MEDICAID PRIOR AUTHORIZATION TRANSITION

Transcription

1 MEDICAID PRIOR AUTHORIZATION TRANSITION Prepared for: Mississippi Medicaid Physicians and Providers Expanded EPSDT November 2013

2 December 1, 2013 The Road Ahead 2

3 Today s Goals and Objectives What stays the same and what changes? When does the new process begin? What do I need to know? 3

4 What stays the same? Admin Code and DOM regulations are the same : Prior Authorization (PA) of physician visits are required when a beneficiary has exhausted the state plan limit of 12 visits within a state fiscal year (July 1 June 30) 4

5 What is changing? The Prior Authorization Process changes effective December 1, 2013 Where and when you send the authorization request Envision is only used for checking eligibility and claims No DOM forms Who reviews the request Timeframes for submitting your request Increased speed of approvals and communication 5

6 When does the new process begin? Effective December 1, 2013 eqhealth will perform prior authorization reviews for Expanded Physician Visits 6

7 What happens to requests for services prior to December 1, 2013? Services requested prior to December 1, 2013 Continue to submit requests via Envision through November 30, 2013 DOM will continue to process these requests Any service approved by DOM will remain in effect Requests previously submitted to DOM should not be resubmitted to eqhealth 7

8 eqhealth has a 16 year Utilization Management partnership with DOM Our multidisciplinary review team includes register nurses and Mississippi licensed physicians The review team is overseen by our Medical Director, Dr. Thomas Joiner 8

9 What do we need to know? Admin Code and DOM Regulations eqhealth Systems & Review Process 9

10 Getting to Know Mississippi Division of Medicaid (DOM) Physician Services Coverage For comprehensive information about Expanded Physician Visits covered, limitations and exclusions; the following are important resources to be familiar with: Mississippi Administrative Code Title 23 Medicaid, Part 203, Physician Services Mississippi Medicaid Provider Reference Guide (PRG 203) Medicaid Physician Fee Schedule 10

11 Will all physician service codes require prior authorization (PA) on December 1, 2013? Good question, let s take a closer look 11

12 Physician Codes Requiring PA after a beneficiary exhausts the state plan limit of 12 visits, per state fiscal year (July 1 June 30) Code & Description All Current Procedural Terminology (CPT) Codes and Descriptors are copyrighted 2013 by the American Medical Association New Patient Office visit Problem Focused New Patient Office visit Expanded Problem Focused New Patient Office visit Detailed New Patient Office visit Comprehensive New Patient Office visit Comprehensive 12

13 Physician Codes Requiring PA after a beneficiary exhausts the state plan limit of 12 visits, per state fiscal year (July 1 June 30) Code & Description All Current Procedural Terminology (CPT) Codes and Descriptors are copyrighted 2013 by the American Medical Association Established Patient Office Visit Expanded Problem Focus Established Patient Office Visit Detailed Established Patient Office Visit Comprehensive Established Patient Office Visit Comprehensive 13

14 Physician Codes Requiring PA after a beneficiary exhausts the state plan limit of 12 visits, per state fiscal year (July 1 June 30) Code & Description All Current Procedural Terminology (CPT) Codes and Descriptors are copyrighted 2013 by the American Medical Association Office or Other Outpatient Consultations (new or established patient) Problem Focus Office or Other Outpatient Consultations (new or established patient) Expanded Problem Focus Office or Other Outpatient Consultations (new or established patient) Detailed Office or Other Outpatient Consultations (new or established patient) Comprehensive Office or Other Outpatient Consultations (new or established patient) Comprehensive 14

15 Physician Codes Requiring PA after a beneficiary exhausts the state plan limit of 12 visits, per state fiscal year (July 1 June 30) Code & Description All Current Procedural Terminology (CPT) Codes and Descriptors are copyrighted 2013 by the American Medical Association Home Visit Level New Patient Problem Focused Home Visit Level New Patient Expanded Problem Focused Home Visit Level New Patient Detailed Home Visit Level New Patient Comprehensive Home Visit Level New Patient Comprehensive 15

16 Physician Codes Requiring PA after a beneficiary exhausts the state plan limit of 12 visits, per state fiscal year (July 1 June 30) Code & Description All Current Procedural Terminology (CPT) Codes and Descriptors are copyrighted 2013 by the American Medical Association Home Visit Level Established Patient Problem Focused Home Visit Level Established Patient Expanded Problem Focused Home Visit Level Established Patient Detailed Home Visit Level Established Patient Comprehensive 16

17 Physician Codes Requiring PA after a beneficiary exhausts the state plan limit of 12 visits, per state fiscal year (July 1 June 30) Code & Description All Current Procedural Terminology (CPT) Codes and Descriptors are copyrighted 2013 by the American Medical Association Ophthalmological Visit new patient Ophthalmological Visit new patient comprehensive 1 or more visits Ophthalmological Visit established patient Ophthalmological Visit established patient comprehensive 1 or more visits 17

18 Before getting started on your Prior Authorization journey, lets look at the information needed along the way 18

19 Before You Get Started: Checkpoint #1 Did you check beneficiary eligibility? You are responsible for verifying a Medicaid beneficiary s eligibility each time the beneficiary appears for service. You are also responsible for confirming the person presenting the card is the person to whom the card is issued Verify eligibility by accessing any of the following services: Website verification: Envision Automated Voice Response System (AVRS) at Provider/Beneficiary Services Call Center at Using personal computer (PC) software or point of service (POS) swipe card verification device 19

20 Before You Get Started: Checkpoint #1 The following beneficiaries do require prior authorization by eqhealth: The following beneficiaries do not require prior authorization by eqhealth: Fee-for-service EPSDT eligible beneficiaries Dual Coverage (Private Insurance and Medicaid) Beneficiaries who are not eligible for EPSDT Beneficiaries enrolled in Mississippi Coordinated Access Network (MSCAN) and CHIP Beneficiaries in COE 29, Family Planning Waiver (No Expanded Physician Visit Benefit) Beneficiaries with no Medicaid coverage for the date of service Dual Eligible Medicare & Medicaid Note: The Federal Government is requiring Medicaid programs to change their categories of eligibility by January 1, Making sure you check eligibility becomes a business necessity 20

21 Before You Get Started: Checkpoint #2 Select your eqsuite Web Administrator 21

22 Selecting Your Key Players Who is the best person to be the eqsuite Web Administrator? When is this information due to eqhealth? What type of skills should this person have? 22

23 23

24 Get Your Provider Contact Form Visit our Web site at ms.eqhs.org 24

25 To assist with helpful reminders please welcome your Prior Authorization buddy. Pete the PA Parrot 25

26 Before You Get Started: Checkpoint #3 Effective December 1, 2013, discontinue using all DOM Expanded Physician prior authorization forms DOM forms will be replaced by eqhealth s automated Web based review submission process When a EPSDT eligible beneficiary requires more than 12 physician visits per state fiscal year (July 1 June 30), the following information must be obtained in order to submit your request to eqhealth Review Questions The following slides provide the questions you will need to answer in our web based review system eqsuite Note: A printable version of this form can be found at 26

27 Before You Get Started: Checkpoint #3 The reason for this request is: (select all that apply) My claim denied and stated service limits have been exceeded Service was provided and visits were available on the date(s) of service but my claim denied Service not yet provided Service provided, beneficiary now retroactively eligible for Medicaid Service provided, but not as a result of retroactive Medicaid eligibility 27

28 Before You Get Started: Checkpoint #3 Is the reason for the request a new complex problem identified within the last six (6) months? (Must be identified as the primary diagnoses on the DX/Codes/Items tab) Yes No The beneficiary is experiencing an exacerbation in their chronic medical condition and has been unresponsive to treatment interventions Yes No 28

29 Before You Get Started: Checkpoint #3 The beneficiary is experiencing an urgent episodic medical condition/event that could be managed in an outpatient physician's office. Interventions were attempted to prevent beneficiary from experiencing an exacerbation in their health condition or an unnecessary ER visit Yes No Other situation: Please explain Yes No Textbox 29

30 Before You Get Started: Checkpoint #3 When should I send my request to eqhealth? New Service Request/Admission for dates of service prior to April 1, 2014 Submit the PA request a minimum of two (2) business days prior to the planned service date; however, Service dates older than 30 days from the request date should be sent within 30 days of the service date to be processed within two (2) business days For service dates older than 30 days we will process these requests as quickly as possible but no later than twenty (20) business days 30

31 Before You Get Started: Checkpoint #3 When should I send my request to eqhealth? New Service Request/Admission for dates of service beginning and after April 1, 2014 For dates of service beginning April 1, 2014, all requests for prior authorization must be requested at least two (2) business days in advance of the service or submitted to eqhealth for review within 120 days of the service date. All requests outside of this time frame will be cancelled 31

32 Before You Get Started: Checkpoint #3 When should I send my request to eqhealth? Retrospective Only applies when beneficiary did not have Medicaid benefits (fee for service) on the date service was provided For beneficiaries who are retroactively eligible and have been discharged from care (service already provided) Submit the review request as soon as eligibility is confirmed and within one (1) year of the retroactive eligibility determination date If services are in progress when the retroactive eligibility is determined, submit a new request/admission review request 32

33 A Quick Checklist Review Before You Get Started: Know the codes requiring PA, the rules in Administrative Code and DOM Regulation Check beneficiary eligibility Collect answers to review questions and incorporate timeframes for submitting PA requests into your business process Congratulations now you are ready to send the information to eqhealth 33

34 The next step of the transition journey Checkpoint #4: Learning how to use our Web tool equniversity Review Process and eqsuite Web Administrator Registration Support and Training 34

35 35

36 36

37 37

38 38

39 39

40 40

41 41

42 42

43 43

44 44

45 45

46 46

47 47

48 48

49 Beginning 12/1/13: What will eqhealth do with your request? 49

50 eqhealth Solutions First Level Reviewers registered nurses, pediatricians and other specialty physicians Apply Admin Code and DOM regulations Apply DOM approved medical necessity guidelines May request additional information Pending a review Approve services based on DOM regulations and guidelines Refer requests they can not approve to a second level reviewer (physician) 50

51 eqhealth Solutions Second Level Reviewers pediatricians and specialty physicians May contact the ordering physician to obtain additional information Pending a review Approve services Partially approve services Deny services 51

52 National Guidelines for Expanded Physician Visits eqhealth Solutions uses DOM approved National Clinical Guidelines (referred to as Clinical Guidelines) as tools when making clinical determinations concerning the medical necessity of care. These guidelines are available at 52

53 What is a Pend? Pends are questions submitted to providers from either a first level reviewer or a second level reviewer that generally involve a need for clarification or additional information before a review can be completed Pends may occur anytime there are: Questions about the information that has been submitted Missing required information 53

54 How Do I Know I ve Been Pended? eqsuite will provide information about your request/case at all times eqsuite is accessible 24 hours a day, 7 days a week to check the status of your request/case, including pend messages The image on the left highlights where to respond to a pend question. The upper box will contain the question. The lower box is where you may respond eqhealth will contact the review submitter or physician s office by phone to inform you of the information needed to complete your request If you are not available we will leave a message to check eqsuite 54

55 How Do I Respond To a Pend? Responding to pends as soon as possible keeps the review process progressing You can respond to pends online via the eqsuite 55

56 Should I Like Being Pended? How do I prevent being pended? 56

57 Is getting Pended good? The up side about a pended review is that it opens a line of communication between eqhealth and the provider The down side, the review process stops until you respond Applying a few easy tips can keep your review moving along 57

58 Pend Prevention Tips To prevent pends or apendaphobia: Don t copy and paste clinical information into reviews Attend equniversity trainings Answer the pend question completely and accurately If you feel you are receiving numerous pends, immediately consult an equniversity Team Member at for assistance 58

59 How Many Business Days Does eqhealth Have To Process Your Request? eqhealth completes requests for services as quickly as possible, but within specific timeframes. The timeframe depends on when the service is anticipated to occur (New Request/Admission review) or has already been provided. The request/review completion timeframe is measured from the date eqhealth receives your request New Request/Admission review requests: 2 business days Retrospective review requests: 20 business days 59

60 How old can a service date/request be? Remember: eqhealth completes requests as quickly as possible, but within specific timeframes. The older the request, the slower the processing time. Beginning 12/1/13 through 3/31/14, service dates older than 30 days from the request date will be processed as a retrospective review reviews will be completed as quickly as possible, but no later than 20 business days from receipt; however, For dates of service beginning April 1, 2014, all requests for prior authorization must be requested in advance of the service or submitted to eqhealth for review within 120 days of the service date. Service requests falling into one of the two categories will be processed as a New Request/Admission completed as quickly as possible, but no later than 2 business days from receipt. All requests outside of this time frame will be cancelled 60

61 Denials 61

62 What Is a Denial? A denial occurs when any portion of requested services are not approved Clinical Denial Any portion of requested services are not approved by a second level reviewer for a clinical reason 62

63 Reconsiderations 63

64 Reconsiderations - Another Look Must be requested within 30 calendar days of the denial notification Beneficiary or provider may request a reconsideration 64

65 Reconsiderations - Another Look A reconsideration is another look at your request/case by a different eqhealth Solution second level reviewer (a different physician who was not involved in the original denial decision) Available when eqhealth Solution issues a clinical denial The denial notification will have specific instructions for requesting a reconsideration HELPLINE assistance is available by calling

66 Reconsiderations - Another Look Outcomes: Upheld denial remains in place Modified part of the request is approved and the remainder is denied Overturned denial is removed and request is certified, and Treatment Authorization Number (TAN) Approval information sent daily to fiscal intermediary 66

67 Appeals 67

68 DOM Administrative Appeal Right If a reconsideration is Upheld or Modified(partially approved) ONLY the beneficiary, parent, legal guardian/caregiver may request an administrative appeal of the eqhealth determination Administrative Appeals must be requested in writing within 30 calendar days of the reconsideration notification date DOM performs the Administrative Appeal/Hearing 68

69 A Helpful Transition Aide for December 1, 2013 Do not use existing DOM Expanded Physician forms eqsuite replaces DOM forms. Our web site ms.eqhs.org has a sample copy of questions to assist in planning ahead Know the Rules - Admin Code and DOM regulations Check Eligibility prior to visits. Minimally at every visit. Eligibility changes will be occurring on 1/1/2014 Answer the questions thoroughly in eq Suite Plan ahead to allow time for eqhealth to process the request 69

70 A Helpful Transition Aide for December 1, 2013 For dates of service beginning 4/1/2014: All requests for expanded physician services must be requested in advance of the service OR submitted to eqhealth for review within 120 days of the service date. All requests outside of this time frame will be cancelled By12/1/13: Send your completed Provider Contact Form to eqhealth via at OR call Completing this form allows your eqsuite Administrator to setup access for submitting PA requests. Get a form at ms.eqhs.org 70

71 November 2013 and going forward equniversity will continue to provide education support to you: Monthly and Quarterly webinars Education materials posted on website ms.eqhs.org HELPLINE Tailored educational offerings to meet your needs 71

72 November 2013 and going forward Training is free No limit on the number of times you can attend Idea: Incorporate equniversity into your new employee orientation 72

73 73

74 74

75 For additional training and links to resources: Visit our Web site at ms.eqhs.org 75

76 76

77 Thank you for attending.. 77