IMPORTANT PROVIDER UPDATES

Transcription

1 December 28, 2015 IMPORTANT PROVIDER UPDATES Dear Provider, Please find attached important updates, reminders and policy changes for Coordinated Care providers regarding: Page Title Number 2 Notice 1: Motion Fluoroscopic Swallow Studies Summary Changes in Prior Auth procedures 2 Notice 2: Home Dietician Visits Changes in Prior Auth procedures 2 Notice 3: CPAP Rentals Changes in Prior Auth procedures 2-3 Notice 4: Non-Emergent Spine Surgical Procedures Auths New authorization required for all providers 3 Notice 5: Upcoming Holidays Business office closures 3 Notice 6: Private Duty Nursing Services Policy New clinical policy Thank you for being our partner in care and for helping us collectively improve the health of our members. Happy Holidays! To be removed from these notices or to request to be added to our list for these notices, please reply to CoordinatedCareProvider@centene.com. 8 pages total. 1

2 NOTICE 1: Motion Fluoroscopic Swallow Studies Effective 11/3/2015 Motion Fluoroscopic Swallow Studies (92611) no longer require authorization for ALL providers. NOTICE 2: Home Dietician Visits Effective 11/9/2015 Home Dietician visits and no longer require authorization for ALL providers. NOTICE 3: CPAP Rentals Effective 1/1/2016 CPAP rentals will no longer require authorization for PAR providers. Purchases of CPAPs will continue to require authorization for ALL providers. NOTICE 4: Non-Emergent Spine Surgical Procedures Auths In order to better serve our members, Coordinated Care authorization for non-emergent surgical procedures of the spine will be added for all providers starting March 1, For clinically emergent surgeries, no prior authorization or review of procedure is required. All inpatient admissions still require notification to the health plan within 1 business day of admission. InterQual Mckesson 2015 clinical criteria will be used to review all procedures. The following CPT codes will require authorization: 0092T 0098T 0163T 0195T 0196T 0200T 0202T 0219T 0220T 0221T 0222T 0274T 0275T 0309T

3 S2348 S2350 S2351 NOTICE 5: Upcoming Holidays Coordinated Care business office/customer service will be closed the following dates for the holidays: New Year s Eve Thursday, December 31 New Year s Day Friday, January 1 Urgent Prior Authorizations or Concurrent Review notifications can be made through the online portal or fax and we will have staff to respond to these requests. Our 24-Hr Nurse Advice Line will be available to members for medical or mental health assistance. NOTICE 6: Private Duty Nursing Services Policy Effective March 1, 2016, Coordinated Care has a new clinical policy for determining medical necessity of Private Duty Nursing services. These services are covered by the Health Plan for members age 17 and under. Please see the attached policy at the end of this blast. 3

4 Thank you once again for your feedback and continued partnership. Please reach out to your Provider Services team if you have questions. Coordinated Care Provider Services (877)

5 DEPARTMENT: Utilization Management PAGE: 1 of 4 APPROVED DATE: EFFECTIVE DATE: PRODUCT TYPE: Medicaid DOCUMENT NAME: Private Duty Nursing REPLACES DOCUMENT: RETIRED: REVIEWED/REVISED: REFERENCE NUMBER: WA.UM. Subject This policy outlines medical necessity criteria for Private Duty Nursing Services. Definition Private duty nursing services consists of four or more hours of continuous skilled nursing services provided in the home to members with complex medical needs that cannot be managed within the scope of intermittent home health services. Private Duty Nursing Services are a covered benefit through Coordinated Care Health Plan for individuals age 17 and younger; for individuals 18 years and older requests for service should be directed to the Aging and Disabilities Services Administration. Policy/Criteria I. Coordinated Care considers home nursing care medically necessary when recommended by the member's primary care and/or treating physician as part of a treatment plan when the following criteria are met: A. The attending physician must approve a written treatment plan B. The care will be provided in the member s home C. Placement of the nurse in the home is done to meet the skilled needs of the member D. The member s condition is unstable and requires frequent nursing assessments and changes in the plan of care. It must be determined that the member s needs could not be met through a home skilled nursing visits but only through private duty nursing services. The nursing and other adjunctive therapy progress notes must indicate that such interventions or adjustments have been made and are necessary. Also, the physician s orders dealing with the member s unstable condition must reflect that changes or adjustments have been made. In most cases, more than 12 hours per day of skilled nursing care is not considered medically necessary. However, more than 12 hours per day of skilled nursing care may be considered medically necessary in any of the following circumstances: A. Within the first thirty days when a member is being transitioned from an inpatient setting to home; or Centene Medical Policy Statements represent technical documents developed by the Medical Management Staff. Questions regarding interpretation of these policies for the purposes of benefit coverage should be directed to a Medical Management Staff personnel.

6 DEPARTMENT: Utilization Management PAGE: 2 of 4 APPROVED DATE: EFFECTIVE DATE: PRODUCT TYPE: Medicaid DOCUMENT NAME: Private Duty Nursing REPLACES DOCUMENT: RETIRED: REVIEWED/REVISED: REFERENCE NUMBER: WA.UM. B. Member becomes acutely ill and the additional skilled nursing care will prevent a hospital admission, considered necessary until stabilization of acute condition; or C. Member meets the clinical criteria for confinement in a skilled nursing facility (SNF), but a SNF bed is not available. In this situation additional skilled nursing may be provided until a SNF bed becomes available. D. All requests for 12+ hours of PDN services require an automatic secondary review by a medical director unless ventilator criteria below is met. Private Duty Nursing for Members on Ventilators: Coordinated Care considers home nursing medically necessary for members who are on ventilators or continuous positive airway pressure (CPAP) for respiratory insufficiency at home when the primary care physician or specialist has agreed to the home care plan and all of the following criteria are met: A. Member is on either a pressure or volume ventilator or CPAP; and B. Member meets the medical necessity criteria for confinement in a SNF; and C. Placement of the nurse is for the care and benefit of the member with a skilled need only. Note: For members on a ventilator at home, Coordinated Care considers home nursing medically necessary for up to 24 hours per day for up to 3 weeks upon an initial discharge from an inpatient setting as a transition to home, as long as the member requires continuous skilled care to manage the ventilator. Thereafter, up to 16 hours of home nursing per day is considered medically necessary if the member requires continuous skilled care to manage the ventilator. Once the member is stabilized at home, Coordinated Care does not consider continued ventilator management a skilled need requiring home nursing unless the member is unstable and needs close monitoring and frequent ventilator adjustments. This instability may be the result of an acute event (e.g., respiratory infection or exacerbation of chronic obstructive pulmonary disease (COPD)) or weaning from a ventilator. Centene Medical Policy Statements represent technical documents developed by the Medical Management Staff. Questions regarding interpretation of these policies for the purposes of benefit coverage should be directed to a Medical Management Staff personnel.

7 DEPARTMENT: Utilization Management PAGE: 3 of 4 APPROVED DATE: EFFECTIVE DATE: PRODUCT TYPE: Medicaid DOCUMENT NAME: Private Duty Nursing REPLACES DOCUMENT: RETIRED: REVIEWED/REVISED: REFERENCE NUMBER: WA.UM. If 24 hours per day of nursing care is being requested for an indefinite period of time, the case manager may offer a SNF placement as the alternative. If the family agrees and a SNF bed is not available, Coordinated Care considers home nursing for up to 24 hours medically necessary until a SNF bed is available. All requests for Private Duty Nursing must be referred to Case Management, for member already enrolled in CM the Case Manager must be notified by Prior Authorization for any new requests for PDN or increases in PDN hours. II. Private Duty Nursing is not medically necessary for the following reasons: A. Placement of the nurse in the home for the convenience of the family caregiver, including to solely allow the member s family or caregiver to go to work or school. B. Ongoing skilled private duty nursing is not considered medically necessary for members who are on continuous or bolus nasogastric (NG) or gastrostomy tube (GT) feedings and do not have other skilled needs. Intermittent home nursing care may be considered medically necessary for these members as a transition from an inpatient setting to the home. C. PDN for maintenance or custodial care. a. PDN services become maintenance or custodial care when any one of the following situations occur: i. Medical and nursing documentation supports that the condition of the client is stable/predictable; or ii. The plan of care does not require a Licensed Nurse to be in continuous attendance; or iii. The member, family, or caregivers have been taught the nursing services and have demonstrated the skills and ability to carry out the plan of care. iv. PDN is not considered medically necessary solely because there is no caregiver available to assume this role Custodial Care: Private duty nursing is not appropriate if the member does not require a skilled intervention and the care provided is custodial in nature. Custodial care is defined as services and supplies that are primarily intended to help members meet personal needs. Custodial care can be prescribed by a physician or given by trained medical personnel. It may involve artificial methods such as feeding tubes, ventilators or catheters. Examples of custodial care include: Centene Medical Policy Statements represent technical documents developed by the Medical Management Staff. Questions regarding interpretation of these policies for the purposes of benefit coverage should be directed to a Medical Management Staff personnel.

8 DEPARTMENT: Utilization Management PAGE: 4 of 4 APPROVED DATE: EFFECTIVE DATE: PRODUCT TYPE: Medicaid DOCUMENT NAME: Private Duty Nursing REPLACES DOCUMENT: RETIRED: REVIEWED/REVISED: REFERENCE NUMBER: WA.UM. Routine patient care such as changing dressings, periodic turning and positioning in bed, administering oral medications; Care of a stable tracheostomy (including intermittent suctioning); Care of a stable colostomy/ileostomy; Care of stable gastrostomy/jejunostomy/nasogastric tube (intermittent or continuous) feedings; Care of a stable indwelling bladder catheter (including emptying/changing containers and clamping tubing); Watching or protecting a member; Respite care, adult (or child) day care, or convalescent care; Institutional care, including room and board for rest cures, adult day care and convalescent care; Help with the daily living activities, such as walking, grooming, bathing, dressing, getting in or out of bed, toileting, eating or preparing foods; Any services that a person without medical or paramedical training could be trained to perform; and Any service that can be performed by a person without any medical or paramedical training. Revision Log Date Approval: VPMM Electronic Signature on File Centene Medical Policy Statements represent technical documents developed by the Medical Management Staff. Questions regarding interpretation of these policies for the purposes of benefit coverage should be directed to a Medical Management Staff personnel.