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Implementation of ClaimsXten – Effective December 19, 2022

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Bulletin
Effective Date:

To:
All Providers and Managed Care Organizations Participating in the Virginia Medicaid and FAMIS Program
From:
Cheryl J. Roberts, Director Department of Medical Assistance Services (DMAS)

The purpose of this bulletin is to inform providers that DMAS is implementing a new claims software. Effective December 19th 2022 all claims will be processed via Change Healthcare’s ClaimsXten® software, replacing the current ClaimCheck software. The functionality of the new software remains the same with two new enhancements described below. 

ClaimsXten® Solutions is a flexible claims payment management solution that identifies billing errors before claims are adjudicated.  ClaimsXten® is proprietary, rules-based technology that applies edits and business rules across claims.  The Medicaid National Correct Coding Initiative (NCCI) is still in effect and ClaimsXten® edits will occur after the Medicaid NCCI edits.  DMAS will continue to update Medicaid NCCI edits quarterly as mandated by Centers for Medicare and Medicaid Services (CMS).  Please refer to the previous Medicaid Memorandums, Implementation of ClaimCheck for all Physician and Laboratory Services – Effective January 9, 2006 AND Implementation of the Medicaid National Correct Coding Initiative (NCCI), Procedure to Procedure (PTP), and Medically Unlikely Edits (MUE) – Effective June 3, 2013.  The Memo dates are December 2, 2005 and May 1, 2013 respectively.

Pay Percent Multiple Radiology:   Multiple radiology procedures billed on the same date of service by the same provider will receive a payment reduction.  This applies to all radiology procedures billed as a global service or with modifiers 26 (professional component) or TC (technical component).  Subsequent radiology procedures will reimburse at 50% of the rate if the TC modifier is appended and/or 95% if modifier 26 is appended.

CT modifier:  Use of the CT modifier will cause a reduction in the rate for specific Computed Tomography procedures/services.  This modifier indicates use of equipment that is outdated and does not meet the National Electrical Manufacturers Association (NEMA) standard.  The rate reduction only applies to the technical component and is a 15% reduction of the DMAS allowed amount.

DMAS will continues to use Relative Value Units (RVUs) within the pay percent rules for assistant surgeons, radiology, and multiple procedures when sequencing payment.

Providers that disagree with an action taken by a ClaimsXten® edit may request a reconsideration via email (ClaimCheck@dmas.virginia.gov) or by submitting a request to the following mailing address:

 

                                         Department of Medical Assistance Services

                                         Payment Processing Unit – ClaimsXten

                                         600 East Broad Street, Suite 1600

                                         Richmond, Virginia 23219

 

PROVIDER CONTACT INFORMATION & RESOURCES

Virginia Medicaid Web Portal Automated Response System (ARS)

Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice.

https://vamedicaid.dmas.virginia.gov/

Medicall (Audio Response System)

Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice.

1-800-884-9730 or 1-800-772-9996

KEPRO

Service authorization information for fee-for-service members.

 

 

https://dmas.kepro.com/

 

Provider Appeals

DMAS launched an appeals portal in 2021. You can use this portal to file appeals and track the status of your appeals. Visit the website listed for appeal resources and to register for the portal.

https://www.dmas.virginia.gov/appeals/

Managed Care Programs

Medallion 4.0, Commonwealth Coordinated Care Plus (CCC Plus), and Program of All-Inclusive Care for the Elderly (PACE).  In order to be reimbursed for services provided to a managed care enrolled individual, providers must follow their respective contract with the managed care plan/PACE provider.  The managed care plan may utilize different guidelines than those described for Medicaid fee-for-service individuals.

Medallion 4.0

http://www.dmas.virginia.gov/#/med4

CCC Plus

http://www.dmas.virginia.gov/#/cccplus

PACE

http://www.dmas.virginia.gov/#/longtermprograms

Magellan Behavioral Health

Behavioral Health Services Administrator, check eligibility, claim status, service limits, and service authorizations for fee-for-service members.

www.MagellanHealth.com/Provider

For credentialing and behavioral health service information, visit:

www.magellanofvirginia.com, email: VAProviderQuestions@MagellanHealth.com,or

Call: 1-800-424-4046

Provider Enrollment

In-State- 1-804-270-5105

Out of State Toll Free 1-888-829-5373

Email: VAMedicaidProviderEnrollment@gainwelltechnologies.com

 

Provider HELPLINE

Monday–Friday 8:00 a.m.-5:00 p.m.  For provider use only, have Medicaid Provider ID Number available.

1-804-786-6273

1-800-552-8627

Aetna Better Health of Virginia

www.aetnabetterhealth.com/Virginia

 1-855-270-2365

 1-866-386-7882 (CCC+)

Anthem HealthKeepers Plus

www.anthem.com/vamedicaid

1-833-207-3120

1-833-235-2027 (CCC+)

Molina Complete Care

 

1-800-424-4524 (CCC+)

1-800-424-4518 (M4)

Optima Family Care

1-800-643-2273

1-844-374-9159 (CCC+)

 www.optimahealth.com/medicaid

United Healthcare

www.Uhccommunityplan.com/VA

www.myuhc.com/communityplan

1-844-284-0149

1-855-873-3493 (CCC+)

Virginia Premier

1-800-727-7536 (TTY: 711), www.virginiapremier.com