Transcript KEPRO Fall 2016 - Health PAS

Molina/BMS 2016
Fall Provider
Workshops
Updates October 2016
1
What’s New?
• APS Healthcare, Inc. was acquired in May 2015 by KEPRO.
• August 1, 2016 APS Healthcare, Inc. formally changed its
company name to KEPRO to unite with its parent company’s
brand, mission and values.
• All future business activity will be conducted under the
KEPRO name.
2
KEPRO Scope of Work
Existing Programs
• Health Homes
• I/DD Waiver Services
• ADW Waiver Services
• Personal Care Services
• TBI Waiver Services
• Nursing Home PAS Review
• Behavioral Health Services
• Medical Services
• BHHF
• BCF-Socially Necessary
Services
New Programs
• Non-EMERGENCY
Ambulance Transportation
(Not NEMT)
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Websites/Direct Data Entry Portals
If you have submitted requests via the direct data entry on one of APS’
web-portals, that web address has changed to reflect the name change to
KEPRO. The submission process has NOT changed.
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Medical Requests:
Health Homes:
Behavioral Health
Nursing Home PAS
Personal Care
Aged & Disabled Waiver
I/DD Waiver
TBI Waiver
https://providerportal.kepro.com
https://providerportal.kepro.com
https://careconnectionwv.kepro.com
https://c3.kepro.com
https://wvltc.kepro.com
https://wvltc.kepro.com
https://wvltc.kepro.com
https://wvltc.kepro.com
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WV Medicaid Health Homes Program
A Health Home provides a comprehensive system of care coordination for Medicaid members
with chronic conditions. Health Home Providers coordinate all primary, acute, behavioral
health and long-term services and supports to treat the “whole person” across a Medicaid
member’s lifespan. Members are free to choose any provider for treatment services;
therefore, your current patients can remain with you.
Current Health Home member enrollment = approximately 700 members.
There are currently seven (7) existing Health Homes Providers located in Cabell, Kanawha, Mercer, Putnam,
Raleigh and Wayne counties:
 FMRS HEALTH SYSTEMS
 MARSHALL HEALTH
 PRESTERA CENTER FOR MENTAL HEALTH
 PROCESS STRATEGIES
 SOUTHERN HIGHLANDS COMMUNITY HEALTH CENTER
 WOMENCARE, INC. (FAMILY CARE)
 WV HEALTH RIGHT
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Health Homes Quality Measures
 During the SFY 2015, a total of 1,243 individuals received Health Homes Program services; 82
were new Medicaid members who had not received any Medicaid services in SFY 2014.
 118 Health Homes Program members were reported as Hepatitis positive; 161 were identified at
high risk for Hepatitis.
 732 (59%) Health Homes Program members smoke/and/or use tobacco; 473 received smoking
and tobacco use cessation.
 100% of the enrollees age 12 and older were screened for depression; 79% were clinically
depressed at the time of the screening.
 SFY 2015 emergency department costs were reduced by $17,639 for Health Homes Program
members.
 A 42% reduction in the average length of stay in a hospital for all Health Homes Program members
who had Medicaid coverage in both SFY 2014 and SFY 2015. Those members who were enrolled in
a Health Homes for the entire year saw a decrease of 32% from SFY 2014. The decrease can be
attributed to better discharge planning.
Additional Health Homes Program information is available on the WV Bureau for Medical Services website:
www.dhhr.wv.gov/bms/ or KEPRO: www.kepro.com
Questions/concerns – contact KEPRO at 304-343-9663 or 1-800-461-0655
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Personal Care Services Update
• Policy manual revision posted 10/1/2016.
• PAS can now be signed by FNP/PA-C.
• Agencies are required to include all documentation in the
request (POC and assessment required for all requests).
• If services do not start within 60 days of authorization, reauthorization must be requested.
For questions, contact the Bureau of Senior Services (304)558-3317; (877)987-3646
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Traumatic Brain Injury (TBI) Waiver Updates
• 300 units per Calendar Month on Non-Medical Transportation Services
Code
• Personal Attendant Services:
• Can be provided on the day of admission and the day of discharge from a
nursing home, hospital or other inpatient medical facility.
• At no time may the time spent on Incidental services (changing lines, meal
preparation and light housekeeping) exceed the amount of time spent on
hands-on-personal acre assistance.
• KEPRO is able to verify the following to assist providers with denied
claims:
• Authorization span
• KEPRO will correct or modify the authorization span, when applicable and
appropriate.
• Authorization number(s)
• KEPRO will correct or modify the authorization number or create a new
authorization number, when applicable and appropriate.
• Financial eligibility/Medicaid Benefit Plan coverage
• KEPRO will notify the provider of the issue; the provider must follow up with the
member's local DHHR to have the coverage type corrected.
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Reminders to Providers Submitting
Medical Prior Authorization Requests
• Remember to update your contact information when submitting via DDE (direct
data entry). This should include extensions. Having the incorrect contact
information can result in cases being closed and delaying services to the patient.
• Remember to make sure that the referring/servicing providers are active in MolinaKEPRO cannot export authorizations to Molina when the referring or servicing
provider is termed. Just because a provider can be selected in our system does not
mean the provider is active.
• Remember user log-ins are only to be used by the person they are assigned to. Each
registered provider has an organization manager who can add a user. Password resets
completed by KEPRO staff can only be done for the user to whom the log-in is
assigned.
• Remember to Search by CPT/HCPCS Codes when selecting services-this will ensure
that when services are grouped the correct group is selected.
• Remember to attach all clinical information referenced or required in the request if
you indicate attached (e.g. diagnostic reports, H&P, imaging findings, lab results, etc.)
• Please remember that a case may be pended for additional information. You may
want to check the C3 system to be sure no additional documentation has been
requested. This will prevent closure of the request in the absence of the necessary
clinical documentation.
• A facility’s IQ review does not replace clinical documentation. It is fine to include this
with a request, but we must receive the appropriate clinical information to conduct a
review.
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Faxing Prior Authorization Requests or
Attachments
• If faxing attachments for a request that has been submitted via Direct Data
Entry (DDE), please make sure to use the proper fax cover sheet, and make
sure you put the Authorization Request ID on the form. We cannot attach
information without that ID because a patient could have multiple requests
and we wouldn’t have any way of knowing which one it is for.
• If submitting an authorization request via fax, you MUST fill out the form in
its entirety. UM Support staff who enter the requests are not authorized to
guess on any information that is left blank.
• Any additional documentation needs to be submitted with the faxed request.
Failure to do so could result in having the request faxed back to you or the request
being closed because the information requested was not received in a timely
manner.
• Providers who fax requests are still required to check the C3WV system to
determine approvals/denials and to check status of the request.
• Diagnosis, CPT, or HCPC descriptions will not be accepted. UM Support staff
cannot retrieve this information from the order/CMN.
• Please be sure that the start date listed on the form is correct. Failure to do
so can result in a case being denied for retrospective policy.
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Medically Urgent Prior Authorization
Requests
• Definition of “Medically Urgent”
• A delay could seriously jeopardize the life or health of the consumer
• A delay could seriously jeopardize the ability of the consumer to
regain maximum function
• In the opinion of a physician with knowledge of the consumer’s
medical condition, would subject the consumer to severe pain that
cannot be adequately managed without the care or treatment that is
the subject of the case
• NOTE: Some review areas do not recognize medically urgent requests.
In these instances, it is not a choice in the admission type drop-down.
For those review areas that recognize medically urgent (e.g. inpatient),
each admission type has a medically urgent choice (e.g. direct admission
OR direct admission-medically urgent).
• Requests not meeting the medically urgent definition WILL NOT be
reviewed as medically urgent.
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Reminders Regarding Urgent and Phone
Prior Authorization Requests
• Please only mark requests urgent when they meet the medically urgent
definitions listed on the previous slide.
• Telephone requests are only entered for review types and circumstances
listed and accepted as medically urgent.
• Requests can only be expedited when the two-day review timeline has
passed AND when delaying the review can cause problems for the
MEMBER. (e.g. A provider entering a request one day prior to an
elective surgery and a possibility of having to reschedule is not a reason
to expedite a request; a member with cancer does not necessarily need
to have an imaging request expedited unless the request is already out
of timelines and the procedure is scheduled for the next day, etc).
• DME requests are ONLY considered emergent when the member’s
discharge order has already been signed and they cannot be released
until the equipment is available OR for apnea monitors or nebulizers for
children under three years-of-age.
• Retrospective requests are not considered medically urgent. Although
the study may have been medically urgent at the time, once the study is
completed it is no longer an urgent request.
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Vision Update
• The Bureau for Medical Services has reached a decision to remove the recent prior
authorization requirement on the following CPT codes:
• 92002, 92004, 92012, 92014, 92018, and 92019.
• Effective September 1, 2016.
• As of September 1, 2016, we began faxing back requests for these Vision Codes.
• KEPRO removed these codes from their PRODUCTION system and from the listing of codes
requiring prior authorization.
• KEPRO, Molina, and BMS will place announcements on their websites.
• BMS has updated the Vision Chapter in the Provider Manual to remove the Vision PA
requirement on these codes.
• Molina has removed the PA requirement on these codes and will reprocess claims back to May
1, 2016.
Adults 21 Years of Age or Greater:
Eye Examinations are limited to comprehensive exam/evaluation for medical necessity only.
Visual examinations to determine the need for eyeglasses are covered for children only.
Additionally, diagnostic evaluations and examinations may be reimbursed when documentation in
the medical record justifies the medical need for more frequent exams.
The Provider Manual Vision Chapter 525.1.1 can be located at http://www.dhhr.wv.gov/bms
The Vision Webinar PowerPoint is available at
http://wvaso.kepro.com/providers/manuals-reference-materials/
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Laboratory Updates
Points to Remember
• There is a proposal for an upcoming change effective January 1,
2017. Drug screening codes will require prior authorization for
medical necessity after 2 units per calendar month.
• The list of codes requiring PA will be updated to reflect this change.
• Current requirement for prior authorization is 30 units per calendar
year.
• Specimen validity testing is not eligible to be separately billed under
any procedure code. The code description for G0477 – G0483
indicates that this testing is included if it was performed.
• Drug confirmation testing is not eligible to be separately reported
under any procedure code, unlisted or otherwise. This service is
considered included in the presumptive or definitive drug testing
procedure codes (G0477 – G0438).
• Be on the look out for possible code change/update in 2017.
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Laboratory Updates
Criteria for Substance Abuse Treatment and Program Monitoring:
• Member non-compliance with prescribed drug regimen OR evidence of intoxication or behavior suggesting recent
use;
• The provider believes a previous sample has been tainted;
• Reports from member’s support network OR other medical providers indicate that drug screening in excess of 30
in the calendar year are indicated;
• Chaotic or deteriorating function despite apparent treatment compliance;
• Testing should be in compliance with the Federal opioid treatment standard (42 CFR 8.12) that states Opioid
Treatment programs must provide adequate testing or analysis of drugs of abuse, including at least (6) random
drug abuse tests per year (but no more than one test per month) for member’s maintenance treatment.
Justification for medical necessity to exceed 30 drug screens in a calendar year must be provided to support the
request. This includes but is not limited to:
• Progress notes indicating reports of non-compliance or abuse and treatment progress;
• Documentation of incidences of suspected intoxication;
• Member treatment plan indicating why more than 30 screens are indicated in a calendar year and anticipated
outcomes specifically related to additional testing;
• Documentation of circumstances leading to suspicion of tainted sample(s);
• Documentation must support one of the criteria above and provide documentation that additional screens are not
for confirmatory purposes ONLY
Criteria for Emergency Drug Screening:
• Unexplained coma;
• Unexplained altered mental status in the absence of a clinically defined toxic syndrome;
• Severe or unexplained cardiovascular instability;
• Unexplained metabolic or respiratory acidosis;
• Seizures with an undetermined history.
Prior authorization is ONLY required to EXCEED 30 drug screens in a calendar year. Prior Authorization requests to
exceed 30 screens in instances where the member has used the allowable screenings only need to include the medical
justification listed above AND should be submitted as EMERGENT requests. NOTE: Screening performed in the ER is
part of the ER visit and does not require separate prior authorization.
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Laboratory Updates
Criteria for Drug Screening for Pain Management Programs:
• Testing is performed as a baseline screening before initiating treatment AND a plan is in
place to use the test findings clinically;
• Subsequent monitoring is done at a frequency appropriate for the risk level of the member.
To determine a member’s risk, providers should use a validated screening tool. In addition,
members should also be screened for behavioral health conditions that may increase their
risk of misuse of controlled medications and/or overdose.
• In cases of use/abuse or monitoring suspected abuse, testing should be in compliance with
the Federal opioid treatment standard (42 CFR 8.12) that states Opioid Treatment programs
must provide adequate testing or analysis of drugs of abuse, including at least (6) random
drug abuse tests per year (but no more than one test per month) for member’s
maintenance treatment.
Justification for medical necessity to exceed 30 drug screens in a calendar year must be
provided to support the request. This includes but is not limited to:
• Progress notes indicating reports of non-compliance or abuse and treatment progress;
• Documentation of clinical findings from previous screens supporting the need for
additional testing;
• Member treatment plan indicating why more than 30 screens are indicated in a calendar
year and anticipated outcomes specifically related to additional testing as well as
coordination with behavioral health programs if abuse is determined or suspected
(including referrals and care coordination if member is receiving active treatment)
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DMEPOS (Prosthetic & Orthotic) Prior
Authorization Requests
• Incontinence supplies are not to exceed 200 diapers per month, 150 underpads per month,
or combination of 250 per month with neither exceeding their individual service limit.
• DME providers must complete a written DME home assessment before authorization is
requested, which includes, but is not limited to, the access to and physical layout of the
home, doorway width, doorway thresholds, floor surfaces, and turning radius. The home
must be able to accommodate the DME. Providers must document in the medical record at
each occurrence.
• If requests for equipment exceed service limits, medical documentation/justification is
required as to why the limit needs exceeded.
• Vendors requesting items using a miscellaneous code (E1399 or K0108), as well as any item
that requires a cost invoice, must provide a quote for the item(s) being requested.
• Back-up ventilators are only authorized for members who live 30 miles or greater from a
trauma center or hospital that handles ventilators.
• Requests for DME to follow discharge from long-term care facility must include physiciansigned discharge order or physician-signed discharge summary.
• We are unable to accept clinical information older than 6 months (ex: sleep studies, oxygen
saturations, office notes, hospital records, etc). To support a request for prior authorization.
• The quantities for each item must be submitted (whether it is documented in C3, or
preferably listed on the CMN) because C3 defaults quantities to one, even if a different
amount is submitted.
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DMEPOS (Prosthetic & Orthotic) Prior
Authorization Requests
• Manufacturer’s warranty for DME is required for not less than one year. When the item is
under warranty and repair or replacement is required, the provider of the service is
responsible to provide the repair and/or replacement. The warranty begins on the date of
the delivery to the member. The original warranty must be given to the member and a copy
is maintained in the member’s individual medical record. A copy of the warranty must also
be provided to Medicaid or its designee upon request.
• For repairs of DME, vendors must provide: Written service tech evaluation form indicating
specifically what is wrong with item/equipment, quote for parts, as well as quotes for repair
versus replacement.
• Wheelchair requests with multiple accessories MUST have patient-specific justification for
all accessories.
• If a request for replacement wheelchair (ex: upgrading from manual wheelchair to PWC)
within the service limits of 5 years; vendors must provide clinical documentation signed by
the prescribing practitioner indicating how the member has changed functionally since
placement of original wheelchair, to justify the need to exceed the service limits.
• The quantities for each item must be submitted (whether it is documented in C3 notes, or,
preferably listed on the CMN) because C3 defaults the quantities to a specific amount
which may be greater or less than the amount needed.
• For codes requiring Cost invoices- the cost invoice must be non-altered and specify the
individual Medicaid member. We cannot accept quotes or screen-shots of shopping carts as
invoices. The cost calculation form should match the pricing on the cost invoice. The
requested codes should also be listed on the cost invoice.
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Imaging Prior Authorization Requests
• Remember to attach or fax information to justify medical necessity.
This is includes but is not limited to:
• Symptoms.
• Physical examinations.
• Previous imaging studies (MRI, CT, X-ray) with results and date(s) of
procedures.
• Remember to report conservative treatment history (e.g. physical
therapy/duration; home exercise/duration) and NSAIDS history
(duration/dosages)- these are the two most commonly omitted items
that are required for review. If these interventions are
contraindicated specify reason in medical justification.
• Remember to check the Mastercode List or search by the CPT code.
There are some studies that do not require authorization. Do NOT
just select a code description.
• Remember to include the number of needle placements needed for
CT guided biopsies or ultrasonic guidance for biopsies.
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OP Surgery Prior Authorization Requests
• Include all CPT codes and descriptions of service that is needed on the
request.
• The primary procedure should be on the service request line-additional
procedures may be placed in the annotation section. We do not select
service codes for you!
• Be sure to include if an assistant surgeon is going to be used.
• Prior authorization requests require the clinical documentation to
support medical justification: Office note(s), complaints or symptoms,
physical exam findings, diagnostic testing (labs/x-rays), conservative
treatment/medications.
• When applicable be sure to document which side (left or right), what
level, upper or lower extremity, or if the request is bilateral.
• For services that require photographs and if you are not able to attach
to request or fax, please mail to:
KEPRO
Medical Department
100 Capitol Street, Suite 600
Charleston, WV 25301
• Please note if photographs need returned.
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Dental/Orthodontic Prior Authorization
Requests
• Please use the appropriate ICD-Diagnosis code when
submitting requests via DDE.
• The general ICD-10 Code is R68.89 and can be used for dental
requests.
• X-rays, photographs, periodontal scaling and other
documentation may be required for review depending on
what is being requested.
• If you are not able to attach to request or fax, please mail to:
KEPRO
Medical Department
100 Capitol Street, Suite 600
Charleston, WV 25301
• If x-rays are mailed, please note if they need to be returned.
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Speech/Audiology Prior Authorization
Requests
Speech Therapy Services
• Short term goals must include baseline
data.
• Parent Waiver Letter is required for
school aged patients. A copy of this
letter should be sent to the school
district to notify them to not seek
Medicaid reimbursement for the
relevant services. This must include:
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The current school year.
County of school in which patient attends .
Signature of guardian/parent.
• Please do not use “N/A” if patient is not
in school. Documentation is needed if
the patient has graduated, is
homeschooled, currently not enrolled,
etc.
• Orders must be for speech therapy, and
include diagnosis code or description.
Orders expire after one year and must
cover timeframe being requested.
• If patient is part of the IDD Waiver
Program and the request is for a chronic
condition, the waiver budget should be
utilized first. Once the budget is
exhausted, authorization may be
submitted through the C3WV portal.
Hearing Aids/Cochlear Devices
• Replacement of cochlear accessories
(headset, headpiece, microphone,
transmitting coil and transmitter cable)
is covered for Medicaid members up to
21 years of age AND Medicaid
members 21 years of age and older IF
the member received a cochlear
implant and BMS paid for it before they
reached the age of 21 years.
• Service limits for hearing aids are one
per five years. Just because it has been
5 years, does not mean a new set of
hearing aids is necessary- medical
necessity needs to be justified.
• Speech therapy and audiology services
may be provided in an outpatient
setting by Medicaid enrolled speech
language pathologists and audiologists.
Acute care and critical access hospitals
are not eligible for direct
reimbursement for outpatient therapy
services or hearing aids.
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KEPRO Contact Information
Behavioral Health
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Local Line: 304.346.6732
Toll Free: 800.378.0284
Fax: 866.473.2354
Aged & Disabled Waiver
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Toll Free: 844-723-7811
Fax: 866.212.5053
General Email:
[email protected]
Email to submit documentation:
[email protected]
I/DD Waiver
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Local Line: 304.380.0617
Toll Free: 866.385.8920
Fax: 866.521.6882
General Email:
[email protected]
Nursing Home PAS
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Toll Free: 844.723.7811
Fax: 844.633.8425
General Email:
[email protected]
Personal Care
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Toll Free: 844.723.7811
Fax: 866.212.5053
General Email:
[email protected]
FQHC
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Toll Free: 888.571.0262
Fax: 866.438.1360
Medical
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Toll Free: 800.346.8272
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General Email: [email protected]
Faxes:
• 844.633.8426 - Bariatric/Inpatient/Inpatient Rehab
Under 21/ Organ Transplants
• 844.633.8427 - Outpatient Surgery
• 844.633.8428 - Imaging/Radiology/Lab
• 844.633.8429 - Cardiac & Pulmonary
Rehab/DME/Orthotics & Prosthetics
• 844.633.8430 - Home Health/Hospice/Private Duty
Nursing
• 844.633.8431 - Audiology/Speech/Chiropractic/
Dental/Orthodontic/Podiatry/PT/OT/ Vision
• 866-209-9632 - Modification Requests/EPSDT/ Out
of Network
Social Necessity
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Local Line: 304.380.0616
Toll Free: 800.461.9371
Fax: 866.473.2354
TBI Waiver
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Toll Free: 866.385.8920
Fax: 866.607.9903
[email protected]
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KEPRO Contact Information
1-800-346-8272
MEDICAL SERVICES GENERAL VOICEMAIL- EXT. 7996
MEDICAL SERVICES EMAIL: [email protected]
HELEN SNYDER
ASSOCIATE DIRECTOR
[email protected]
EXT. 4463
ANGELA HOBBS
UM NURSE SUPERVISIOR
[email protected]
EXT. 4477
ALICIA PERRY
OFFICE MANAGER
[email protected]
EXT. 4452
CINDY BUNCH
ELIGIBILITY SPECIALIST
[email protected]
EXT. 4408
TONYA TACY
ELIGIBLITY SPECIALIST
[email protected]
EXT. 4468
JASPER SMITH
ELIGIBILITY SPECIALIST
[email protected]
EXT. 4490
JUSTIN VANWYCK
TRAINING SPECIALIST
[email protected]
EXT. 4448
SIERRA HALL
TRAINING SPECIALIST
[email protected]
EXT. 4454
GENERAL KEPRO INFORMATION: WWW.WVASO.KEPRO.COM
FAX #: 866-209-9632 (REGISTRATION AND TECHNICAL SUPPORT ONLY)
WEBSITE FOR SUBMITTING AUTHORIZATIONS: HTTPS://PROVIDERPORTAL.KEPRO.COM
WEBSITE FORE ORG MANAGERS TO ADD/MODIFY USERS: HTTPS://C3WV.KEPRO.COM
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