MEDICAID PRIOR AUTHORIZATION TRANSITION

Transcription

1 MEDICAID PRIOR AUTHORIZATION TRANSITION Prepared for: Mississippi Medicaid Providers of - Psychological, Neuropsychological and Developmental Testing 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 and what changes? DOM regulations is the same: No change in coverage for Therapeutic and Evaluative Services including Psychological, Neuropsychological and Developmental Testing The Prior Authorization Process changes Where you send the authorization request Only use Envision to check eligibility and claims Who reviews the request 4

5 When does the new process begin? Effective December 1, 2013 eqhealth will perform prior authorization reviews of Therapeutic and Evaluative Services to include Psychological, Neuropsychological and Developmental Testing 5

6 eqhealth has a 16 year Utilization Management partnership with DOM Our multidisciplinary review team includes: Mississippi licensed registered nurses, certified social workers, psychologists, psychiatrists, and physicians The review team is overseen by our Medical Director, Dr. Thomas Joiner 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 DENTAL PROVIDER EDUCATION PRESENTATION 7

8 What do we need to know? DOM Regulations eqhealth Systems & Review Process 8

9 Getting to Know Mississippi Division of Medicaid (DOM) Therapeutic and Evaluative Services Coverage For comprehensive information about Therapeutic and Evaluative services covered, limitations and exclusions; the following are important resources to be familiar with: Medicaid Regulations Mississippi Medicaid Provider Reference Guide (PRG 206) Medicaid Physician Fee Schedule Medicaid Billing Guidelines for (formerly billing guidelines for community-based mental health services) 9

10 Will all therapeutic and evaluative service codes require prior authorization (PA) on December 1, 2013? Good question, let s take a closer look 10

11 Therapeutic and Evaluative Codes Requiring PA Therapeutic and Evaluative services are for beneficiaries under age 21 Beneficiaries under age 3 always require prior authorization of behavioral health services The following tables provide information about available services, procedure codes, and maximum units by age All Current Procedural Terminology (CPT) Codes and Descriptors are copyrighted 2013 by the American Medical Association 11

12 Service Description Therapeutic and Evaluative Codes: The following services and codes always require PA *Procedure Code Maximum Units Services for Age Biopsychosocial Assessment H per state fiscal year (combined with 24 unit max with family) Under age 21 Day Treatment H per day Under age 21 Psychological Evaluation per state fiscal year Under age 21 Developmental Evaluation per state fiscal year Under age 21 Developmental Evaluation per state fiscal year Under age 21 Neuropsychological Evaluation per state fiscal year Under age 21 *Reminder: Therapeutic and Evaluative services are ONLY for beneficiaries under age 21 12

13 Therapeutic and Evaluative Codes Requiring PA Therapeutic and Evaluative services are for beneficiaries under age 21 * Note: All codes below are covered when medically necessary for ages However, codes ONLY require PA when the benchmark will be exceeded Example: Psychotherapy - Codes 90832, 90834, and only require PA if a beneficiary age 3 thru 20 exceed the state plan benchmark of 36 units combined. Beneficiaries ages 0 thru 2 ALWAYS require PA for any and all behavioral health services. All Current Procedural Terminology (CPT) Codes and Descriptors are copyrighted 2013 by the American Medical Association 13

14 Therapeutic and Evaluative Codes Requiring PA 2012 Code (for services prior to 1/1/13) 2013 Code See *Note See **Note (for services after 1/1/13) Report with Code for Interactive Complexity (90785) Maximum Units per Day Maxi. Units per State Fiscal Year 90804: outpatient psychotherapy, min : psychotherapy, 30 minutes + When appropriate 1 service *36 or Maximum of 5 complex services within benefit of * : outpatient psychotherapy, min : psychotherapy, 45 minutes + When appropriate 1 service *36 or Maximum of 5 complex services within benefit of * : outpatient psychotherapy, min : psychotherapy, 60 minutes + When appropriate 1 service *36 or Maximum of 5 complex services within benefit of *36 14

15 Therapeutic and Evaluative Codes Requiring PA 2012 Code (for services prior to 1/1/13) 2013 Code See *Note (for services after 1/1/13) Report with Psychotherapy Add-on Code Report with Code for Interactive Complexity (90785) Max. Units per Day **Max. Units per state fiscal year *Note: Group therapy ONLY requires PA when beneficiary s age 3 thru 20 will exceed 45 sessions within the state fiscal year (SFY). **Note: Beneficiaries age 0-2 ALWAYS require PA for All services : interactive group psychothera py *90853: group psychotherapy (other than multiple-family group) n/a + When appropriate 2 services **45 or maximum of 5 complex services combined, within the scope of the state plan benchmark of 45 15

16 Therapeutic and Evaluative Codes Requiring PA Codes NOT impacted by 2013 CPT coding updates. *PA is required when 90846, 90847, and/or H0031 in combination will exceed the benchmark of 24 units per state fiscal year (SFY) for beneficiaries ages **Beneficiaries ages 0-2 ALWAYS require PA for all behavioral health services. Maximum Units per Day n/a Maximum Units per state fiscal year n/a 90846: Family psychotherapy (without the patient present) 1 Service * : Family psychotherapy (with patient present) 1 Service *24 H0031: Biopsychosocial Assessment 1 service (maximum of 4 per SFY) *24 16

17 Therapeutic and Evaluative Codes Requiring PA A KEY TO REMEMBER ALL BEHAVIORAL HEALTH FEE FOR SERVICE BENEFICIARIES UNDER AGE 3 ALWAYS REQUIRE PRIOR AUTHORIZATION 17

18 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 access 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 18

19 Before You Get Started: Checkpoint #1 The following beneficiaries do require prior authorization by eqhealth: Fee-for-service, including those who have third party coverage Dually eligible (eligible for Private insurance and Medicaid) The following lists beneficiaries who do not require prior authorization by eqhealth: Beneficiaries over age 21 Beneficiaries enrolled in Mississippi Coordinated Access Network (MSCAN) and CHIP Beneficiaries in COE 29, Family Planning Waiver Beneficiaries with no Medicaid coverage for the date of service Dual Medicare and 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 19

20 Before You Get Started: Checkpoint #2 Select your eqsuite Web Administrator 20

21 Selecting Your Key Players Who is the best person to be the eqsutie Web Administrator? When is this information due to eqhealth? What type of skills should this person have? 21

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23 Get Your Provider Contact Form Visit our Web site at ms.eqhs.org 23

24 To assist with helpful reminders please welcome your Prior Authorization buddy. Pete the PA Parrot 24

25 Before You Get Started: Checkpoint #3 Effective December 1, 2013, discontinue using all DOM Therapeutic and Evaluative prior authorization forms DOM forms will be replaced by eqhealth s automated Web based review submission process 25

26 Before You Get Started: Checkpoint #3 Review Questions - When a beneficiary requires psychological, neuropsychological, or developmental testing, the following information must be obtained in order to submit your request to eqhealth The table below details the questions you will need to have answer for prior to submitting codes 96101, 96110, 96111, or in our Web based review system. Note: A printable version of this form can be found at and used as a reference tool. Review for behavioral health service codes such as Day Treatment (H2012) and Biopsychosocial Assessment (H0031) are covered in a separate eqhealth presentation Prior Authorization training for other behavioral health service codes should contact eqhealth at

27 Before You Get Started: Checkpoint #3 Is the testing required as part of the process for determining treatment planning or placement? If yes, please check all that apply. PRTF/MYPAC ICF-MR Nursing care DCLH eligibility DHS Other, please specify 27

28 Before You Get Started: Checkpoint #3 Is testing for the beneficiary court ordered? Yes No If the beneficiary is in detention/incarcerated, what is the anticipated date of release MM/DD/YYYY 28

29 Before You Get Started: Checkpoint #3 Why is testing being requested at this time? Select all that apply. Suspected Autism spectrum Suspected Attention deficit IQ needed for placement in a PRTF/MYPAC/ICF-MR Closed head injury in past six (6) months Car accident Bike and/or sporting accident Poisoning IEP or educational planning Separation/divorce/custody Court order Suspected thyroid dysfunction Recent death (with the past year) Recent change in medications (within the past three (3) months) Change in sleep pattern Substance abuse Other, please specify 29

30 Before You Get Started: Checkpoint #3 If known, enter the date of the beneficiary's last physical exam. MM/DD/YYYY Has the beneficiary been evaluated by a psychiatrist? If yes, enter the date of the evaluation. Y or N MM/DD/YYYY Describe how the proposed testing will enhance treatment and impact future coordination of treatment needs for the beneficiary. Textbox List all medications the beneficiary is taking, along with the dosage and frequency. Textbox 30

31 Before You Get Started: Checkpoint #3 What are the referral questions related to this request? Textbox Has the beneficiary received any prior psychological/neuropsychological or developmental testing in the past three (3) years prior to this request? If yes, please list the test(s) administered, referral questions, and findings. Y or N Textbox Has the beneficiary had multiple treatment failures in the past two (2) years prior to this request? If yes, provide the type of treatment and dates Y or N Textbox 31

32 Before You Get Started: Checkpoint #3 When should I send my request to eqhealth? New Request/Admission Submit the PA request a minimum of three (3) business days prior to the planned service date 32

33 Before You Get Started: Checkpoint #3 When should I send my request to eqhealth? Recertification Request All service recertification requests are submitted for PA at least seven (7) business days prior to expiration of current authorization number (TAN) Excludes all testing services 33

34 Before You Get Started: Checkpoint #3 When should I send my request to eqhealth? Retrospective: Applies to beneficiaries who are determined retroactively eligible, and have been discharged from care 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 34

35 A Quick Checklist Review Before You Get Started: Know the codes requiring PA and DOM regulation Check beneficiary eligibility in Envision Collect answers to review questions and factor in timeframes for submitting and processing of PA requests Congratulations now you are ready to send the information to eqhealth 35

36 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 36

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38 The following screens only apply to requests for Psychological, Neuropsychological and Developmental Testing Providers requiring training for submission of PA requests for other behavioral health services should contact eqhealth Solutions at

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45 Therapeutic and Evaluative Services 45

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51 Beginning 12/1/13: What will eqhealth do with your request? 51

52 eqhealth Solutions First Level Reviewers (certified social workers, psychologists and psychiatric RN s) Apply DOM regulation Apply DOM approved medical necessity guidelines May request additional information Pending a review Approve services based on DOM regulation and guidelines Refer requests that cannot be approved to a second level reviewer (psychiatrists) 52

53 Second Level Reviewers - (psychiatrists) May contact the requesting, ordering and/or the referring therapist, psychologist, or physician to obtain additional information Pending a review Approve services Partially Approve services Deny services 53

54 National Guidelines for Therapeutic and Evaluative Services 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 54

55 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 55

56 How Do I Know I ve Been Pended? eqsuite will provide information on cases that have been pended eqsuite is accessible 24 hours a day, 7 days a week, check for pend messages here 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 provider by phone to inform them of the information needed before the review can be processed If you are not available we will leave a message to check eqsuite 56

57 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 57

58 Should I Like Being Pended? How do I prevent being pended? 58

59 Is getting Pended good? The up side about a pended review is that it opens a line of communication allowing provider to submit additional information specifically requested by eqhealth The down side, the review process stops until you respond Applying a few easy tips can keep your review moving along 59

60 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 with an equniversity Team Member at for assistance 60

61 How Many Business Days Does eqhealth Have To Process Your Review? eqhealth completes requests for services as quickly as possible, but within specific timeframes. The timeframe depends on when the service is anticipated to occur (admission review) or has already been provided. The review completion timeframe is measured from the date eqhealth receives your request New Request/Admission review - Testing requests - 2 business day from receipt All other requests - 3 business days from receipt Recertification: All requests 7 business days from receipt Retrospective review requests: 20 business days 61

62 Denials 62

63 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 63

64 Reconsiderations 64

65 Reconsiderations - Another Look Must be requested within 30 calendar days of the denial notification Beneficiary or provider may request a reconsideration 65

66 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

67 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 67

68 Appeals 68

69 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 69

70 A Helpful Transition Aide for December 1, 2013 Do not use existing DOM 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 - DOM regulations Check Eligibility prior to beneficiary 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 By12/1/13: Send your completed Provider Contact Form to eqhealth via at Education@eqhs.org 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

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

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77 Thank you for attending.. 77