Participating Provider Prior Authorization Guide

Transcription

1 This is a list of common services that typically require prior authorization and may not be all-inclusive. For questions, please contact Magellan Complete Care Customer Services at (800) Participating Provider Guide All out of network services require prior authorization except family planning, new enrollee continuity of care and emergency care. Service Inpatient Hospital Care Crisis Stabilization Unit (CSU) Emergency Inpatient Hospital Admissions Behavioral and Medical (acute, OB-ante partum, etc.) Medical necessity will be assessed on day 1 based on clinical information received Elective Inpatient Admissions Behavioral and Medical (acute, OB-ante partum, inpatient surgeries, Inpatient Rehabilitation, Long Term Acute Care, Inpatient Drug Rehab for pregnant enrollees and enrollees less than 20 years tification Yes, within 24 hours with Yes, within 24 hours with Yes, once the member is admitted for scheduled services or if admission date changes Yes Yes As applicable, 45 days/benefit year for adults (BBA exceptions to 45-day cap), up to 365 days/benefit year for children <21 or pregnant women Yes Yes As applicable, 45 days/benefit year for adults, up to 365 days/benefit year for children <21 or pregnant women 1 Updated 11/3/2015; Updated 2/18/2016;

2 of age only) Service Inpatient Hospital Care Cont d Inpatient Hospital - Transplant Maternity/Newborn Delivery Observation Days Medical necessity will be assessed on day 1 based on clinical information received Electroconvulsive Therapy (ECT) Inpatient Setting Sub-Acute Care Short-term Skilled Nursing Facility Services tification Yes, within 24 hours of admission with Yes, within 24 hours with Yes, within 24 hours with Yes Yes Yes, if stay exceeds hospital length of stay of fortyeight (48) hours for normal vaginal delivery and ninety-six (96) hours for cesarean section Yes Up to 48 hours Observation services includes revenue codes 0761 and 0762 Yes Yes See Downward Substitution Section Other Inpatient Services Inpatient alcohol and drug Yes, within Yes As applicable, 45 2 Updated 11/3/2015; Updated 2/18/2016;

3 detoxification services in a free- 24 hours days/benefit year for adults Service tification Other Inpatient Services - Cont d standing detox unit or addiction receiving facility with 3 Updated 11/3/2015; Updated 2/18/2016; (BBA exceptions to 45-day cap), up to 365 days/benefit year for children <21 or t Inpatient Substance Abuse pregnant women Rehabilitation Outpatient Hospital Care Cardiac Procedures (nonemergency) Yes Dialysis -Outpatient Hospital Yes Yes -Free Standing Dialysis Center Electroconvulsive Therapy Yes Yes (ECT) Emergency Room Visit Yes Elective Surgery Yes Hospital OB Floor Labor Check Yes, within & hours with Transplant Evaluation Yes Primary and Specialty Care Office or Clinic Based Primary Care Specialty Care with PCP s NPI noted (except as listed below): -Allergy Testing and Immunotherapy -Chiropractic Services ** Yes** One new patient visit plus 23 established patient

4 Service tification Primary and Specialty Care Office or Clinic Based Cont d -Dermatology ** -Obstetrics Yes, with -Oncology Yes visits per year or 24 established patient visits per year -Podiatry Yes** -Pain Management Yes Office Surgery Yes Except for codes on the Quick Form (QAF) Other Medical/Ancillary Air Ambulance Yes Ambulatory Surgery Center Yes Assistive/Personal Care Services T1020 Birth Center Obstetrics and Delivery Dialysis (Free Standing Dialysis Center or Outpatient Hospital) DME and Medical Supplies (including nutritional/enteral feedings except orthotics and prosthetics) Yes, within 24 hours of admission with Yes Yes Dialysis authorizations are valid for 6 months Yes, for Yes See AHCA fee schedules for specific adults and enrollees under procedure 21 codes 4 Updated 11/3/2015; Updated 2/18/2016;

5 Service tification Other Medical/Ancillary Cont d Orthotics and Prosthetics Yes Endoscopic Capsule Yes Genetic Testing (Cytogenetic, Reproductive and Molecular Diagnostic Laboratory testing) Yes Hearing Aids Yes Home Health Care Services Yes Yes Home Health Infusion Therapy Yes Hospice Yes Yes Hyperbaric Oxygen Therapy Yes Yes Lab Services (preferred vendors) Lab Services (non-par) Yes For services not available through preferred vendors Newborn Hearing Screening Prescribed Pharmacy Drugs Medications on the state s PDL, except those with state (PA) requirements for quantity limits, age limits, or other state-noted PA requirement Transportation Ambulance (Emergent) Transportation Ambulance (n-emergent) Transportation (n- Ambulance, n-emergent) 5 Updated 11/3/2015; Updated 2/18/2016; Yes Except for transfer from a non-par facility to a participating facility Advance Scheduling

6 Service Other Medical/Ancillary Cont d Specialty Medications and Infusion for home or at a skilled nursing facility tification Yes Advanced Radiology and Procedures by National Imaging Associates (NIA): Diagnostic Imaging (MRI, MRA, CT /CCTA, PET, Nuclear Cardiology/MPI, Stress Echo, Echocardiography) Cardiac Catherization Interventional Pain Management-Spine (Spinal Epudural Injections, Para vertebral Facet Joint Injections or Blocks, Para vertebral Facet Joint Denervation [Radiofrequency Neurolysis]) Radiation Oncology Management All Radiation Therapy Spine Surgery (Both Inpatient and Outpatient) Lumbar Microdiscectomy, Lumbar Decompression, Lumbar Spine Fusion (Arthrodesis) Yes, please go to D.com to submit service requests Except for non-advanced radiology and procedures listed on the Quick Form (QAF) Refer to NIA Website for Covered Services Grids 6 Updated 11/3/2015; Updated 2/18/2016;

7 Service Other Medical/Ancillary Cont d n-advanced Radiology and procedures (see Quick Form QAF) Including OB U/S Portable n-advanced Radiology and procedures (xray imaging, swallowing studies, EKGs, non-ob ultrasounds) Therapies: A) Physical, B) Occupational, C) Respiratory, & D) Speech E) Vestibular Rehab therapy F) Lymphedema therapy (this applies to outpatient free standing facilities, outpatient hospitals and/or home health care therapy service requests) tification Effective 2/1/16, no authorization is required for OB U/S Yes Yes Yes Unlimited for ages 20 and younger; Adults 21 and over limits apply as follows: A) 1. Physical therapy covered only for wheelchair evaluations and fittings; 2. Physical therapy treatments require medical necessity determination by the Plan; B) Occupational therapy is only covered for prosthesis and orthodics fittings and wheelchair evaluations; C) Respiratory therapy is not covered; D) Speech therapy is only covered for augmentative / alternative communication services; E) Vestibular Rehab 7 Updated 11/3/2015; Updated 2/18/2016;

8 tification Service Other Medical/Ancillary Cont d Therapies: Cont d Behavioral Health Services Statewide Inpatient Psychiatric Program (SIPP) for enrollees under the age of 21 Routine Behavioral Health Care Behavioral Health Day Srvcs Day Treatment, per hour, MH Intensive Case Management age 18+ yrs Targeted Case Management age Adults Targeted Case Management Children age 0-17 yrs Targeted Case Management for Children at risk of abuse and neglect Community Support and Rehabilitative Services (Psychosocial Rehabilitative Services) Mental Health Clubhouse Services Adult 8 Updated 11/3/2015; Updated 2/18/2016; therapy is not covered; F) Lymphedema therapy is not covered. Yes Yes ** Limits apply Yes Yes Enrollees ages units/yr H2012 Yes Yes 48 quarter hr units/day T1017 HK Yes Yes 344 quarter hr units/month T1017 Yes Yes 344 quarter hr units/month T1017 HA Yes Yes Under the age of 21 years T2023 HA Yes Yes 1,920 units (480 hours; 20 days) These units count against Clubhouse service units H2017 Yes Yes 1,920 units (480 hours; 20 H2030 days) These units count against Psychosocial Rehabilitative service units Service tification

9 Behavioral Health Services Cont d Therapeutic Behavioral On-site Services (TBOS) Therapy Therapeutic Behavioral On-site Services (TBOS) Therapeutic Support Therapeutic Behavioral On-site Services (TBOS) Behavior Management Specialized Therapeutic Group Care/ Therapeutic Group Care Services Psychological Testing/Neuropsychological testing Yes Yes 36 Qtr Hr Units/Mo. (0-20 yrs) Yes Yes 128 Qtr Hr Units/Mo. (0-20 yrs) Yes Yes 36 Qtr Hr Units/Mo. (0-20 yrs) H2019 HO H2019 HM H2019 HN Yes Yes under the age of 21 years H0019 Yes 40 Qtr Hr Units or 10 hrs Per FY H2019, 96101,96102, 96103, 96118, 96119, Outpatient ECT Yes Yes Behavioral Health overlay services ( BHOS) in child welfare settings Yes Yes under the age of 21 years H2020 HA Specialized Therapeutic Foster Care, level I Specialized Therapeutic Foster Care, level II Specialized Therapeutic Foster Care, Crisis Intervention Expanded Benefits Expanded Primary Care Visits for n-pregnant Adults Yes Yes under the age of 21 years S5145 Yes Yes under the age of 21 years S5145 HE Yes Yes 1 per month S5145 HK One per day Updated 11/3/2015; Updated 2/18/2016;

10 Service Expanded Benefits Cont d Expanded Home Health Visits for n-pregnant Adults Expanded Prenatal/Perinatal Visits Expanded Outpatient Hospital Services Coverage Over-The-Counter (OTC) Medication/Supplies tification Yes Yes Unlimited: Medical Necessity review Yes Ten to fourteen (10-14) visits for routine pregnancy care; no limit for high risk pregnancy care; one (1) postpartum home health visit Yes Yes Increased annual limit by $ Total limit is $2, per fiscal year Prescription Twenty-five dollars ($25) per household per month. Limited to an approved list of products from a planapproved vendor H1000, 59425, 59426; (home visit) Requires appropriate billing per MCC guidelines e.g. modifiers to indicate trimester; appropriate high risk diagnosis codes; V-code for postpartum Blood pressure cuff (A4660) added to approved list 10 Updated 11/3/2015; Updated 2/18/2016;

11 Service Expanded Benefits Cont d Expanded Adult Dental Services DentaQuest tification Yes One thousand five hundred dollars ($1,500) limit per year for preventive services which includes: one (1) cleaning every six (6) months; one (1) exam every six (6) months; one (1) x-ray per year; one (1) fluoride treatment every year; and treatment for periodontal disease subject to prior authorization D 0120, D1110,D1206, D1208, D0270, D0272, D0274, D4341/D4342, D4355 Waived Copayment Expanded Vision Services Yes One (1) pair of glasses every twelve (12) months without prior authorization; Additional pairs of glasses subject to medical necessity and authorization Adult Pneumonia Vaccine One (1)vaccination per lifetime as medically advised Adult Influenza Vaccine One (1) vaccination per year Available at any 5 minute clinic community pharmacy Available at any 5 minute clinic community pharmacy 11 Updated 11/3/2015; Updated 2/18/2016;

12 Service Expanded Benefits Cont d tification Adult Shingles Vaccine One (1) vaccination per lifetime as medically advised Post Discharge Meals Yes Three (3) home delivered meals per day for member and up to 3 family members; limited to two (2) days post discharge; enrollee is required to give the Plan forty-eight (48) hours prior notice Available at any 5 minute clinic community pharmacy S5170, S9977 Nutritional Counseling Yes Up to 15 visits per year S9470 Intensive Outpatient Therapy Yes Yes Unlimited substance abuse H0015 for Substance Abuse intensive outpatient Downward Substitution Ambulatory Setting Substance Abuse Treatment and Detoxification Service Yes Yes 3 hours per day for up to 30 days S9475 Adult In Home Therapy Includes rehabilitative and supportive counseling in the enrollee s home Yes, first 52 units Yes, subsequent 52 units after initial 52 Yes 52 units (1 unit = 15 minutes) upon notification. Additional units up to 52 units will be reviewed for MNC and require prior authorization. Travel time to enrollee s call is not covered H2019HB 12 Updated 11/3/2015; Updated 2/18/2016;

13 Service Downward Substitution Cont d Self Help Peer Services May include peer specialist activities, peer mentoring, peer education, recovery coach services and mental health services provided by peers Short-term Skilled Nursing Facility Services tification 16 units per day (1 unit = 15 minutes) Yes Yes Covered for 20 years of age and under. For adults 21 and older, the Plan may authorize a specific number of days for a stay in a nursing facility for services that are a downward substitution for inpatient hospital care. Under the hospital benefit but days not counted towards 45-day inpatient limit H0038 Psychiatric Health Facility Service Mobile Crisis and Crisis Intervention Services Contracted and/or Delegated Services: Call Magellan Complete Care Customer Services at (800) Coastal Care Services DME, Home Health, Infusion Pharmacy for Home Health Services ONLY Yes 96 units per year; maximum of 12 units per day (1 unit = 15 minutes) Yes Yes, for Home Health Care Services and certain respiratory DME items H2011HO 13 Updated 11/3/2015; Updated 2/18/2016;

14 tification Service Contracted and/or Delegated Services Cont d Call Magellan Complete Care Customer Services at (800) DentaQuest Dental (routine and preventive) Yes DaVita Dialysis Centers Fresenius (Dialysis) Medical Care Ultracare-Dialysis Advanced Care Dialysis Centers Yes Yes Dialysis authorizations are valid for 6 months Yes Yes Dialysis authorizations are valid for 6 months Florida Eye Care , Option #1 Vision (Routine and preventive) Ophthalmologist Premier Eye Care , Option #1 Hear USA - Hearing Evaluations Only Providers: Member: Yes Dade and Broward Ophthalmologist and optometrist will be provided by FEC Logisticare Transportation (n-emergent) Reservations: Advance Scheduling 14 Updated 11/3/2015; Updated 2/18/2016;

15 tification Service Contracted and/or Delegated Services Cont d Call Magellan Complete Care Customer Services at (800) Magellan Pharmacy Auth MCC Florida (800) Yes Medications on the state s PDL, except those with state (PA) requirements for quantity limits, age limits, or other state-noted PA requirement LabCorp Diagnostics (888) Quest Laboratories (866) , Option #2 Provider Network Solutions Web Portal: Podiatry Network: (866) Dermatology Network: (866) Orthopedic Network: (866) A. Derm and Podiatry network is Statewide B. Podiatry network provides assistance to SNFs and ALFs C. Orthopedic network only available for Dade and Broward 15 Updated 11/3/2015; Updated 2/18/2016;

16 tification Service Contracted and/or Delegated Services Cont d Call Magellan Complete Care Customer Services at (800) Walgreens Infusion Medication Infusion services at a skilled nursing facility (SNF) Ft. Myers: (239) Gainesville: (352) Miramar: (800) Panama City: (800) St. Petersburg: (800) tes: *tification required with clinical information in order to provide an authorization, review for MNC where indicated and/or provide support for continuity of care and case management services **Specialists are required to provide the NPI of the member s PCP in field 17b on the claim form Any service may come under more detailed review for the following triggers: Under and over-utilization Adverse incident and quality of care review Chart audit failure Treatment inconsistent with clinical practice guidelines Fraud, waste and abuse monitoring Retrospective medical necessity review Florida Medicaid Web Portal Provider Handbooks Link: dbooks/tabid/53/default.aspx Florida Medicaid Web Portal Link: s/tabid/51/default.aspx 16 Updated 11/3/2015; Updated 2/18/2016;