if service limits have been reached are advised to use the

automated Voice Response System (VRS). The VRS can be accessed by dialing 802.878.7871, option 1 and

then option 1 again.

CPT and HCPCS Code Information for Providers with CLIA Certifications CPT and HCPCS codes associated with Clinical Laboratory Improvement Amendments (CLIA) certifications

are updated and maintained by CMS. This information can be found at: https://www.cms.gov/Regulations-

and-Guidance/Legislation/CLIA/Categorization_of_Tests.html. Providers should check this site regularly for

the most up-to-date information.

Continuous Passive Motion (CPM) Devices Effective date of service 5/1/2016, in accordance with CMS guidelines, Continuous Passive Motion devices

are covered for patients who have received a total knee replacement. Use of the device must commence in

the home within 2 days following surgery and rental is limited to a maximum of 21 days per beneficiary per

lifetime. When a CPM device is needed for a separate episode (e.g. contralateral knee or the replacement of

a total knee prosthesis), billers need to provide supporting documentation with the claim. HCPCS E0935

requires modifier RR (CPM devices are only rented). One billed unit = One day of rental.

Please note that HCPCS code E0936(RR), a CPM device for joints other than the knee, is covered only with

prior authorization from the DVHA.

For additional information, please see Section 11.11.6 of the Provider Manual

(http://vtmedicaid.com/#/manuals)

Medicare Attachment Summary Forms Providers are reminded that, per Section 6.6 of the Provider Manual, the Medicare Attachment Summary

Form is only to be used for beneficiaries who are enrolled in both Medicare and Vermont Medicaid. It is not to

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be used for reporting actions by any other insurers. If there are payments made by a non-Medicare third party

insurance, providers must indicate the payment in the “prior payments” field on paper claims (or Paid

Date/Amount on the OI tab in PES). For additional information, please see Section 6.8 Third Party Liability

(TPL)/Other Insurance (OI) in the Provider Manual.

Member Eligibility Inquiries Providers are reminded they need to direct members with inquiries to the Green Mountain Care Member

Services Unit (1-800-250-8427), not to Vermont Medicaid Provider Services Help Desk. Help Desk

Representatives are not able to aid members with inquiries.

Server Maintenance - March 13, 2016 The Provider Web Portal server maintenance is scheduled from midnight to 8:00AM on Sunday, March 13,

2016. During this time, all Provider Web Services will be unavailable. Providers wishing to check eligibility,

receive other insurance information or determine if service limits have been reached are advised to use the

automated Voice Response System (VRS). The VRS can be accessed by dialing 802.878.7871, option 1 and

then option 1 again.

Professional & Technical Components Vermont Medicaid methodology for the reimbursement of the professional and technical components is

structured similar (but not identical) to Medicare. Please refer to the Vermont Medicaid Fee Schedule

(http://dvha.vermont.gov/for-providers/claims-processing-1) to see more about the reimbursement of codes.

The PC (26) and TC RVU and Allowed amount columns were added to the Vermont Medicaid Fee Schedule,

effective January 2016. Providers are expected to follow correct coding guidelines.

The physician component includes the physician’s supervision and interpretation portion of the procedure.

The physician component is reported by using modifier 26 for procedure codes that allow the 26 and TC

modifiers.

The technical component includes reimbursement for the facility, equipment, film processing, and the

technician.

Vermont Tobacco Control Medicaid Provider Survey Please complete the Vermont Tobacco Control Program’s Medicaid provider survey for a chance to win a

$100 Visa gift card! The brief survey will take about 10 minutes to complete and will help the Vermont

Tobacco Program understand provider awareness and use of Medicaid’s tobacco cessation benefit and

reimbursement codes. Click on the link to complete the survey:

https://www.surveymonkey.com/r/VTMedicaidCessation

Condition Code - G0 Effective date of receipt April 1, 2016, please use condition code “G0” (G-Zero) to indicate a second, distinct

visit when there are two Outpatient claims for a member from the same billing provider, with the same date of

service but different primary diagnosis codes. Providers should stop entering the admission time in the notes

field on their electronic claims.

Closed for President’s Day Holiday The DVHA and Hewlett Packard Enterprise offices will be closed on Monday, February 15, 2016 in

observance of President’s Day.

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Additional Procedure Codes for Area of Oral Cavity Effective date of service April 1, 2016, the following 5 procedure codes will require reporting for area of oral

cavity: D4341, D4342, D7310, D7311 and D7320.

As a reminder, the full list of procedure codes requiring reporting for area of oral cavity is available at:

http://dvha.vermont.gov/for-providers/dental-1. Please check this link frequently for additional updates.

Correction: 99201-99205 and 99211-99215 on Outpatient Claims (UB04) Effective date of service 03/01/2016, the DVHA will no longer reimburse for codes 99201-99205 and 99211-

99215 when billed on an outpatient facility claim. Providers should begin using G0463 (hospital outpatient

clinic visit for assessment and management of a patient) in place of the previous E&M codes.

The DVHA has made the decision to implement this policy in order to further align with Medicare and to

ensure providers are getting the most appropriate reimbursement for outpatient facility claims, which are

reimbursed using our Outpatient Prospective Payment System (OPPS).

Server Maintenance - February 14, 2016 The Provider Web Portal server maintenance is scheduled from midnight to 8:00AM on Sunday, February 14,

2016. During this time, all Provider Web Services will be unavailable. Providers wishing to check eligibility,

receive other insurance information or determine if service limits have been reached are advised to use the

automated Voice Response System (VRS). The VRS can be accessed by dialing 802.878.7871, option 1 and

then option 1 again.

HPE Mailing Address Changes HPE reduced the number of PO Boxes accepting mail. Please continue to send checks to PO Box 1645. All

other claims, inquiries and other mail should be sent to PO Box 888, Williston, VT 05495.

As of November 16, 2015, PO Boxes 777, 999 and 1710 stopped accepting mail.

Closed for Martin Luther King Holiday The DVHA and Hewlett Packard Enterprise offices will be closed on Monday, January 18, 2016 in observance

of Martin Luther King Day.

Server Maintenance - January 10, 2016 The Provider Web Portal server maintenance is scheduled from midnight to 8:00AM on Sunday, January 10,

2016. During this time, all Provider Web Services will be unavailable. Providers wishing to check eligibility,

receive other insurance information or determine if service limits have been reached are advised to use the

automated Voice Response System (VRS). The VRS can be accessed by dialing 802.878.7871, option 1 and

then option 1 again.

Interrupted Psychiatric Stays The following changes are effective date of service 1/1/2016:

Providers must indicate an interrupted stay to a medical floor in the same facility by using Occurrence Span

Code 74 with the days the individual was on the medical floor.

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Providers must use Value Code 75 and the number of days the patient was inpatient prior to the rapid

readmission on claims when the patient was admitted from another inpatient psychiatric facility within 3 days

of discharge from that facility or readmitted to the same facility.

Facilities must hold claims for 3 days to ensure a readmission does not occur. Stays are considered

continuous for the purpose of applying the variable per diem adjustment and is considered one continuous

stay for payment.

Paper Claims Submission Providers are reminded when submitting paper claims that the attachments are required to be single sided.

Double sided attachments may result in a denied claim. Additionally, each claim must be accompanied by its

own set of complete attachments. You may not submit one set of attachments for multiple claims.

Electronic Billing Reminder Providers submitting claims electronically (whether with PES or third party software) are reminded that they

must make sure all codes that include alpha characters are entered as upper case. This includes, but is not

limited to, diagnosis codes, procedure codes, HCPCS, etc. Alpha characters entered as lower case will result

in claim denial.

HCPCS Code S8032 No Longer Covered Effective date of service February 1, 2016, Vermont Medicaid will no longer cover claims submitted with

HCPCS Code S8032. Please use the updated 2016 HCPCS code G0297 for low dose CT for lung cancer

screening instead.