Transcript Prior Authorization - indianamedicaid.com

Presented
by ADVANTAGE Care Select and
MDwise Care Select Provider Relations
PCS0080 (09/09)
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Agenda
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Welcome
Session Objectives
Eligibility Review – The Key to Success
The Prior Authorization (PA) Process
Questions/Answers
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Session Objectives
Following this session, providers will be able to:
• Identify the two care management organizations (CMOs)
• Understand eligibility and its relationship to PA
• Understand the suspended PA procedures when a member
switches health plans
• Understand which contractor processes pharmacy PA requests
• Common PA submission procedures by specialty
• Common PA processing procedures by specialty
• Understand the PA appeal process
• PA contact information
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Care Select Eligibility Review
Verify eligibility using Web interChange, OMNI or Automated Voice
Response (AVR)
• Always verify the Care Select member’s eligibility
• Review the entire eligibility record to determine the
member’s Care Management Organization (CMO)
• The member’s CMO affiliation determined on the date of
eligibility verification determines everything:
1. Which CMO receives the member’s PA request
2. Member’s Care Manager
3. Member’s Primary Medical Provider (PMP)
4. CMO who processes restricted card information
5. Where members can change PMP
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Care Select Eligibility Review
Reminders:
• Know the member’s assigned PMP and contact information
• Providers rendering services that require the PMP’s two
character certification code must obtain that certification code
prior to rendering the service (see BT200804 for a list of
services requiring the certification code)
• Services where the PMP declines to provide the certification
code are non – covered by the Indiana Health Coverage
Programs (IHCP)
• A patient waiver as described in Chapter Four, Section 5 of
the IHCP Provider Manual can be requested from the member
if he/she insists on receiving the service not authorized by the
assigned PMP
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Prior Authorization
Two health plans were selected to function as CMOs for the Care
Select program
– ADVANTAGE Health Solutions, Inc.sm
• www.advantageplan.com/advcareselect
• 1-800-784-3981 – Care Select PA
• 1-800-269-5720 – Traditional PA
– MDwise, Inc.
• www.mdwise.org
• 1-866-440-2449 – Care Select PA
ADVANTAGE was selected to function as the Traditional
Medicaid fee – for – service
Note: All PA for prescription drugs are processed and
adjudicated by ACS and not the CMOs
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Prior Authorization
General Information
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The STATE plan requirements for Prior Authorization are the same for both
Indiana Care Select and Traditional Medicaid (FFS)
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The CMO’s PA departments use OMPP approved criteria in addition to the
Indiana Administrative Code (IAC), PA guidelines, and Indiana Health
Coverage Programs (IHCP) bulletins, banner pages, and newsletters when
considering PA requests
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The CMO’s PA Departments review all medical, facility, or dental PA requests
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Decisions to authorize, modify, or deny a PA is based on medical
reasonableness, necessity, and other criteria outlined in 405 IAC 5-3 and
reflects the current standards of practice in the provider community
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For a full detailed explanation of PA processes and procedures, please refer
to Chapter 6 of the 2008 IHCP Provider Manual
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Out of state providers must obtain PA prior to performing services (except
emergencies)
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Prior Authorization
Methods of Submission – All PAs are submitted to the plan the
member is assigned to
By Fax – Providers may fax the Indiana Prior Review and Authorization
Request form along with supporting documents Note: CMO preferred
method
By Web interChange - application on the IHCP website allows providers
to submit non-pharmacy PA requests and to inquire on request via web
interChange. Note: Providers must have administrator capability setup
on Web interChange in order to submit PA or to perform PA Inquiry on
Web Interchange
By Mail – Written requests for PA are submitted using an Indiana Prior
Review and Authorization Request form along with supporting
documents
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Prior Authorization
Web interchange
• The following provider types can submit PA requests via Web
interChange:
– Chiropractor
– Dentist
– Doctor of Medicine
– Doctor of Osteopathy
– Home Health Agency (authorized agent)
– Hospice
– Hospitals
– Optometrist
– Podiatrist
– Psychologist endorsed as a Health Service Practitioner in
Psychology (HSPP)
– Transportation providers
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CMO Prior Authorization Process
Procedures
• Use the fee schedule at www.indianamedicaid.com to locate services
which require PA due to State regulations for Care Select and
Traditional Medicaid
Reminder: Care Select service PA rules are not the same as Hoosier
Healthwise PA requirements – don’t get them confused
• Services which require PA are processed according to the guidelines
specified in the IHCP Provider Manual Chapter 6, Indiana
Administrative Code, and bulletins, banner pages, and newsletters
Reminder: Do not submit PA requests to a MDwise HHW Delivery
System
• New services require a new Prior Authorization request form
Reminder: Providers may not add new services to an existing PA
request as this constitutes a new PA request
• Indiana Prior Review and Authorization Request Form, System
Update Form and Dental Prior Review and Authorization Request
Form
– These forms are available on the Forms page of the IHCP Website at
www.indianamedicaid.com.
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Prior Authorization Process
Request Sent to Wrong CMO
• Paper and faxed requests are rejected
– Requesting provider will receive a decision letter advising of
rejected status
• PA requests sent electronically via the 278 transaction are rejected
with reason code 78 – Subscriber/Insured not in Group/Plan
identified
– Requesting provider will not receive a decision letter
• PA requests sent via web interChange are systematically routed to
the correct CMO
• Providers will need to resubmit the PA request to the appropriate
CMO
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Prior Authorization
Outstanding Prior Authorizations
• Members can change between Traditional Medicaid fee-for-service,
Hoosier Healthwise, and Care Select
• The receiving organization must honor PAs approved by the
member’s previous organization for the first 30 days following the
re-assignment, or for the remainder of the PA dates of service,
whichever comes first
Example:
Member transitions from Hoosier Healthwise MCO to a Care Select
CMO on November 14, 2007. The MCO approved PA for dates of
service 10/22/07 through 12/13/07
The CMO must honor the approved PA for 30 days from November 14,
2007
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Suspended Prior Authorization
• PA requests are suspended when additional information is needed
by the provider to determine medical necessity
• Requested documentation must be received within 30 calendar days
Member switches CMO’s
• Important: When a member is re-assigned to a different CMO after a
PA request is suspended:
– Providers must send the added documentation to the CMO
which received the original PA request from the provider
– Providers should verify member eligibility for the original PA
request date via web interChange prior to sending additional
documentation
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Prior Authorization
Does the service require PA under the State Plan?
• Examples of general services the State requires PA for:
1. Transplants
2. Outpatient surgeries
3. Home Health - No inpatient discharge
4. Durable Medical Equipment and Home Medical Equipment
5. Inpatient psychiatric admissions, inpatient surgeries,
rehabilitation, burn and substance abuse
6. Therapies (Physical, Speech, and Occupational) – No
inpatient discharge
7. Transportation (>20 one way trips or >50 miles one way)
8. Outpatient Mental Health (>20 visits)
9. Psychiatric Residential Treatment Facility (PRTF)
• PA determines the medical necessity of a service or item
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Prior Authorization
General Institutional PA Guidelines
• Criteria used to process PA requests for institutional services are
located in 405 IAC 5
• Inpatient services that require PA are substance abuse, inpatient
psychiatric, surgical procedures, rehabilitation, and certain burn
cases
• Days that are not approved by PA are non – covered by the IHCP
• The PA Request Form is always required when submitting a PA
(located at www.indianamedicaid.com)
• Note: The CMOs request that hospitals notify us via web
interChange, fax, or phone when one of our Care Select members
becomes an inpatient so we can assist in planning patient discharge
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Prior Authorization
Supporting Documents Necessary for Institutional PA
Requests
Note: Free-Standing Inpatient Psychiatric Hospitals or Acute
Care Hospital Psychiatric Units
• Pre-certification must be phoned in for all emergent and
non-emergent requests
• The Division of Family Resources 1261A must be submitted
within 10 days of a non-emergent request and 14 days of an
emergent request
• Recertification as specified by the State for continued
inpatient psych admissions
• Reimbursement is not allowed if pre-certification and the
Form 1261 A are not completed within the time frames
specified
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Prior Authorization
Psychiatric Residential Treatment Facility PA requests must
include the PA request form and the following:
Psychiatric Residential Treatment Facility (PRTF)
Supporting Documentation Requirements:
• Intake Assessment
• Form 1261A
• Physician History
• Physical
• Current Inpatient Treatment Plan
• Physician Progress Notes
• Inpatient Nursing Notes
• Physician Recommendation Letter
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Prior Authorization
Inpatient emergency services requiring PA
• Reported to CMO within 48 hours of admission
• See Chapter 8 of the IHCP Provider Manual for a list of
applicable emergency diagnosis codes.
• Complete the PA Request form
• Report emergency services to member’s PMP within 48 hours
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Prior Authorization
Non-Institutional PA Requirements (Physician)
• Criteria used to process PA requests for non-institutional services
are located in 405 IAC 5
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Practitioners:
Doctor of Chiropractic Medicine
Medical Doctor
Doctor of Osteopathy
Doctor of Podiatric Medicine
Health Services Provider in Psychology
Optometrist
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Prior Authorization Process - Physician
Physician PA requirements found in 405 IAC 5-25
• Bariatric surgery
• Blepharoplasties
• Bone marrow or stem cell transplants
• Brand name medically necessary drugs
• Genetic testing for detection of cancer
• Home health services
• Intersex surgeries
• Long-term acute care hospitalization
• Mastectomies for gynecomastia
• Maxillo-facial surgeries related to diseases of the jaw and
contiguous structures
• Organ transplants
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Prior Authorization Process - Physician
Physician Services:
• PA required for Evaluation and Management (E&M) services that
exceed 30 visits per member per rolling calendar year:
E&M Codes subject to PA after 30 visits:
99201 – 99205
99211 - 99215
99241 - 99245
99381 - 99387
99391 - 99387
99401 - 99429
• Please note: Physician services rendered during an inpatient stay
that do not receive PA are not reimbursable
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Prior Authorization Process – Physician
PA requirements for podiatry services are found in 405 IAC 5-26
• Corrective features built into shoes for members younger than age
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• Orthopedic shoes for members with severe diabetic foot disease
• Palliative or hygienic care
• Routine foot care in excess of six services per year for patients
with diabetes mellitus, peripheral vascular disease or preripheral
deuropathy
• Podiatry services furnished during an inpatient stay requires PA
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Prior Authorization Process – Physician
PA requirements for chiropractic services are found in 405
IAC 5-12
• Reimbursement limited to 50 office visits or treatments
per member per year (includes five office visits per
year)
• New patient office visits are reimbursable once per
provider per lifetime of the member
• Chiropractic services rendered without PA are subject
to denial
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Prior Authorization Process – Home Health
PA criteria for home health services located at 405 IAC 5-16
Note: PA is required for home health services except for those
services ordered in writing by a physician before the patient’s
discharge from a inpatient stay that do not exceed 120 hours within
30 days of discharge provided by:
• Registered nurse
• Licensed practical nurse
• Home health aide
PA requests submitted must include the following:
- Appropriate home visit nursing level code – 99600 TD-Unlisted
home visit, service, or procedure-registered nurse
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Prior Authorization Process – Home Health
Documentation Reviewed by the PA Department:
• Copy of written plan of treatment signed by attending physician,
current through date of request that documents effectiveness of
treatment
• Estimate of costs for the required services ordered by the
physician and signed by the physician reflected in plan of
treatment
• Number and availability of non-paid caregivers that assist in
member care (even if none available)
• Number of members in household receiving home health services
to coordinate care efficiently
• Number of hours of service per day, number of visits per day, and
number of days per week the service is to be provided
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Prior Authorization Process – Home Health
Documentation Reviewed by the PA Department continued:
• Home health visits greater than three per day provided to the same
household or member
• Other non-IHCP home health services provided to the member
including Medicare, CHOICE, Waiver, private insurance, private pay,
school system, and other paid caregivers (include number of hours
per day and number of days per week for each service)
• Encounter – direct personal contact between patient and authorized
person to furnish services to patient
• Frequency of visits is the number of encounters in a given period
between patient and person authorized to furnish services (specific
number of range)
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Prior Authorization Process – Home Health
Documentation Reviewed by the PA Department continued:
• Prescribed in writing by physician (medically confined to home)
• Medically necessary and reasonable
• Less expensive than alternative modes of care
• Progress notes detailing patient evaluation and physical involvement
by physician to document acute needs
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Prior Authorization Process – Home Health
Documentation Reviewed by the PA Department continued:
Medical plan of care must be developed with home health agency and in
consideration of all pertinent diagnoses, includes the following:
• Mental status
• Types of services/equipment
• Frequency of visits
• Prognosis
• Rehabilitation potential
• Functional limitations
• Activities permitted
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Prior Authorization Process – Home Health
Documentation Reviewed by the PA Department Continued:
• Nutritional requirements
• Medications and treatments
• Safety measures to protect against injury
• Instructions for timely discharge or referral
• Specific procedures/modalities to be used along with
frequency, amount, and duration of each
Note: The medical plan of care must be reviewed by the
practitioner at least every two months
Note: A written summary by the agency must be sent to the
practitioner every two months
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Prior Authorization Process – Home Health
New authorization requests for home health services must include:
• The clinical summary of PA form must be updated to reflect any
change in patient’s status (as documented in the patient plan of
care)
• Non-covered services under home health benefit:
• Homemaker
• Chore services
• Sitter/companion services
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Prior Authorization Process - Therapy
General Information
Criteria for therapy services is located in 405-IAC 5-22-6 through 405IAC-5-22-11
Note: Therapy service PA requests may be submitted by home health
agencies or individual therapy providers (See BR200831) for
limitations
PA is not required for:
• Initial evaluations
• Emergency respiratory therapy
• Therapy services ordered in writing by a physician at inpatient
discharge, up to 30 hours, sessions or visits in 30 calendar days
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Prior Authorization - Therapy
PA not Required Continued:
• Deductible or co-payment for services covered by Medicare
• Therapy services provided by a nursing facility of ICF/MR which are
included in the facility’s per diem rate
PA criteria for occupational, physical, respiratory, or speech therapy
• Written evidence of physician involvement and patient evaluation
needed to document acute needs
• Current plan of treatment
• Physician order
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Prior Authorization - Therapy
PA Criteria Continued:
• Current plan of treatment and progress notes documenting necessity
and effectiveness of therapy
• Qualified therapist or qualified assistant under supervision of therapist
must provide therapy
• Therapy must be of a level of complexity and sophistication and the
condition of the member must be such that judgment, knowledge, and
skills of a qualified therapist are required
• Medically necessary
• Rehabilitative service covered for a member no longer than two years
from initiation of therapy unless a significant change in medical
condition is noted
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Prior Authorization Process - Therapy
Additional Information:
• Maintenance therapy not covered
• Progress evaluations not separately reimbursable and are covered
as part of the therapy program
• One hour of therapy must include minimum of 45 minutes of direct
patient care with balance spent in patient related services
• Therapy services not approved for more than one hour per day per
type of therapy
• Duplicate therapy services are not covered
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Prior Authorization Process – Mental Health
Mental health PA criteria are listed in 405 IAC 5-20-8
PA required for mental health services provided in an outpatient or
office setting that exceed 20 units per member, per provider, per
rolling 12-month period
Criteria reviewed:
• PA request form
• Current treatment plan
• Progress notes – necessity and effectiveness of therapy
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Prior Authorization Process – Mental Health
Note: PA required for neuropsychological and psychological testing and
includes 96101 – psychological testing, 96111 – developmental test
extended, and 96118 – neuropsychological testing battery
• PA not required:
• 2 units of psychiatric diagnostic interview allowed per 12 months per
member, per provider if a physician or HSPP and a mid level
practitioner separately evaluate the member (90801)
• Medicaid Rehabilitation Option (MRO) services are not subject to PA
as outlined in 405 IAC 5-21
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Prior Authorization Process – Mental Health
Assertive Community Treatment (ACT)
PA is required for ACT services covered by the IHCP per 440 IAC 5.22-3 and PA requirements in 405 IAC 5-21-8(d)
• Required Documents:
• Assessment of current medical status
• Psychiatric history
• Status at time of review for ACT
• Treatment goals reviewed by ACT team psychiatrist
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Prior Authorization Process – Mental Health
Note: Care Select members can self refer to any IHCP enrolled mental
health provider. However, mental health services furnished to
members by providers enrolled with specialties other than mental
health must contact the member’s assigned MDwise Care Select
PMP to obtain that PMP’s two character certification code
• All services billed to EDS as fee for service
• The CMO’s do not retain a mental health benefits administrator for
their respective Care Select products
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Prior Authorization Process – DME/HME
Medical Supplies and Equipment
Criteria for medical supplies, durable medical equipment, and home
medical equipment can be found in 405 IAC 5-19
• PA is not required for the following items:
• Cervical collars
• Back supportive devices
• Hernia trusses
• Oxygen, supplies, and equipment for its delivery for nursing facility
residents
• Parenteral infusion pumps used with parenteral hyperalimentation
• Eyeglasses
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Prior Authorization Process – DME/HME
Chapter 6, section 5 details other DME and HME which does not
require PA. Also, see the IHCP fee schedule at
www.indianamedicaid.com
Oxygen:
• All oxygen equipment and supplies require PA for members in a
home setting
• Physician order required
• Note: DME/HME that is purchased and require repair also require
PA
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Prior Authorization Process – DME/HME
A Medical Clearance Form is required for certain types of DME, HME or
medical supplies and must accompany the PA request form
Note: The medical clearance form is used to justify the medical
necessity of certain DME, HME, or medical supplies:
• Augmentative communication systems – Augmentative
Communication System Selection form
• Certificate of Medical Necessity (CMN) for home oxygen therapy –
Certificate of Medical Necessity: Oxygen form
• CMN parenteral or enteral nutrition – Certificate of Medical
Necessity: Parenteral or Enteral form
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Prior Authorization Process – DME/HME
• Audiometric tests for hearing aid fitting – Medicaid Medical
Clearance and Audiometric Test form
• Hearing Aids – IHCP Medical Clearance and Audiometric
Test form
• Hospital beds – Medical Clearance Form: Hospital and
Specialty beds
• Motorized wheelchairs or other power-operated vehicles –
IHCP Medical Clearance for Motorized Wheelchair
Purchase form
• Negative pressure wound therapy – IHCP Medical
Clearance form for Negative Pressure Wound Therapy
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Prior Authorization Process – DME/HME
• Non-motorized wheelchairs – IHCP Medical Clearance form for Nonmotorized Wheelchair Purchase
• Standing equipment – Medical Clearance Form: Physical
Assessment for Standing Equipment
• Transcutaneous electrical nerve stimulator (TENS) – Medical
Clearance form for TENS Unit
Note: All forms are available in the IHCP Provider Manual or by
contacting EDS Customer Service at 1-800-577-1278 or at
www.indianamedicaid.com
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Prior Authorization – DME/HME
PA request for DME and HME are reviewed on a case-by case basis
based on the following:
• The item must be medically necessary for the treatment of an illness
or injury or to improve the function of a body part
• The item must be adequate for the medical need; however, items
with unnecessary convenience or luxury features are not allowed
• The anticipated period of need, plus the cost of the item is
considered in determining whether the item is rented or purchased
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Prior Authorization – DME/ HME
Traditional Medicaid members – Nursing home benefits and DME/HME
Note: The IHCP case mix rate for long term care facilities includes
costs for the following and cannot be separately authorized or billed
to the IHCP:
• Medical and non-medical supplies
• Mental health service
• Nursing care
• Room and board
• Therapy services
• Transportation
• Habilitation
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Prior Authorization - Transportation
PA criteria for transportation services are found in 405 IAC 5-30
PA is required for:
• Transportation trips exceeding 20 one – way trips per member, per
rolling 12-month period (exception: emergency ambulance, transport
to or from a hospital admission or discharge, patients on dialysis,
and patients in nursing homes)
• Trips 50 or more miles one way
• Out – of – state or non – designated trips
• Airline or air ambulance by a provider located out-of-state or in a
non – designated area
• In – state bus or train services
• Family member transportation (authorized by the county office of the
DFR)
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Prior Authorization
Contact Information
• Advantage Health Plan (Traditional Medicaid)
P.O. Box 40789
Indianapolis, IN 46240
800-269-5720
• MDwise – CMO
P.O. Box 44214
Indianapolis, IN 46244-0214
866-440-2449
• Advantage Health Plan – CMO
P.O. Box 80068
Indianapolis,IN 46280
800-784-3981
• ACS
866-879-0106
866-780-2198 (Fax)
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Prior Authorization Process - Transportation
Submit the following information:
• PA form
• Proper procedure codes
• Member’s age, diagnosis, and condition
• Level of service needed
• Reason for and destination of service
• Frequency of service
• Duration of service
• Total mileage for each trip
• Total wait time for each trip
Note: PA not required for accompanying parent or attendant unless the
trip exceeds 50 miles one - way
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Prior Authorization Process – Genetic Tests
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Genetic testing for breast and ovarian cancer
Documentation required:
PA request form
Appropriate procedure codes
Medical necessity documentation
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Prior Authorization Process – Hearings/Appeals
Hearing, Appeal and Administrative Review
• Procedures for hearings, appeals, and administrative review remain
unchanged
• Providers may exercise PA appeal rights to the CMO that denied the
PA request
– If the member is re-assigned to another program after the PA
request is denied, the provider may send a PA request to the
new organization, or appeal to the organization that denied the
request
– Appeals sent to the wrong CMO are returned to the provider
unprocessed
• Refer to Chapter 6 of the IHCP Provider Manual as well as each
CMO’s Provider Manual regarding the hearing, appeal, and
administrative review procedures
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Prior Authorization – Summary
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Verify member eligibility
Verify member’s CMO affiliation on date of PA request
Verify if the service requires PA
Complete the PA request form for all PA requests
Complete with appropriate CPT/HCPCS codes
All out – of – state services providers must receive PA before
providing services (except designated IFSSA areas)
• Fax PA form and supporting documentation to appropriate CMO
MDwise: 877-822-7186 or 317-822-7515
ADVANTAGE Care Select:
800-689-2759
ADVANTAGE Traditional Medicaid: 800-689-2759
• Verify PA status using web interChange PA inquiry
• Finalize all PA requests (including suspended PAs) with CMO
receiving original PA request
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Questions
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Presentation by ADVANTAGE Health Solutions, Inc. and MDwise, Inc. Provider
Relations Team in cooperation with each organization’s PA Department
Kelvin Orr – Provider Network Director, ADVANTAGE Care Select
Mark Willeman – PA Director, ADVANTAGE Care Select & FFS
Chris Kern – Provider Relations Manager – Care Select
Marcia Franklin – Senior Manager – Care Select Prior Authorization
ADVANTAGE Traditional Medicaid PA
P.O. Box 40789
Indianapolis, IN 46240
ADVANTAGE Care Select PA
P.O. Box 80068
Indianapolis, IN 46280
MDwise Care Select PA
P.O. Box 44214
Indianapolis, IN 46244
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