Medicare Advantage 2014 Precertification Requirements

Transcription

1 Medicare Advantage 2014 Precertification Requirements (Effective for Jan 1, 2014 to June 30, 2014) The precertification requirements filed with the Centers for Medicare & Medicaid Services remain in effect for calendar year The following Medicare Advantage plans require precertification i for in network providers. Call the telephone number listed on the back of the member s identification card for precertification, verification of member eligibility, benefits and account information. This document replaces Precertification lists effective prior to January 1, Changes included the addition and non-renewal of some plans as well as new and removed procedures requiring precertification as listed below. Medicare Advantage Plans requiring in-network provider precertification. Medicare Advantage Senior Advantage OH, KY HMO Plans requiring precertification (in network) BlueValue GA Medicare Advantage PPO Plans requiring precertification (in-network) MediBlue **Medicare Preferred **Medicare Access **MediBlue CT, NY, WI,, ME, NH, MO OH, IN, KY, VA, MO, WI, GA, CA, ME, NH, CT OH, IN, KY NY ** = Indicates there is a national service area for select Employer Group Retiree Medicare Advantage plans. Precertification is the determination that selected medical services meet medical necessity criteria under the member's benefits contract. For the member to receive maximum benefits, the health plan must authorize or precertify these covered services prior to being rendered. Precertification includes a review of both the service and the setting. Care will be covered according to the member's benefits for the services and/or number of days precertified unless our concurrent review determines that additional services and/or days do not qualify for coverage. Certain services may require the member to use a provider designated by the health plan s Utilization Management staff. A copy of the approval will be provided to you, the physician and the hospital or facility. For benefits to be paid the member must be eligible for benefits and the service must be a covered benefit under the contract at the time the services are rendered. Precertification Responsibility For HMO type health plans: It is the participating physician s or provider s responsibility to contact the health plan s Utilization Management Department to obtain precertification. The request must come from the provider or facility rendering the service, not the referring physician. If precertification is not obtained, the claim may be penalized or denied by the Plan and the member must be held harmless. The Precertification number is listed on the back of the member s health plan ID card. For PPO type health plans: It is the network provider s responsibility to contact the health plan s Utilization Management Department to obtain precertification. Claims from out of network providers will typically pend for a medical necessity review prior to payment if 19001WPPENMUB Page 1 of 8 Y0071_14_18239_I 10/01/2013

2 associated with a service in this document. The Precertification number is listed on the back of the member s health plan ID card. Inpatient Admissions Also see Behavioral Health and Transplants sections for precertification requirements. The health plan must be notified of emergency admissions or transfers within 1 business day of admission. Precertification required for non-emergent inpatient transfers between acute facilities. Precertification is required for: o Elective Inpatient Admissions o Rehabilitation Facility admissions o Long Term Acute Care (LTAC) o Skilled Nursing Facility admissions Precertification is NOT required, however notice is requested for all members initiating dialysis treatment. Outpatient Services: Select Outpatient Surgery and Outpatient Procedures (see appendix for specific procedures) Sleep Studies and Sleep Study related equipment and supplies. UPPP surgery (Uvulopalatopharyngoplasty - removal of excessive soft tissue in the back of the throat to relieve obstruction.) Bariatric/ Gastric Obesity Surgery All potentially Cosmetic surgeries Non-emergent ground air and water transportation Home Infusion Therapy Home Health Care Physical Therapy Chiropractic Care Page 2 of 8

3 DME/ Prosthetics Precertification is required for: Prosthetics, Orthotics Power Wheelchairs, Accessories, and POV Non-Standard Wheelchairs Non-Standards Beds Patient Transfer Systems Speech Generating Devices and accessories Sleep Study related equipment and supplies. Continuous Glucose Monitoring Systems Radiology Services Precertification is required for: PET Nuclear Cardiac CT Scan (includes CTA) MRI MRA MRS Echocardiograms Behavioral Health Services Mental Health/ Substance Abuse Services: Specially trained professionals will handle referrals and coordinate care for mental health and substance abuse. This includes: referrals to mental health and substance abuse treatment providers, general information about mental health and substance abuse benefits and treatment, emergency and urgent care information and assistance Plan must be notified of emergency admissions within 1 business day of admission. Precertification is required for: o Inpatient admissions o Rehabilitation Facility admissions (Rehabilitation requires precertification but benefit availability is limited. Please be sure to check benefits the member s benefits.) o Day Hospital admissions o Intensive Outpatient therapy Page 3 of 8

4 Transplants: Human Organ and Bone Marrow/ Stem Cell Transplants Precertification is required for Medicare Covered Transplant admits. All Inpatient admits for the following: Heart transplant Liver transplant Lung or double lung transplant Simultaneous Pancreas/ Kidney Pancreas transplant Kidney transplant Small bowel transplant Multi-visceral transplant Stem cell/ Bone Marrow transplant (with or without myeloablative therapy) All Outpatient services for the following: Stem Cell/ Bone Marrow transplant (with or without myeloablative therapy) Donor Leukocyte Infusion Specialty Pharmacy Part D drugs - please refer to separate Precertification list. Part B drugs Please see the Appendix. The codes related to the services above that require prior authorization are listed in the appendix. Precertification requirements document is posted to the Medicare Advantage Provider Portals. i Precertification For the purpose of this document, precertification (aka - prior authorization) indicates a requirement to precertify prior to rendering a service which includes authorization of additional days on concurrent review. Out of network providers may optionally choose to call the health plan to obtain precertification (or a predetermination) regarding whether a service meets benefit and medical necessity criteria. Page 4 of 8

5 APPENDIX The following codes which required Pre-Certification in 2013, continue to require Pre- Certification in T C8920 J1568 K E0193 J1569 K E0194 J1572 K E0265 J2503 K E0266 J2505 K E0277 J2778 K A0430 E0296 J2820 K A0431 E0297 J7321 K A0435 E0300 J7322 K A0436 E0329 J7323 K A4604 E0371 J7324 K A7027 E0372 K0005 K A7028 E0373 K0010 K A7029 E0462 K0011 K A7030 E0470 K0012 K A7031 E0471 K0013 K A7032 E0561 K0014 K A7033 E0562 K0800 K A7034 E0601 K0801 K A7035 E1002 K0802 K A7036 E1003 K0806 K A7037 E1004 K0807 K A7038 E1005 K0808 K A7039 E1006 K0812 K A7044 E1007 K0813 K A7045 E1008 K0814 K A7046 E1230 K0815 K A9274 E1239 K0816 K C1789 G0289 K0820 K C8900 J0585 K0821 K C8901 J0587 K0822 K C8902 J0881 K0823 K C8909 J0882 K0824 K C8910 J0885 K0825 K C8911 J0886 K0826 K C8912 J1440 K0827 K C8913 J1441 K0828 K C8914 J1459 K0829 K C8918 J1561 K0830 K C8919 J1566 K0831 K0898 Page 5 of 8

6 (Continuation of codes which required Pre-Certification in 2013, and will continue to require Pre-Certification in 2014.) K0899 L5930 L L8685 L0454 L5968 L L8686 L0456 L5979 Q L8687 L0458 L5980 S A7025 L8688 L0460 L5981 S C8903 Q0515 L0462 L5987 S C8904 S0196 L0464 L5988 S C8905 S2112 L0466 L5990 S C8906 S3818 L1005 L6025 S C8907 S3819 L1831 L6611 S C8908 S3820 L1832 L E0481 S3822 L1834 L E0483 S3823 L1836 L E0485 S3828 L1840 L E0486 S3829 L1843 L E0784 S3830 L1844 L G0219 S3831 L1845 L G0235 S3833 L1846 L G0252 S3834 L1847 L G0398 S3840 L1850 L G0399 S8042 L1860 L G0400 L5250 L J0129 L5270 L J0135 L5280 L J1325 L5301 L J1438 L5311 L J1745 L5321 L J2278 L5331 L J2357 L5341 L J2940 L5610 L J2941 L5611 L J3285 L5613 L J9035 L5614 L J9055 L5616 L J9303 L5617 L J9355 L5814 L L8614 L5828 L L8619 L5830 L L8680 L5840 L L8682 L5845 L L8683 Page 6 of 8

7 The following codes will require Pre-Certification beginning January 1, T C C C E E E E E E E E E G G G G L L L Q Q S S2351 Page 7 of 8

8 The following Specialty Pharmacy Codes required Pre-Certification in 2013 and will continue to require Pre-Certification in J2505 J1745 J7325 J0135 J9035 J0897 J7322 J2278 J3940 J0881 J0129 J1325 J1566 J0882 J7321 J3285 J1572 J0885 J7323 J9303 J1569 J0886 J7324 J1561 J9055 J2357 J1568 J1440 J2940 J1459 J1441 J2941 J9355 J0585 J1438 The following Specialty Pharmacy Codes will require Pre-Certification beginning January 1, J9310 J9263 J9305 J9041 J2323 J9033 J9171 J3487 J9228 J3488 J7686 J2352 J2354 J2353 J9025 J3590 J9395 J0894 J0941 J0640 J7192 Page 8 of 8