Aetna. NOMNC Letter -- SNF needs to fax to NOMNC Fax

Transcription

1 FINAL APPROVED 3/17/2015 Aetna Optum has contracted with Aetna Better Health to provide NP model of care during a nursing facility event and has assumed responsibility for obtaining service authorizations for Part A Skilled Services. Facility representatives should contact Optum NP/RN when an authorization is needed. Optum is not responsible for authorizations of Part A skilled services. The facility will manage these services through Traditional Medicare or the alternative health plan. Member type Aetna - Dual Medicare/Medicaid Aetna Opt Out NOMNC Letter -- SNF needs to fax to NOMNC Fax Health Plan Authorization # # ; Select option #2; then option #4 Authorization Fax# # Claims # # ; Select option #2; then option #3 Scenarios PART A AUTHORIZATION Optum NP will submit clinical information to Health Plan for authorization purposes. The Health Plan will fax the authorization numbers back to the facility representative designated by the Optum NP. NOMNCS are administered by the facility representative as they do for traditional Medicare. Facility will follow CURRENT RESIDENT Enrolled in MyCare while in the facility - prior authorization. Skilling without 3 day hospital stay. NEW TO FACILITY FROM HOSP OR COMMUNITY New Fully Integrated Dual Member being admitted to your facility for the first time from the hospital or community: CURRENT MEMBER READMIT TO FACILITY Current Fully Integrated member is being readmitted to facility following a hospitalization Three Day qualifying stay has been waived. Optum NP will submit clinical information to Health Plan for any new skilled services and/or skilled services after hospitalization. The Health Plan will fax the Authorization numbers to the facility representative designated by Optum NP. Plan CM and UM staff will work with the inpatient discharge planner to identify a network facility for safe discharge. The Plan CM and Optum NP/RN will collaborate with each other to support the member's transition from the hospitalization. A custodial admission to the nursing facility does not require authorization if the member is not receiving non-skilled services. Plan CM will notify plan UM staff of all long-term or custodial admissions. Medicare guidelines. Facility will follow traditional Medicare process. The nursing facility will notify Optum NP/RN of the member's readmission. Optum NP will submit clinical information to Health Plan UM staff to determine skilled benefit. Aetna will fax the authorization of any new services to the nursing facility representative designated by Optum NP/RN. If the member is returning to their previous custodial level of care, and no new services are being provided, no authorization is required. Facility will follow

2 Member type Aetna - Dual Medicare/Medicaid Aetna Opt Out SHORT TERM COMMUNITY MEMBER FROM HOSP TO FACILITY If the member is new to the facility short term care or transitional care needed. (Member discharged from the hospital as skilled; Medicare benefits). How does the provider get a prior authorization number to put on the claim for reimbursement? CONTINUATION OF SKILLED TIME How does the provider communicate a need for continued skilled care? N/A-This population is not managed by Optum. Facility to communicate through collaboration with Optum NP/RN. Optum NP/RN will communicate additional needs to Health Plan. Extension of skilled benefit will be determined by Medicare guidelines. The authorization determination will be provided by the plan and will be faxed to the facility representative identified by Optum NP/RN. Medicare guidelines. Facility will follow traditional Medicare process. Medicare guidelines. Facility will follow traditional Medicare process. AFTER HOURS/HOLIDAY AUTHORIZATIONS How can authorizations be obtained after hours, holidays and weekends? Part A and B Please provide the member will all medically necessary services. Notify Optum NP/RN of the need for service authorization. Optum will notify the Health Plan who will fax the authorization number to the nursing facility representative designated by Optum within the next business day. Part B authorizations are processed directly by the Health Plan. Please call or fax the Aetna Better Health Prior Authorization team (contact information above) while providing all medically necessary services. RETROACTIVE AUTHORIZATIONS Are retroactive authorization requests for Part A skilled? BED HOLD AUTHORIZATION Is an authorization required for Bed Hold days when member is admitted to hospital or on LOA? HOSPITAL ADMIT AUTHORIZATION When members are admitted to the hospital from the facility, is the facility responsible for obtaining an authorization for the hospitalization? 911 ADMISSION What are the requirements for an emergency 911 admission? PART B AUTHORIZATION When patient condition changes and Optum is not notified, retroactive authorization may be considered based on Medicare criteria. Notify Optum NP of the event. Contact the Health Plan Prior Authorization team using the contact information listed above to obtain an authorization. The hospital is responsible for notifying the Health Plan of the admission and for obtaining an authorization. The hospital is responsible for notification of an admission. The nursing facility should follow their standard emergency protocols. Three day hospital stay required. Notification to Health Plan required. Facility will follow Traditional Medicare guidelines. Per discussion with health plan Part B is the responsibility of Health Plan. The NP will write the order, the facility representative to contact Health Plan for authorization number.

3 Member type Aetna - Dual Medicare/Medicaid Aetna Opt Out PHYSICIAN APPOINTMENTS When members are sent out for physician appointments or other services, is the facility responsible for obtaining authorization for those services? An authorization is not required for wellness or follow up visits after a medical event. Outpatient and out-ofnetwork authorizations are the responsibility of the treating provider. A transportation authorization may be necessary according to plan benefits (See Transportation section below). Please review the transportation benefit with the Aetna Better Health Care Manager for your facility. DME / OUTPATIENT SERVICES AUTHORIZATION Will the facility be required to obtain authorization for services such as DME, Outpatient Services when provided and billed by the facility for skilled and/or LTC? The service provider is responsible for obtaining the service authorization. Behavioral Health Managing Provider The service provider is responsible for obtaining the service authorization through Aetna. Facility needs to contact Health Plan for authorization number When the Plan is the secondary payer, will the facility receive a paid claim EOP for the Medicaid portion of the benefit even if there is a $0 payment? This is needed for Medicare cost reporting. EXPEDITE Facility needs to call Health Plan Provider Relations/Claims number above for information Facility is responsible for expedition of authorizations through the health plan. If unsuccessful, contact Optum NP/RN or Provider Relations Advocate for help in communication. Facility needs to call Health Plan for information. APPEAL PROCESS If the nursing facility would like to discuss a service denial, within 24 hours of denial receipt, contact the Health Plan Prior Authorization team (see contact information above). If after 24 hours of denial receipt, : standard Medicare Appeal process is followed

4 Member type Aetna - Dual Medicare/Medicaid Aetna Opt Out TRANSPORTATION Emergency transportation is covered for all members under the health plan WAIVER MEMBERS: Medical and non-medical covered; members may be ambulatory NON- WAIVER MEMBERS: Med transportation ONLY covered for ambulette and non-emergency ambulance; Ambulatory members only over 30 miles and medically necessary; ambulatory members must arrange own transportation under 30 miles. NOTE: arranged via Logisticare & Medically necessary: non-emergency transportation, greater than 30 miles to be seen by provider/practitioner For Transportation Contact Logisticare: Members Questions: Reservations: Ride Assistance: Facilities Contact for Standing Orders: Facility Fax Contact: Emergency Transportation is covered for all members under the health plan and is billed directly to the health plan. Waiver Members: Medical and non-medical transportation is covered Arranged via Logisticare with no mileage restriction Members may be ambulatory Non-waiver Members: Medical transportation ONLY - is covered for ambulette (non-ambulatory, wheelchair bound) and non-emergency Ambulance (i.e. Stretcher, ALS/BLS) transportation - Arranged via Logisticare with no mileage restriction Ambulatory members are covered ONLY if transport is over 30 miles and is medically necessary** Arranged via Logisticare Ambulatory members must arrange own transportation for under 30 miles this includes community and skilled nursing members. They do not need to contact Logisticare for these arrangements. **Medically Necessary: non-emergency transportation, greater than 30 miles, to be seen by a provider/practitioner

5 FINAL - APPROVED 3/18/15 Buckeye Optum has been contracted with Health Plan to deliver case management and nursing home model of care with a NP and RN. NP/RN is responsible for authorizing Part A and Part B skilled events for long-term nursing facility residents. Facility should notify Optum NP/RN to obtain an authorization. Optum has ben contracted with Buckeye to provide the Monthly Bio-Psych-Social Survey through RNs and LPNs. Optum is not responsible for authorizations of skilled time Part A for long-term nursing facility residents. The facility will manage through Traditional Medicare or alternative health plan. Member type Buckeye - Dual Medicare/Medicaid Buckeye Opt Out NOMNC letters - SNF needs to fax to Health Plan Health NOMNC Fax Plan Concurrent Review Queue at Authorization # (Need reference Inpatient if Inpatient) (866) (866) Authorization Fax# (877) (877) Claims # (866) (866) Medicaid Custodial Authorization (866) X Scenarios PART A AUTHORIZATION Optum NP will submit clinical information to Buckeye. Authorization numbers will come from Health Plan to your facility representative. NOMNCS are administered by the facility representative as they do for traditional Medicare. (NEED TO REFERENCE INPATIENT) Facility representative to follow Traditional Medicare guidelines. CURRENT RESIDENT Enrolled in MyCare while in the facility - prior authorization. Skilling without 3 day hospital stay. Optum designated NP/RN will Authorize based on Medicare skilled criteria for Part A and B. Optum will notify health plan. Facility should follow Traditional Medicare process for skilled events, or contact health plan for additional questions. NEW TO FACILITY FROM HOSP OR COMMUNITY New Fully Integrated Dual Member being admitted to your facility for the first time from the Facility representative to contact Health Plan for custodial hospital or community: authorization. (telephone #) Facility representative to contact Health Plan for custodial authorization. CURRENT MEMBER READMIT TO FACILITY Current Fully Integrated member is being readmitted to facility following a hospitalization Notify Optum NP to see member when readmitted. Optum NP will submit clinical information to Health Plan once return to facility to determine skilled benefit. Facility representative to follow Traditional Medicare guidelines.

6 Member type Buckeye - Dual Medicare/Medicaid Buckeye Opt Out SHORT TERM FROM HOSP TO FACILITY If the member is new to the facility short term care or transitional care needed. (Member discharged from the hospital as skilled; Medicare benefits). How does the provider get a prior authorization number to put on the claim for reimbursement? CONTINUATION OF SKILLED TIME How does the provider communicate a need for continued skilled care? AFTER HOURS/HOLIDAY AUTHORIZATIONS How can authorizations be obtained after hours, holidays and weekends? Part A and B RETROACTIVE AUTHORIZATIONS Are retroactive authorization requests for Part A skilled? Authorizations needs to be provided by Health Plan. Optum NP/RN will collaborate in clinical management upon arrival to facility. Facility to communicate through collaboration with Optum NP/RN. Optum NP/RN will communicate additional needs to Health Plan. Extension of skilled benefit will be determined by Medicare guideline and communicate to facility by Optum clinician. Facility may contact Health Plan s 24/7 NurseWise for assistance. NurseWise staff can verify eligibility and authorize services Option #7 During initial MyCare implementation, Health Plan will accept retroactive requests. However, standard policy would require authorization to be in place prior to admission where applicable. Medicare guidelines. Facility will follow traditional Medicare process. Medicare guidelines. Facility will follow traditional Medicare process. Three day hospital stay required. Notification to Health Plan required. Facility will follow BED HOLD AUTHORIZATION Is an authorization required for Bed Hold days when member is admitted to hospital or on LOA? Yes. Please contact MyCare UM team option 1. HOSPITAL ADMIT AUTHORIZATION When members are admitted to the hospital from the facility, is the facility responsible for obtaining an authorization for the hospitalization? 911 ADMISSION What are the requirements for an emergency 911 admission? PART B AUTHORIZATION No. The hospital is responsible for authorizing the admission. However, the Health Plan would like to be notified of the transfer as expeditiously as possible. Hospital is required to notify Health Plan to verify membership. Facility should follow their standard protocols. Health Plan would like to be notified of an emergency admission as expeditiously as possible. Notification: Therapist completes evaluation and submit via the Part B Portal NP approves and provides reference number. Optum will provide authorization number facility. Facilities can call their Optum CM or NP for authorization numbers.

7 Member type Buckeye - Dual Medicare/Medicaid Buckeye Opt Out THERAPY LOG PHYSICIAN APPOINTMENTS When members are sent out for physician appointments or other services, is the facility responsible for obtaining authorization for those services? DME / OUTPATIENT SERVICES AUTHORIZATION Will the facility be required to obtain authorization for services such as DME, Outpatient Services when provided and billed by the facility for skilled and/or LTC? PSYCH AUTHORIZATIONS EXPEDITE Notification: Therapist completes evaluation and submit via the Part B Portal NP approves and provides reference number. Optum will provide authorization number facility. Facilities can call their Optum CM or NP for authorization numbers. No. The rendering provider is responsible for obtaining authorizations where applicable. Refer to the QRG for services requiring prior authorization. Yes. Please refer to the QRG for services that require prior authorization. Facility should contact Health Plan UM for authorization option 1. Facility should contact Health Plan UM for authorization option 1. Facility is responsible for expedition of authorizations through the health plan. If unsuccessful, contact Optum NP/RN or Provider Relations Advocate for help in communication. Facility should contact Health Plan UM for authorization option 1. APPEAL PROCESS TRANSPORTATION Process, documentation to distribute LEVEL OF CARE (LTC Pt from Hospital to Facility) See Provider Manual for further details. Buckeye Community Health Plan Appeals Department 4349 Easton Way, Suite 200 Columbus, OH See Buckeye Transportation Quick Reference Guide. Chemo, dialysis, or any other treatment that requires additional visits - Buckeye will call Assess 2 care and get it noted on the account. This is for non-wheelchair. If they are wheelchair they get unlimited already. Hospital can send patient back from Hospital, NP will determine skilled requirements based on Medicare guidelines. See Provider Manual for further details. Buckeye Community Health Plan Appeals Department 4349 Easton Way, Suite 200 Columbus, OH See Buckeye Transportation Quick Reference Guide.

8 Member type Buckeye - Dual Medicare/Medicaid Buckeye Opt Out SECOND PAYER CLAIM When the Plan is the secondary payer, will the facility receive a paid claim EOP for the Medicaid portion of the benefit even if there is a $0 payment? This is needed for Medicare cost reporting. DIABETIC FOOTWEAR MRI Yes. EOP will be sent. Stridelite/Medical Solutions = Corporate office Eligible for 1 pair and 1 set of inserts per year. For Clark County -- contact Hangar 877-4HANGER MRI's must be pre-suthorized by NIA ( or Stridelite/Medical Solutions = Corporate office Eligible for 1 pair and 1 set of inserts per year. For Clark County -- contact Hangar 877-4HANGER

9 25-Jun-15 United HealthCare Optum has been contracted with UHC to deliver case management and nursing home model of care with a NP and RN. NP/RN is responsible for authorizing Part A and Part B skilled events. Facility should notify Optum NP/RN to obtain an authorization. Optum has ben contracted with UHC to provide the Monthly Bio-Psych-Social Survey through RNs and LPNs. Optum is not responsible for authorizations of skilled time Part A. The facility will manage through Traditional Medicare or alternative health plan. Member type UHC Opt In (Dual Medicare/Medicaid) UHC - Opt Out (Medicaid Only) NOMNC Optum is providing NOMNC letter to facilities for skilled care for long-term residents N/A Authorization (DME, Hospitalizations ) # Authorization Fax# Authorization (Part A Skilling for Long term resident in SNF) Contact your Optum Nurse Practitioner N/A Claims # Member Matters Customer Service SCENARIOS CUSTODIAL AUTHORIZATIONS As of 6/1/2015 United Healthcare will no longer require authorization for custodial, long term care stays for United Healthcare Connected for MyCare OH members within skilled nursing facilities. This change does include claims with dates of service beginning 5/1/2015. Please direct any questions to Provider Service unit at As of 6/1/2015 United Healthcare will no longer require authorization for custodial, long term care stays for United Healthcare Connected for MyCare OH members within skilled nursing facilities. This change does include claims with dates of service beginning 5/1/2015. Please direct any questions to Provider Service unit at Revenue code 0101 for custodial care does not require an auth. Revenue code 0101 for custodial care does not require an auth. HOSPICE AUTHORIZATIONS As of 6/1/2015 revenue code 0658 and CPT code T2046 for Hospice, no longer require an auth.

10 Member type UHC Opt In (Dual Medicare/Medicaid) UHC - Opt Out (Medicaid Only) PART A AUTHORIZATION (Current LTC resident with or without 3 day qualifying hospital stay) Optum NP will evaluate member and determine skilled benefit eligibility. Authorization numbers will come from the Optum NP or designee in Optum Client Services to your facility representative. NOMNCS will be faxed to the facility fax number that Optum has on record. If there is an issue with the fax number on record, please optumohio.clientservices@optum.com Optum is not responsible for authorizations of skilled time Part A. The facility will manage through Traditional Medicare or alternative health plan. 3 day Hospital stay is required by Medicare. CONTINUATION OF SKILLED TIME How does the provider communicate a need for continued skilled care for a LTC member? NEW TO FACILITY FROM HOSP OR COMMUNITY New Fully Integrated Dual Member being admitted to your facility for the first time from the hospital or community: CURRENT MEMBER READMIT TO FACILITY Current member is being readmitted to facility following a hospitalization Facility to communicate through collaboration with Optum NP/RN. Extension of skilled benefit will be determined by the appropriate Medicare and MMP guidelines and communicated to the facility by Optum clinician. Facility representative to contact UCS Intake ( ) for custodial authorization. If there is a delay, please contact client services at ohiooptum.clientservices.com Inpatient Care Manager to notify Optum NP to see member when readmitted. Optum NP will determine skilled care and submit clinical information once the member returns to facility to determine skilled benefit. Optum Benefit Determination will provide facility with authorization number. Medicare guidelines. Facility will follow traditional Medicare process. Facility representative to contact UCS Intake ( )for custodial authorization. Facility representative to contact UCS intake ( ) SHORT TERM FROM HOSP TO FACILITY If the member is new to the facility short term care or transitional care needed. (Member discharged from the hospital as skilled; Medicare benefits). How does the provider get a prior authorization number to put on the claim for reimbursement? Provider should call UM intake Department ( ) for an Authorization. It is important to notify intake department if the member is an inpatient in a hospital. Optum NP/RN will collaborate in clinical management upon arrival to facility. Medicare guidelines. Facility will follow traditional Medicare process.

11 Member type UHC Opt In (Dual Medicare/Medicaid) UHC - Opt Out (Medicaid Only) CONTINUATION OF SKILLED TIME FOR NEW SHORT- TERM MEMBER (PAS - Post Acute Services). How does the provider communicate a need for continued skilled care for a Short Term member? Provider should call UM Intake Department ( ) or the assigned ICM. Medicare guidelines. Facility will follow traditional Medicare process or Medicare Advantage Plan as appropriate. AFTER HOURS/HOLIDAY AUTHORIZATIONS How can authorizations be obtained after hours, holidays and weekends? RETROACTIVE AUTHORIZATIONS Are retroactive authorization requests for Part A skilled? BED HOLD AUTHORIZATION Is an authorization required for Bed Hold days when member is admitted to hospital or on LOA? HOSPITAL ADMIT AUTHORIZATION When members are admitted to the hospital from the facility, is the Hospital responsible for obtaining an authorization for the hospitalization? 911 ADMISSION What are the requirements for an emergency 911 admission? Contact the Optum NP on-call Up to 30 days; if after 30 days the facility can appeal NO bed hold authorization is needed Yes, the hospital is responsible. They should contact UM Intake Department If the facility determines that a member requires emergency care, please follow emergency protocols. Please notify the Optum NP/RN upon a patient transfer Yes, the hospital is responsible. They should contact UM Intake Department If the facility determines that a member requires emergency care, please follow emergency protocols. Please notify the Optum NP/RN upon a patient transfer PART B AUTHORIZATION PHYSICIAN APPOINTMENTS When members are sent out for physician appointments or other services, is the facility responsible for obtaining authorization for those services? Notification: Therapist completes evaluation and submit via the Part B Portal NP approves and provides reference number. Optum will provide authorization number facility. Facilities can call their Optum CM or NP for authorization numbers. Please follow prior authorization guidelines on UHC website Please follow prior authorization guidelines on UHC website

12 Member type UHC Opt In (Dual Medicare/Medicaid) UHC - Opt Out (Medicaid Only) DME / OUTPATIENT SERVICES AUTHORIZATION Will the facility be required to obtain authorization for services such as DME, Outpatient Services when provided and billed by the facility for skilled and/or LTC? PSYCH AUTHORIZATIONS WHEN PLAN IS SECONDARY PAYER, will the facility receive a paid claim EOP for the Medicaid portion of the benefit even if there is a $0 payment? This is needed for Medicare cost reporting. Facility/Provider will contact Heath Plan for preauthorization benefits. Facility can contact United Behavioral Health at Claims submitted for $0 payment will get back denial codes on the PRA that explain $0 payment that should be used for bad debt reporting. Facility can contact United Behavioral Health at EXPEDITE APPEAL PROCESS TRANSPORTATION Process, documentation to distribute If an urgent request is needed, the facility may request an urgent authorization. Please contact Optum NP/RN or Provider Relations Advocate for help in communication. A peer to peer discussion can be requested within 48 hours. Please reach out to the Optum NP/RN who will direct you to the appropriate health plan or Optum Medical Director Please follow prior authorization guidelines on UHC website A peer to peer discussion can be requested within 48 hours. Please reach out to the Optum NP/RN who will direct you to the appropriate health plan or Optum Medical Director Please follow prior authorization guidelines on UHC website LEVEL OF CARE Custodial auth (post-hospitalization) Custodial authorizations are not required for stays as of 5/1/15. Facilities should not bill until after 6/1/15 so the programming can take place. Optum will issue a Level of Care for the following events: 1. Returning to a different SNF (transferring facilities) 2. Going from short term to long term (funding change) 3. Bed Hold days are exhausted

13 Member type UHC Opt In (Dual Medicare/Medicaid) UHC - Opt Out (Medicaid Only) REPATRIATION Optum will notify UHC Case Manager via (cacmmp@uhc.com) that a member is appropriate for Repatriation Optum will notify UHC Case Manager via (cacmmp@uhc.com) that a member is appropriate for Repatriation