DD WAIVER. New Mexico Medicaid Utilization Review. Presented by. Blue Cross Blue Shield of New Mexico

Transcription

1 2009 DD WAIVER Presented by New Mexico Medicaid Utilization Review Blue Cross Blue Shield of New Mexico

2 Prior Authorization Requests US Mail P.O. Box Albuquerque NM Delivery services (e.g., FedEx) 4373 Alexander Boulevard NE Albuquerque NM Hand-Carried and Drop Box Submissions 4373 Alexander Boulevard NE Albuquerque NM 87107

3 Sending Prior Authorization Requests Hand-Carried Reviews If you wish to personally deliver reviews, take them to: 4373 Alexander Boulevard NE (Located just to the southwest of I-25 and Montano) Signature receipts are available between 6:30 a.m. and 5:00 p.m., Monday through Friday

4 Sending Prior Authorization Requests Drop Box Also located at the Alexander Boulevard address. Available 24-hours a day/seven days a week. Signature is not available at the drop box.

5 Completeness of Requests Be sure request is clear and legible. Do not use arrows, scratch outs, etc. Do not highlight the documentation if it is faxed this will black out the data Verify Demographic Information Use the correct form Double check SSN and/or Medicaid Number Complete ALL required areas, including provider number(s)

6 Completeness of Requests Be sure to include all applicable code(s). Being thorough and very clear to avoid Requests for Information (RFI)!!!!

7 Revision Requests Verify correctness of category codes. End services with the old provider information noted on one line. Check for correct dates and units Begin new provider services on next line. Check for correct dates and units

8 Revision Requests If you wish to have MUR adjust units per Omnicaid billing at the time of review, include written permission to do so with the request.

9 Required Documentation for a Successful Review Objective clinical/medical documentation is needed to justify services. Each review must stand on its own. Diagnosis alone does not establish medical necessity. Paint the picture! by clearly illustrating why the client needs the services.

10 Required Documentation for a Successful Review Objective clinical/medical documentation is needed to justify services. Eligibility for HCBSW DD Program Services requires that the recipient meet level of care services provided in an Intermediate Care Facility for the Mentally Retarded (ICF-MR).

11 Mandatory Documentation for Levels of Care Current History and Physical (Current within 12 months) OR current Progress Note that addresses current problems and systems review. MAD-378 including ordered Level of Care and the physician name and signature (no electronic or stamped signatures). Client Individual Assessment Form (CIA) (Current within 12 months) revised edition from DDSD

12 Mandatory Documentation for Levels of Care The Health Assessment Tool (HAT) is no longer required, BUT may still be beneficial for clarifying dangerous behaviors and a behavioral support plan (if one is in place) Adaptive Behavioral Scale (ABS) (Current within 3 years of submission) Letter of Allocation (initial only or reallocation).

13 Mandatory Documentation for Waiver Readmission When a client is hospitalized for 3 midnights or longer: The hospital discharge planner must call MUR customer service on the day of hospital discharge for the recipient s readmission to the waiver.

14 Mandatory Documentation for Waiver Readmission If the waiver readmission request is not done by telephone by the discharge planner upon the recipient s hospital discharge, the case manager must submit a written abstract within 14 calendar days of hospital discharge. The physician s signature on the abstract must be dated post discharge.

15 Mandatory Documentation for Waiver Readmission A physician discharge summary, relevant hospital summary or progress notes to support the current level of care must accompany the abstract (MAD-378). If the level of care changes upon discharge, the case manager must submit a new abstract, CIA and ABS; the HAT is no longer required.

16 Mandatory Documentation for Waiver Readmission The case manager must also submit either a discharge summary or hospital progress notes supporting the change in level of care.

17 DD Waiver Documentation MAD-378 must Be filled out completely Include the MR level based on the score

18 DD Waiver Documentation MAD-046 must include Dates Correct (Annual Resource Allotment) ARA code Procedure codes Provider numbers Number of units Appropriate signatures

19 Outlier Staffing Calculation Worksheets Use correct level of care to ensure accurate calculations. Individual requesting Outlier services must be calculated at pre-outlier level and NOT at level being requested for Outlier (even if they are currently receiving outlier services). Make sure to include awake/asleep status of individuals in residential setting.

20 Outlier Staffing Calculation Worksheets Use correct codes that correspond to the requested level of care.

21 Residential Enhanced Services/Outlier Requests Documentation for initial Supported Living Awake requests: ISP/IDT report indicating Team agreement Justification for living awake services Dated Interdisciplinary Team (IDT) notes and signature sheet from meeting

22 Residential Enhanced Services/Outlier Requests Documentation to support the need for initial and annual living awake requests includes: Number of times awake Assistance required during awake time (summarized for the last 90 days) Annual submission of physician justification letter to support living awake service

23 Residential Enhanced Services/Outlier Requests ISP/IDT meeting notes indicating the need for continued services, including dated signature sheet Current, written, signed report from the physician, psychiatrist, psychologist or neurologist that: Addresses chronic care criteria Is updated every six months

24 Residential Enhanced Services/Outlier Requests Medical outliers require letter from PCP Behavioral outlier requires letter from psychiatrist, psychologist, or neurologist A current nursing support plan (health care plan) for medical outlier or behavioral support plan for behavioral outlier Quarterly reports are acceptable if it is not time for the annual report

25 Initial Residential and Day Habilitation Requests ISP/IDT report or meeting notes indicating need, justification and agreement for the outlier funding Indicate if behavioral or medical outlier Completed signature page on ISP with date ISP/IDT meeting completed within the last 90 days

26 Initial Residential and Day Habilitation Requests Time period for which outlier funding is being requested in ISP Staff Time Reporting Worksheet for all individuals in the residential setting, noting: The level of care Outlier status Awake/asleep status Proposed staffing hours

27 Initial Residential and Day Habilitation Requests Staff Time Reporting Worksheet for Day Hab outlier indicating: Level of care of all participants Outlier status of all participants Proposed staffing hours

28 Initial Request for Family Living Services Now billed in daily units ISP/IDT report indicating and/or including: Agreement to include family living services. Justification for the requested service. An example of a typical day in the recipient s life.

29 Initial Request for Family Living Services ISP/IDT meeting notes with: Dated signature sheet reflecting team agreement Rationale for the service. Explanation (and related documentation) as to why a combination of personal care, respite, day habilitation and natural supports failed to meet the person s needs.

30 Initial Request for Family Living Services Agency failure does not necessary demonstrate failure of the service to meet the client s needs. Give multiple examples. What has been tried and why did it fail to meet the person s needs.

31 DD Waiver Resources Remember that the regional offices are tremendous resources. Use their expertise and knowledge when requesting outlier services. Use appropriate codes when requesting these services.

32 Correct submission of ARA Category Code Splits Do not bill until the category code split is completed!!! Two (2) submissions (MAD-046 s) are necessary; one for each ARA category. The ISP year does not change.

33 Correct submission of ARA Category Code Splits One MAD-046 with the current ARA category must be closed out and all service units must reflect services under the old ARA category. A second MAD-046 with the new ARA category must list all services planned--with the appropriate dates, codes, modifiers, and new ARA category.

34 ARA Category Code Splits The second MAD-046 with the new ARA category will be issued a new authorization number. Case managers will receive copies of both MAD- 046 forms, reflecting the original authorization number and the new authorization number.

35 ARA Category Code Splits It is safe to bill once the new authorization number is received. This prevents the overlapping of services between ARA codes and avoids the possibility of multiple buck-backs.

36 ARA Category Code Splits Remember, total units/dollars cannot exceed maximum units allowed. The term of the ISP remains the same. It is important to remember that there will be two prior authorization numbers, based on dates of category code split for the same ISP year.

37 Avoiding Requests for Information (RFI s) Submit all mandatory forms and supportive documentation (as previously outlined) for DD Waiver requests. Make sure that all forms are COMPLETELY filled out.

38 Avoiding Requests for Information (RFI s) Make sure that the Medicaid/SS number is correct on ALL forms. The correct procedure/provider codes must be present on ALL forms. Use correct ARA category codes on the MAD-046 form in order to insure appropriate payment.

39 Avoiding Requests for Information (RFI s) Ensure all required signatures and dates are submitted: History and Physical must be current and signed/dated by the physician within the 12 months of the initial review date or the continued stay date.

40 Avoiding Requests for Information (RFI s) Level of Care orders, with dates, must be present on the MAD-378 and relevant to the time frame requested. Orders must be signed and dated within the 90 days of the initial or continued stay approval date. Be certain that the order for the level of care is in box 24 (physician statement) NOT in the UR section.

41 Avoiding Requests for Information (RFI s) Re-check the entire document before submitting. Double check all mathematical calculations. Check that the assessment factor scores are all present on the MAD-378. Check that the total score and the calculated score for the MR level of care are added correctly.

42 Avoiding Requests for Information (RFI s) Understand the criteria for the services being requested. DD Waiver clients must meet criteria for ICF- MR level of care. Submit all supporting documentation. Ensure that the information submitted is consistent and relevant to that specific request.

43 Avoiding Requests for Information (RFI s) Clarify the request: What are you requesting? Initial Annual Reassessment Readmit Revision Re-review Reconsideration

44 Avoiding Requests for Information (RFI s) In the event you do receive an RFI, be sure to return ALL requested information and documentation with your response. This will avoid subsequent RFI s. Please send a copy of the RFI. Please do not respond to an RFI without all of the requested information.

45 Avoiding Requests for Information (RFI s) last but not least If a request is unclear, please call customer service at They will obtain the needed clarification and call you back.

46 The Appeal Process The Appeal Process consists of several possible steps: Re-review Reconsideration Fair Hearing

47 Re-Review Process Based on MAD regulations, the written request must be received within 10 calendar days from the date of the denial letter. Requests will be processed within 15 calendar days of receipt. The abstract should be marked RE- REVIEW at the top.

48 Re-Review Process The re-review request must include additional medical/clinical information (in addition to the initial information submitted) in order to meet the requirements for the re-review process.

49 Reconsideration Process The request must be received within 30 calendar days from the date of the re-review denial. In order to meet the requirements for reconsideration, the request must include medical/clinical information in addition to any submitted initial and re-review information.

50 Reconsideration Process If a re-review is unable to be requested within the mandated 10-days, a request may be made for a reconsideration (without benefit of a re-review). The request must be received within 30 days of the date of the original denial letter. Reconsideration should be indicated on the request.

51 The Fair Hearings Process Requests for Fair Hearings are administered through the Administrative Hearings Bureau. A Fair Hearing request can be initiated by either the recipient or provider. (Sections and of the Program Manual).

52 Data Entry All review-related information is keyed into the Omnicaid system. Initial reviews, annual reassessments, and new ARA category code splits will receive new authorization numbers. Revisions will be added to the existing authorization. No new authorizations will be generated.

53 Data Entry With the exception of ARA category splits, no new number will be generated. Reviews are then keyed into the Medicaid Utilization Review system. Customer service representatives use this system to track review information.

54 Customer Service (number is valid both in- and outof-state) Customer Service hours are 8:00 a.m. to 5:00 p.m., Monday-Friday. ACD (Automatic Call Distribution) allows calls to be handled in the order received. MUR may be contacted via the Internet at

55 Following up on Submissions Please allow time for review to reach MUR before calling to ask if it has been completed. MUR has 8 business days to complete reviews (per the HSD/MAD contract). MUR s imaging system allows the Customer Service representatives to view where the review is in the process (and when it was received).

56 State Program Websites MAD DD WAIVER Regulations effective 3/1/07: DDSD Service Standards effective January 1, 2007: _2007DDWStandards.pdf

57 What s New! Frequent BCBSNM-MUR Website Updates Now THE provider s resource for: FORMS!! (MAD/ISD Forms can be downloaded from both the State and BCBSNM-MUR sites; forms are no longer being printed for mailing to providers) General review information

58 What s New! Frequent BCBSNM-MUR Website Updates Time frames for submissions Monthly training schedules and provider training presentations Frequently Asked Questions (FAQs)

59 Medicaid UR Website The Medicaid UR website is located at:

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68 Questions and Comments THANK YOU for your time and attention!