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You’re invited to the 1st Quarter Kaiser Permanente Virginia Medicaid Provider Virtual Townhall – March 20, 2024
Join us virtually on Wednesday, March 20, 2024, from 11 a.m. – 12 p.m. for our quarterly forum just for VA Medicaid providers.
Topics include:
- Kaiser Permanente news
- Optima Health rebranding to Sentara Health
- Brain injury services case management
- Pharmacists as providers
- Behavioral health referrals
- PRSS enrollment requirements
- Online Affiliate features
- And more!
We look forward to seeing you!
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New Online Affiliate Features: Pharmacy Weight Management Service Referrals & Radiology and Lab Order Entry
Kaiser Permanente’s Online Affiliate offers a wealth of time-saving tools. Through this convenient online portal, providers can view eligibility and benefits, submit claims and appeals, as well as much more. Below you’ll find details about two recently added features to the platform.
Pharmacy Weight Management Service Referrals
Effective February 6, 2024, Kaiser Permanente’s Online Affiliate platform offers providers an electronic method to refer patients to KPMAS Pharmacy Weight Management Service. This service will ensure appropriate and safe prescribing of injectable weight loss medication therapy (e.g. GLP-1 RAs), and help our patients fill their prescriptions seamlessly.
Note: This referral is only for evaluation of appropriateness of injectable weight loss medications for adults ages 18 or older; it is NOT for diabetes management. Some GLP-1 RAs medications may have utilization criteria; please review the utilization criteria prior to placing the referral.
Before prescribing an injectable weight loss medication, providers should enter a referral into the Pharmacy Weight Management Service for evaluation of appropriateness of injectable weight loss medication.
If a patient meets the criteria, they will be enrolled into the service, and the clinical pharmacist will contact the provider for an injectable weight loss medication order. Patients who do not meet the criteria will not be enrolled, and alternative therapies will be recommended.
Please follow the instructions below to refer patients to KPMAS Pharmacy Weight Management Service:
- Sign into Online Affiliate: https://epiclink.kp.org/MAS/epiclink
- On the “Home” screen, select the “Order Entry” option from the drop-down menu under the “Patient” category.
- On the “Order Entry” screen, select your patient using the search function or the “My Patients” list, and then select the appropriate “Ordering Clinic” from the dropdown menu.
- On the following screen, in the “New Procedure” field, type “Ref Med Management.” Select “Clin Pharm Chart Review – Injectable Weight Loss Medication Review”
- Complete the referral form, making sure to fill out the required fields indicated by stop signs. Then click “Accept.”
- Click on the “Sign Orders” button on the following screen to submit the referral.
If you would like to request a call back or training regarding this referral process, please fill out the KPMAS Drug Use Management intake form.
Radiology and Lab Order Entry
In 2023, Online Affiliate rolled out a new feature for radiology and lab orders. Kaiser Permanente’s Online Affiliate platform now allows external providers to request radiology and lab order directly through the portal. Providers can select up to 16 laboratory options and over 50 radiology procedures via the order entry screens.
If you have questions about Online Affiliate, please email KP-MAS-OnlineAffiliate@kp.org.
Authorization-waived CPT Codes for Behavioral Health
To help meet the growing demand for mental health services, we have expanded the list of procedures that do not require pre-authorization. This is effective immediately, and we will update the list if any changes are made in the future.
Kaiser Permanente members may contact a Behavioral Health provider directly for an appointment. Pre-authorization is not required for the initial consultation and some routine care services. Please see below for the complete list of authorization-waived CPT codes and their corresponding descriptions.
| CPT Code | Description |
| H0014 | ALCOHOL AND/OR DRUG SERVICES; AMBULATORY DETOX |
| H0020 | ALCOHOL AND/OR DRUG SERVICES; METHADONE ADMIN/SERVICE |
| G2067 | MEDICATION ASSISTED TREATMENT, METHADONE; WEEKLY |
| G2068 | MEDICATION ASSISTED TREATMENT, BUPRENORPHINE; WEEKLY |
| G2078 | TAKE HOME SUPPLY OF METHADONE; UP TO 7 ADD DAY SUPPLY |
| 90791 | PSYCHIATRIC DIAGNOSTIC EVALUATION |
| 90792 | PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES |
| 90832 | PSYCHOTHERAPY W/PATIENT 30 MINUTES |
| 90833 | PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 30 MIN |
| 90834 | PSYCHOTHERAPY W/PATIENT 45 MINUTES |
| 90836 | PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 45 MIN |
| 90837 | PSYCHOTHERAPY W/PATIENT 60 MINUTES |
| 90838 | PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN |
| 90846 | FAMILY PSYCHOTHERAPY W/O PATIENT PRESENT 50 MINS |
| 90847 | FAMILY PSYCHOTHERAPY W/PATIENT PRESENT 50 MINS |
| 90849 | MULTIPLE FAMILY GROUP PSYCHOTHERAPY |
| 90853 | GROUP PSYCHOTHERAPY |
| 96127 | BRIEF EMOTIONAL/BEHAVIORAL ASSESSMENT |
| 99202 | OFFICE/OUTPATIENT NEW SF MDM 15-29 MINUTES |
| 99203 | OFFICE/OUTPATIENT NEW LOW MDM 30-44 MINUTES |
| 99204 | OFFICE/OUTPATIENT NEW MODERATE MDM 45-59 MINUTES |
| 99205 | OFFICE/OUTPATIENT NEW HIGH MDM 60-74 MINUTES |
| 99211 | OFFICE/OUTPATIENT EST PT MAY NOT REQ PHYS/QHP |
| 99212 | OFFICE/OUTPATIENT ESTABLISHED SF MDM 10-19 MIN |
| 99213 | OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20-29 MIN |
| 99214 | OFFICE/OUTPATIENT ESTABLISHED MOD MDM 30-39 MIN |
| 99215 | OFFICE/OUTPATIENT ESTABLISHED HIGH MDM 40-54 |
| 99307 | SUBSEQUENT NURSING FACILITY CARE (10 MIN) |
| 99308 | SUBSEQUENT NURSING FACILITY CARE (15 MIN) |
| 99309 | SUBSEQUENT NURSING FACILITY CARE (25 MIN) |
| 99310 | SUBSEQUENT NURSING FACILITY CARE (35 MIN) |
Ending the COVID-19 Public Health Emergency
On May 11, 2023, the Federal Government will end the public health emergency (PHE). This action marks a significant milestone as we enter the endemic phase of COVID-19.
This will affect how COVID-19 vaccines, testing, and treatment are provided and covered. In most instances, these services will return to being covered like any other condition alongside applicable plan out-of-pocket costs. The pertinent changes are outlined below:
| Commercial Plans | In network: COVID-19 vaccines will continue to be covered under preventive benefits at applicable plan cost sharing, typically $0. Out-of-network: COVID-19 vaccinations will no longer be covered. |
| Medicare Plans | In network: COVID-19 vaccines will continue to be covered by Medicare part B at no cost. Out-of-network: COVID-19 vaccinations will no longer be covered. |
| Medicaid Plans | COVID-19 vaccines will continue to be covered at no cost through September 2024. |
| Commercial Plans | COVID-19 home antigen tests coverage expires and will no longer be covered. |
| Medicare Plans | COVID-19 home antigen tests coverage expires and will no longer be covered, per federal guidance. |
| Medicaid Plans | COVID-19 home antigen tests will continue to be covered at no cost through September 2024. |
| Commercial Plans | In-network: COVID-19 diagnostic PCR testing will be covered under the outpatient diagnostic lab benefit at applicable plan cost-sharing. Testing for other purposes, such as for work, school, or travel is not covered. Out-of-network: COVID-19 PCR testing will only be covered for urgent care and emergency services, when legally required, or when OON coverage is included in a Kaiser Permanente member’s plan. |
| Medicare Plans | In-network: COVID-19 diagnostic PCR testing will be covered under the outpatient diagnostic lab benefit at applicable plan cost-sharing. Testing for other purposes, such as for work, school, or travel is not covered. Out-of-network: COVID-19 PCR testing will only be covered for urgent care and emergency services when legally required or when OON coverage is included in a Kaiser Permanente member’s plan. |
| Medicaid Plans | COVID-19 PCR tests will continue to be covered at no cost through September 2024, in compliance with federal guidance. |
| Commercial Plans | In-network: COVID-19 treatment will be covered under the drug benefit with applicable plan cost-sharing. Out-of-network: COVID-19 treatment will only be covered for urgent care and emergency services, when legally required, or when OON coverage is included in a Kaiser Permanente member’s plan. |
| Medicare Plans | In-network: COVID-19 treatment will be covered under the Medicare Part B drug benefit with applicable plan cost-sharing. Out-of-network: Coverage for COVID-19 treatment from an out-of-network provider expires and will no longer be covered, per federal guidance. |
| Medicaid Plans | COVID-19 treatment will continue to be covered at no cost through September 2024, in compliance with federal guidance. |
Thank you for partnering with Kaiser Permanente to provide quality health care services to our members throughout every stage of the COVID-19 pandemic.
COVID-19
We are working to address questions and concerns you have. Please see the below FAQs and reference guide to assist you with providing critical care to our members. We will continue to keep you informed as the situation evolves.
COVID-19 Claims Processing FAQ for KPIC Providers - updated 5/11/2023
COVID-19 Claims Processing FAQ for Providers – updated 5/9/2023
COVID-19 KPIC Claims FAQ– updated 5/5/2021
COVID-19 Coding Quick Reference Guide – updated 1/22/2021
Telehealth Talking Points
Telehealth Guide – updated 3/10/2022
Medicare Telehealth FAQ
COVID-19 Vaccine FAQ – updated 5/9/2023
COVID-19 KPIC Vaccine FAQ – updated 5/5/2021
MDH COVID-19 #1
MDH COVID-19 #12 Temporary Registration of RBT – expired August 15, 2021
DC Health Vaccine Counseling
DMAS Required PRSS Enrollment
In April 2022, the Virginia Department of Medical Assistance Services (DMAS) launched a new portal to manage provider enrollment – the Provider Services Solution (PRSS). Medicaid providers will use the PRSS portal, located on the Medicaid Enterprise System (MES) website, to complete enrollment and maintenance processes. This platform will be more efficient and make it easier for you to access the information you need as a Medicaid provider. All Medicaid managed care network providers must enroll through PRSS to satisfy and comply with federal requirements in the 21st Century Cures Act. Those network providers that are currently enrolled as FFS in Medicaid do not have to re-enroll in PRSS.
As a Kaiser Permanente Virginia Premier participating provider, you will need to initiate enrollment through the new PRSS Enrollment Wizard: https://virginia.hppcloud.com/. Go to “Enroll as a new provider” or “check your enrollment status”. Only one enrollment application is necessary in PRSS, even if you participate with more than one MCO. The application process allows for selection of one or more MCO plans. Once approved, providers will need to create a PRSS portal online account in order to revalidate their enrollment, make changes to personal or business information and check member eligibility. You may be asked to provide evidence of your submission.
You can find helpful training resources on the MES website: https://vamedicaid.dmas.virginia.gov/training/providers.
Questions? Contact PRSS Provider Enrollment Helpline at (804) 270-5105 or (888) 829-5373 and Provider Enrollment email address at: vamedicaidproviderenrollment@gainwelltechnologies.com. For questions related to non-enrollment, please work with your health plan.
Provider Education and Training Courses
Managed care network providers can get ready to use the new Provider Services Solution (PRSS) portal by using training resources on the Medicaid Enterprise System (MES) website. DMAS offers a variety of live and pre-recorded training opportunities to help prepare providers to receive the maximum benefits from the PRSS portal. Please encourage your staff to register for virtual instructor-led courses to make sure your organization is ready to use the new portal. Please visit the MES website for a comprehensive listing of current courses.
Training Schedule and Registration
You must register to participate in live webinars. Webinar participants must use a computer with internet access and a telephone line to dial in. Registered participants will have the chance to engage with the trainer and ask specific questions.
As you review training options, PLEASE be sure to register for the following three courses:
- PRSS-111 Provider Enrollment Application
This training course explains the provider enrollment process, identifies the different enrollment types and offers guidance on the documentation that providers need to prepare before enrolling. The training also includes an overview of what the provider enrollment application looks like and how to submit a provider enrollment application.
- PRSS-118 Introduction to Provider and MCO Portal Delegate Management
The goal of this virtual training is to offer instructions on this important process for providers, authorized administrators of providers, and delegates of providers. In PRSS, a provider’s primary account holder and/or delegate administrators must register their delegates and assign them permission to access the provider portal to complete enrollments and other tasks.
- PRSS-120- Introduction to the Provider Portal
The goal of this virtual training is to introduce the provider portal registration process and the functions, features, and basic navigation within the provider portal.
There is also an optional working session available (PRSS-111-WS Working Session: Provider Enrollment Support) that provides real-time support from our trainer as you work through one or more provider enrollment applications.
To register for any training, please visit the MES Provider Training Registration page to choose a date and time that works best for you.
Registration is now open. Courses begin on May 31, 2022, and spaces are filling quickly. Register early. Please help us spread the word about this upcoming training opportunity. If you have questions related to training, please contact DMAS_VA_MESregistrations@briljent.com.
Determining the Jurisdiction of a Plan
All of our medical plans are located in Maryland, Virginia, or the District of Columbia or is a Federal plan. Each jurisdiction has unique guidelines for billing claims such as member balance billing. Be sure to know the member’s plan situs to ensure appropriate claim processing.
Finding the situs of a member’s plan is simple. Locate the member’s plan name when verifying the member benefits in Kaiser Permanente Online Affiliate. The plan name is under Coverages & Benefits. The Payor/Plan name will contain one of the following as part of the plan name:
- Maryland or MD
- Virginia or VA
- District of Columbia or DC
- Federal or FD (Maryland guidelines apply to Federal plans)
Some examples of what you will see online are:
- Payor/Plan
- MAS KP-MEDICAID MCO MARYLAND / MD MEDICAID PLAN (20325) 0718
- MAS KP-MID ATLANTIC / VA KPIF ON HCR HMO SILVER $15/$40 (3787
If you are uncertain about the situs of a member’s plan, please contact our Member Services Call Center at 1-800-777-7902.
If you are not registered for access to Kaiser Permanente Online Affiliate, you may register online at www.kp.org/providers/mas.
Emergency Room Reductions and Hospital Readmissions
The Virginia Department of Medical Assistance Services (DMAS) has issued a bulletin, Reimbursement Reductions for Preventable Emergency Room Visits and Hospital Readmissions, which communicates changes to the reimbursement structure of such claims. These changes will become retroactively effective as of July 1, 2020. For details of the changes, see the notice below.
ER Payment Reductions and Hospital Readmission Notice
Introducing Changes Coming to KP Online Affiliate Claims Section
We are excited to inform you of a few new updates coming Saturday, August 8, 2020 to the Kaiser Permanente Online Affiliate.
We are committed to continually improving the online capabilities for our external providers, and the upcoming changes will allow you to easily view specific claim detailed information.
These changes will introduce the following to the claims detail report:
- A brand new look and feel of the claims details report
- Claim related referrals and diagnosis information have been added
- Provider/vendor address on Claim submission will be viewable
Please see our job aid to make it easier for you to get comfortable with the new look.
Please reach out to your regional Online Affiliate representative should you have any questions.
New Provider Email Contacts at KP
Effective January 1, 2020, we’re making some updates to where information should be sent to us so that we can serve you better and ensure that inquiries are going directly to those that will handle them.
Ensuring that your message is sent to the correct email address or that your call is placed to the correct phone number allows us to respond quickly and serve you better.
The below list provides updated contacts at Kaiser Permanente for participating network providers.
You may begin to use the new contacts on January 1, 2020. If you’re unsure about who to contact for an issue, contact Provider Relations at provider.relations@kp.org or 877-806-7470 for assistance.
| Provider Experience Email: provider.relations@kp.org Phone: 877-806-7470 |
|
Member Services Phone: |
|
| Provider Demographic Updates Email: provider.demographics@kp.org |
|
| Utilization Management Phone: 800-810-4766 |
|
| Interested Providers Email: interested.providers@kp.org |
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| Provider Recredentialing Email: ppqa-mas@kp.org |
|
UMOC Fax Number Changes
In an effort to streamline our referral process and improve timelines of requests, the Utilization Management Operations Center (UMOC) has made some adjustments to fax numbers for certain specialty services. All fax numbers previously communicated have not been changed and are currently in operation but have been re-assigned based on the type of referral requested. The chart outlines the service type, old fax number and new.
| Referral Type |
Old fax number |
New fax number |
| Durable Medical Equipment (new URF referrals) | 855-414-1695 | 800-660-2019 |
| Durable Medical Equipment (reauthorizations - add codes to update existing referral) | 855-414-1695 | 855-414-1695 |
| All Physical Therapy/Occupational Therapy/Speech Therapy (PT/OT/ST) (new URF referrals) | 855-414-1695 | 800-660-2019 |
| Skilled Nursing Facility PT/OT/ST (reauthorizations) | 855-414-1695 | 855-414-1698 |
| Outpatient Rehab PT/OT/ST (reauthorizations) | 855-414-1698 | 855-414-1698 |
| Home Health PT/OT/ST (reauthorizations) | no existing fax number | 855-414-1695 |
| Early Intervention | no existing fax number | 855-414-1695 |
These changes will go into effect on June 20, 2019. We have updated our training materials and provider manuals to reflect these changes. If you have additional questions, you can email us at Provider.Relations@kp.org or call us at 800-777-7902.
Diversity
Members have the right to free language services for health care needs. We provide free language services including:
- 24-hour access to an interpreter: When members call to make an appointment or talk to their personal physician, if needed, we will connect them to a telephonic interpreter.
- Translation services: Some member materials are available in the member’s preferred language.
- Bilingual physicians and staff: In some medical centers and facilities, we have bilingual physicians and staff to assist members with their health care needs. They can call Member Services or search online in the medical staff directory at kaiserpermanente.org.Braille or large print:
- Blind or vision impaired members can request for documents in Braille or large print or in audio format.
- Telecommunications Relay Service (TRS): If members are deaf, hard of hearing, or speech impaired, we have the Telecommunications Relay Service (TRS) access numbers that they can use to make an appointment or talk with an advice nurse or member services representative or with you.
- Sign language interpreter services: These services are available for appointments. In general, advance notice of two or three business days is required to arrange for a sign language interpreter; availability cannot be guaranteed without sufficient notice.
- Educational materials: Health education materials can be made available in languages other than English by request. To access Spanish language information and many educational resources go to kp.org/espanol or kp.org to access La Guía en Español (the Guide in Spanish). Members can also look for the ñ symbol on the English language Web page. The ñ points to relevant Spanish content available in La Guía en Español.
- Prescription labels: Upon request, the KPMAS pharmacist can provide prescription labels in Spanish for most medications filled at the Kaiser Permanente Pharmacy.
At Kaiser Permanente, we are committed to providing quality health care to our members regardless of their race, ethnic background or language preference. Efforts are being made to collect race, ethnicity and language data through our electronic medical record system, HealthConnect®. We believe that by understanding our members’ cultural and language preferences, we can more easily customize our care delivery and Health Plan services to meet our members’ specific needs.
Currently, when visiting a medical center, members should be asked for their demographic information. It is entirely the member’s choice whether to provide us with demographic information. The information is confidential and will be used only to improve the quality of care. The information will also enable us to respond to required reporting regulations that ensure nondiscrimination in the delivery of health care.
We are seeking support from our practitioners and providers to assist us with the member demographic data collection initiative. We would appreciate your support with the data collection by asking that you and your staff check the member’s medical record to ensure the member demographic data is being captured. If the data is not captured, please take the time to collect this data from the member. The amount of time needed to collect this data is minimal and only needs to be collected once. Recommendation for best practices for collecting data is during the rooming procedure.
In conclusion, research has shown that medical treatment is more effective when the patient’s race, ethnicity and primary language are considered.
To access organization wide population data on language and race, please see our Diversity & Inclusion Annual Report*.
To obtain your practice level data on language and race, please email the Provider Relations Department at Provider.Relations@kp.org.
Provider Referral Requests
The Kaiser Permanente Utilization Management Operations Center reviews each referral request and determines the number of visits that are medically necessary. When requesting referrals, please only request one visit or the exact number of visits that will be needed for a three (3) month period.
Additional visits can be added if medically necessary before approval but if more visits are requested than needed the member will receive a partial approval/denial letter which has been creating confusion for members as they believe their referral is being denied. To help avoid this, please only request one visit or the exact number of visits necessary.
New Kaiser Permanente HealthConnect AffiliateLink Enrollment System
A new automated Kaiser Permanente HealthConnect AffiliateLink enrollment system was implemented in Spring 2015. With the new automated enrollment system, new users are able to apply online and receive their user ID and password electronically. It will no longer be necessary to submit paper enrollment forms. The new online enrollment system provides greater security measures that will help protect our members’ health information.
Before the new enrollment system was launched, it was necessary that we migrate all current user information into the new system. Current users were sent a revised enrollment form to be completed with the necessary information. If you did not receive the revised enrollment form, you may print, complete, and fax it to 855-414-2624.
KP HealthConnect Affiliatelink
Browser, system, and connection requirements have been updated.
The following Internet browsers are required for access AffiliateLink:
- Microsoft® Internet Explorer® 8.0, 9.0, 10, 11.
- Mozilla Firefox™ 10.0 or later.
- Apple Safari Google Chrome.
While other browsers and operating systems may work with our secure features, we cannot guarantee compatibility.
Renewing your annual subscription
In order to maintain the most secure and confidential care possible, we require that you annually renew your participation. As a part of the KP HealthConnect AffiliateLink User Access Compliance Review Process, the Provider Experience Department will send a survey to ensure that you still need to use the website and have the correct level of access.
Please note:
If you do not access the system for any consecutive 90 days, your account will be deactivated. Deactivated users will need to contact Provider Experience at 1-877-806-7470 to be reactivated.
Password Protection
Password protection is only as secure as the password that you choose. It is imperative that all users have their own individual sign-on and password. Please do not share logins or passwords.