Human Services contracts with Blue Cross Blue Shield of North Dakota for Medicaid Expansion managed care services

On June 28, 2021, the North Dakota Department of Human Services announced it has contracted with Blue Cross Blue Shield of North Dakota to provide managed care services for people who qualify for the state’s Medicaid Expansion program.

This is a four-year contract with optional extensions. The contract will start Jan. 1, 2022.

North Dakota expanded Medicaid in January 2014 to provide health coverage to qualifying low-income, uninsured North Dakotans ages 19 to 64. As of March 2021, 25,841 North Dakotans participated in the Medicaid Expansion program.

See the press release announcing the contract.

Primary Care Case Management (PCCM) Program Review

Approximately 60 percent of all Medicaid members are enrolled in the Primary Care Case Management (PCCM) program.

The program helps ensure Medicaid members have a regular health care provider who assists with coordinating their care.

Choosing a primary care provider

Program enrollees are required to choose a primary care provider.

Upon enrollment, letters are sent to members notifying them that they have 14 days to choose a primary care provider, or one will be automatically assigned to them.

After 14 days, members receive a second letter with the name of their primary care provider. The letter also informs members they must receive their health care services from the primary care provider, or get a referral from the primary care provider before seeing a different provider.

How does the program work for enrolled providers?

When a physician, physician assistant, or family nurse practitioner’s enrollment application specifies the provider works in the specialty of general/family practice, internal medicine, OB/GYN or pediatrics and they are affiliated with a general practice facility, North Dakota Medicaid opens a PCCM participation date span in the Medicaid Management Information System (MMIS), which identifies when the provider is available to be selected as a primary care provider.

Providers that are listed as an “available primary care provider” are not notified each time a member is assigned to them. It is possible providers may have new members assigned to them that they have not seen at their practice.

A member’s primary care provider can be validated in the MMIS through the provider portal or by the North Dakota Medicaid Automated Voice Response System (AVRS) at 877-328-7098. Instructions are available.

The following status options are available to every primary care provider:

Open: The provider is open to acting as a primary care provider for more members.

Full at a Designated Number: The provider wants to be a primary care provider, but only for the current number of members who are assigned to the provider. The provider understands that if some members leave, others may be added to keep the provider at the designated number of members. Once the provider has reached the designated number of members, no new members will be added without the primary care provider’s written permission being submitted to dhsmci@nd.gov.

Full Until Closed: The provider would like to be a primary care provider only to its current members. As members leave the provider, no other members will be added, and eventually, the provider will have no members. At that time, the PCCM participation date span will be closed, and the provider will no longer be listed as an available primary care provider. No new members will be added without the provider’s written permission being submitted to dhsmci@nd.gov.

Closed: The provider would like to have their PCCM participation date span closed. If this happens, all members who currently have the provider designated as their primary care provider will receive a letter informing them to choose a different primary care provider. The provider will no longer be listed as an available primary care provider.

Primary care providers can send a request to change their status, or questions to the North Dakota Medicaid PCCM inbox at dhsmci@nd.gov.

Human Services now accepting applications for its Autism Spectrum Disorder Voucher program

Families of children ages three to 17 who have been diagnosed with autism spectrum disorder can apply for autism voucher program services for the upcoming state fiscal year that begins July 1, 2021.

Vouchers help pay for respite care for family caregivers, assistive technology such as sensory or safety equipment, caregiver training and other support services such as tutoring.

To qualify, household income for a family cannot exceed 200 percent of the federal poverty level, which is currently $4,417 a month for a family of four. Children who are receiving services through a Medicaid waiver do not qualify for the autism spectrum disorder voucher.

To apply, families must complete the ASD Voucher program application or contact the North Dakota Department of Human Services at 701-328-4630, toll-free 800-755-2604, 711 (TTY) or dhsautism@nd.gov.

Families should submit the completed application and required documentation by mail, email or fax to the department’s Medical Services Division, attention Katherine Barchenger, at 600 E. Boulevard Ave., Dept. 325, Bismarck, N.D. 58505-0250, dhsautism@nd.gov or fax 701-328-1544.

For more information on autism spectrum disorder services, visit the department’s website.

Noridian Healthcare Solutions provides provider enrollment support

The North Dakota Department of Human Services has contracted with Noridian Healthcare Solutions (Noridian) to provide North Dakota Medicaid provider enrollment support.

As of March 1, 2021, Noridian enrollment staff will process enrollment updates, applications, revalidations and past-due revalidations for the state. This partnership will provide even better customer service to North Dakota Medicaid providers.

For the time being, the Home and Community Based Services Unit will continue to process qualified service provider applications and revalidations. Qualified service provider enrollment will be transitioned to Noridian in the future.

Noridian enrollment staff may be reached at (701) 277-6999, fax (701) 433-5956, email NDMedicaidEnrollment@Noridian.com. Their mailing address is Noridian Healthcare Solutions, Attn: ND Medicaid Provider Enrollment, PO Box 6055, Fargo, ND 58108-6055.

Payment Error Rate Measurement

The Payment Error Rate Measurement (PERM) program measures improper Medicaid and former Children’s Health Insurance Program (CHIP) payments made to providers and produces error rates for each program. The error rates are based on reviews of the fee-for-service (FFS), managed care and eligibility components of Medicaid and CHIP in the fiscal year (FY) under review. It is important to note the error rate is not a “fraud rate,” but simply a measurement of payments made that did not meet statutory, regulatory or administrative requirements.

The PERM audit is important to all Medicaid providers because the Centers for Medicare and Medicaid Services (CMS) and the review contractor NCI Information Systems (NCI) will be sending letters to various North Dakota Medicaid providers requesting medical records to validate services were ordered, provided, documented and billed appropriately.

Make sure that your Release of Information departments are aware and respond to the records requests in a timely manner.

UPDATE: NCI started sending medical record request letters to providers on May 17, 2021. Record requests will come in a CMS envelope.

• NCI makes initial calls to providers to verify provider contact information.
• NCI establishes a point of contact with providers and sends record requests.
• Providers have 75 days to submit documentation.
• NCI makes reminder calls and sends reminder letters on day 30, 45 and 60 until the medical records are received.
• If the provider does not respond, NCI sends a non-response letter on day 75 to the state PERM representative.
• If submitted documentation is incomplete, NCI requests additional documentation.
• The provider has 14 days to submit additional documentation.
• A reminder call is made, and a letter is sent on day 7.
• If the provider does not respond, NCI sends a 15-day nonresponse letter.

Failure to submit documentation, or if the submitted documentation is incomplete, the claim will be considered an error and subject to recoupment.

When submitting records, the department highly recommends the use of the corresponding medical review (MR) cover sheet with each submission for quick and accurate processing of record submissions.

The MR cover sheet is included with provider PERM letter packet.

For more information and to see a template of the actual medical request letter and MR fax cover sheet being sent to providers, visit the PERM webpage.

Questions may be directed to:

Steven McNichols, PT

Medicaid Program Integrity Audit Coordinator

ND Department of Human Services, Medical Services Division

600 E. Boulevard Ave., Dept. 325

Bismarck, ND 58505-0250

Phone: (701) 328-4831

Email: auditresponse@nd.gov

Photo credit: ND Tourism

Reminder: Provider Requirements for Documentation, Retention and Release

As a condition of enrollment, each Medicaid provider must sign a Medicaid Program Provider Agreement (Agreement).

The Agreement requires providers to:

• Document each item or service for which Medicaid reimbursement is claimed, at the time it is provided, in compliance with documentation requirements of the department.
• Comply with all applicable Medicaid statutes, rules and federal regulations as well as the provisions of the Medicaid Provider Handbook, known as the General Information for Providers Manual.
• Maintain documentation and upon reasonable request, provide the department, the U.S. Department of Health and Human Services or their agencies, access to all records used by the provider to support the services billed to Medicaid.
• Follow all applicable state and federal laws and regulations regarding confidentiality of records.

The provider information chapter in the General Information for Providers Manual includes the following requirements:

• North Dakota Medicaid providers are required to keep records that completely and thoroughly document the extent of services rendered to members and billed to North Dakota Medicaid. Records are used by North Dakota Medicaid to determine medical necessity and to verify that services were billed correctly.
• Medical records must be in their original or legally reproduced form, which may be electronic.
• Documentation must support the time spent rendering a service for all time-based codes.
• Records must be retained for a minimum of six years from the date of its creation or the date when it was last in effect, whichever is later.
• All member and applicant information and related medical records are confidential. Providers are responsible for maintaining confidentiality of protected health information subject to applicable laws. Providers are required to permit North Dakota Medicaid personnel, or authorized agents, access to all information concerning any services that may be covered by Medicaid. This access does not require an authorization from the member because the purpose for the disclosure is to carry out treatment, payment or health care operations permitted under the HIPAA Privacy rule under 45 CFR §164.506.

Documentation includes:

• Medical records: (patient’s name and date of birth; date and time of service; name and title of provider rendering the service, chief complaint or reason for each visit; pertinent medical history; pertinent findings on examination; medication, equipment and/or supplies prescribed or provided; description and length of treatment; recommendations for additional treatments, procedures or consultations; diagnostic tests and results; dental photographs/teeth models; certification of medical necessity (if applicable); plan of treatment and/or care and outcome; and signature and date by the person ordering or rendering the service);
• Service authorization information;
• Claims, billings and records of Medicaid payments and amounts received from other payers for services provided to members;
• Records and original invoices for items that are prescribed, ordered or furnished; and
• Any other related medical or financial data that may include appointment schedules, account receivable ledgers and other financial information.

Based on audit or review, if North Dakota Medicaid determines that provider documentation is not available for services billed, North Dakota Medicaid will recoup the payment to the provider. In accordance with N.D.A.C. 75-02-05-04, a provider may not bill a member for services that are allowable under Medicaid, but not paid due to the provider's lack of adherence to Medicaid requirements.

Providers are encouraged to review the terms of the Provider Agreement, North Dakota Century Code and Administrative Code relevant to the North Dakota Medicaid program, and the General Information for Providers Manual. When reviewing the manual, providers should include chapters that are specific to their specialty, as well as generic chapters that are applicable to all enrolled Medicaid providers such as provider enrollment, provider information, Medicaid eligibility of a member, noncovered Medicaid services and primary care case management.

ND Medicaid contracts with Kepro

The North Dakota Department of Human Services has contracted with Kepro to perform both retrospective reviews and service authorization requests for certain services and supplies for traditional North Dakota Medicaid members.

Who is Kepro

In 1985, Kepro was founded by physicians from the Commonwealth of Pennsylvania Medical Society at the request of the Centers for Medicare and Medicaid Services to serve as the state’s Quality Improvement Organization. Over the past 35 years, Kepro has continued their mission by partnering with government-sponsored health care programs to provide efficient, high quality and well-coordinated care to the vulnerable populations these programs serve.

Kepro’s health-focused solutions drive high-quality oversight for their partners’ programs by optimizing care outcomes and reducing cost through the implementation of their proprietary integrated platform, data analytics, and clinically driven services.

Atrezzo Provider Portal

Request for medical service authorizations and retrospective reviews that Kepro is responsible for reviewing for North Dakota Medicaid must be submitted by Kepro’s Atrezzo Provider Portal.

To utilize Kepro’s provider portal, each provider (facility, clinic, doctor’s office, etc.) must appoint one person to be the administrator or owner of their provider portal account.

To register as the account administrator of your facility, clinic or doctor’s office, email ndatrezzoregistration@kepro.com. Kepro will provide a registration code to access Kepro’s ANG Provider Portal.

Training

Kepro can provide training for providers regarding the Atrezzo Provider Portal.

The training will include how to register, how to create sub-user accounts, how to submit for service authorization and how to check the status of a service authorization request. Recorded trainings are available on Kepro’s website.

Prior Authorization Update

As of June 1, 2021, Kepro will begin authorizing requests for cranial helmets (S1040). Submit requests for this durable medical equipment by the Atrezzo Provider Portal. Clinical questions can be directed to ndumnurses@kepro.com.

Retrospective Review Update

Providers contracting with a third party for medical record releases are still responsible to connect with Kepro to register for an Atrezzo Provider Portal and submit medical records for review. Contact ndumnurses@kepro.com with any questions.

General information regarding documentation containing amendments, corrections or addenda

North Dakota Medicaid follows recordkeeping principles of documents submitted to Medicare administrative contractors, Comprehensive Error Rate Testing review contractors, recovery auditors, Supplemental Medical Review contractors and Unified Program Integrity contractors regardless of whether documentation submission originates from a paper record or an electronic health record.

Documents containing amendments, corrections or addenda must:

• Clearly and permanently identify any amendment, correction or delayed entry as such, and
• Clearly indicate the date and author of any amendment, correction or delayed entry, and
• Clearly identify all original content, without deletion.

Paper medical records: When correcting a paper medical record, these principles are generally accomplished by:

• Using a single line strike through so the original content is still readable, and
• The author of the alteration must sign and date the revision.

Amendments or delayed entries to paper records must be clearly signed and dated upon entry into the record. Amendments or delayed entries to paper records may be initialed and dated if the medical record contains evidence associating the provider’s initials with their name. For example, if the initials match the first and last name of the practitioner documented elsewhere in the medical records including typed or written identifying information, the reviewer shall accept the entry.

More information on documentation standards can be found at Medicare Program Integrity Manual - search recordkeeping.

Providing Services and Medicaid Enrollment

Any physician or nonphysician practitioners who render services, or write orders, prescriptions or referrals for members must be enrolled in North Dakota Medicaid.

In addition, 42 CFR 455.410 requires that all ordering, prescribing and referring (OPR) physicians, as well as other professionals providing services under North Dakota Medicaid or waiver programs be enrolled as participating providers. This includes anyone who orders, refers or prescribes services or items such as pharmaceuticals to North Dakota Medicaid members and seeks reimbursement. This also includes providers directly contracted with managed care organizations.

If services are provided to members in another state, the out-of-state providers are required to enroll with North Dakota Medicaid. Enrollment in another state’s Medicaid program does not exempt a rendering or OPR provider from enrolling with North Dakota Medicaid.

An enrolled provider cannot sign off on documentation that they did not render services performed by a non-enrolled provider.

Photo credit: Visit Fargo-Moorhead