MassHealth Acute Hospital Utilization Management Program. Massachusetts Hospital Association Members
|
|
|
- Penelope June Francis
- 5 years ago
- Views:
Transcription
1 MASSACHUSETTS HOSPITAL ASSOCIATION MassHealth Acute Hospital Utilization Management Program Presentation ti for Massachusetts Hospital Association Members October 27, 2009
2 Introduction University it of Massachusetts Medical School Eloise Porterfield, Director, Prior Authorization and Utilization Management age e Program Tina McCormick, Manager Acute & Chronic Hospital Program Permedion-HMS Tom Schultz, Vice President and General Manager Keith Reinold, Regional Vice President Robert Bargar, MD, Medical Director Maureen Riley, Director, UM Betty Whalen, Contract Manager Laura Ferreira, Provider Relations Manager 1
3 Agenda Introductions Contract Award Overview of Permedion-HMS Utilization Management Program: What s Different? ee Clinical Utilization Management Plan Open Discussion / Questions 2
4 Contract Award Utilization Management Program administered by the University of Massachusetts Medical School (Office of Clinical Affairs) on behalf of the Executive Office of Health and Human Services Contract awarded to Permedion-HMS to perform utilization management on services rendered by acute hospitals to MassHealth members Hospitals will experience minimal changes from the approach currently being used by Masspro Operations begin November 2,
5 About Permedion-HMS ed Founded 1974-Peer Review Systems Wholly owned subsidiary of HMS URAC accredited for both Utilization Management (UM) and Independent Review Organization (IRO) Designated by CMS as: QIO-like entity, Qualified Independent Contractor (QIC) Utilization Review in Ohio for 12 years UM for State Medicaid Agencies in CO,VA, NJ Multiple MassHealth contracts since ,100 employees with physician panel of employees in Charlestown, MA 4
6 Permedion-HMS Experience Management team 18 yrs utilization management experience (average) Medical Director has over 20 years experience Review nurses 13 years experience (average) in Massachusetts Acute Care Hospitals 9 years (average) utilization management experience Specialty experience of reviewers includes: ICU, CCU, ER, RR, Med-Surg, Ortho, Pediatrics, Neuro, ENT, Maternal Health, Workers Comp, Rehab, Homecare VNA and other 5
7 Contracted Services Preadmission Screening Prepayment Review Postpayment Review Review for Acute Rehabilitation Hospitals Concurrent Review, Conversion 6
8 Utilization Management age e Program- What s different? Review Program Provider Relations Manager Desktop Reviews for Prepayment and Postpayment Reviews Provider Relations Plan Regular Meetings and Onsite Visits with hospitals Annual MHA Meeting Newsletter, Website We welcome feedback! 7
9 Pre-admission Screening Transition: Permedion-HMS to Start on November 2, 2009 Masspro ends October 30, 2009 Web Portal, phone, fax and mail review Reviews scheduled by Date of Admission Nurses review and can approve if criteria is met Physician review cases that do not meet criteria or cases where nurses pend to Clinical Review Use Masspro fax form if you do not have an updated form Process for PAS Enter cases into the POSC to complete PAS and to confirm case status, access the Virtual Gateway Request will be reviewed and may be approved on-line by nurse or may be suspended for further review IF a case is started will Masspro they will complete it. PLEASE CHECK TO MAKE SURE IT IS COMPLETED Updated forms will be available to fill in, print and fax Results: Approve, Defer, Deny or Re-review 8
10 Preadmission Screening Notes Providers can start cases online and can call Permedion with specific information or assistance to finish the forms. If started you need to have the PAS number Duplicate requests (fax and online requests) are tracked based on duplicate PAS numbers, duplicate name and date fields When cases are assigned, all information is on the Worklist. No PAS #? It will not be kept in the system 9
11 Prepayment e Review e Transition: Permedion-HMS begins on 11/2/09 Weekly claims selection includes inpatient review (based on data analysis) beginning with 11/2/09 paid claims Medical Records are due within 17 calendar days from the date of the written request. NOTE: If the list of case managers is sent to Betty Whalen, we will enter it into the system for notification Courtesy call on day15 Perform desk review Criteria: InterQual Criteria, MassHealth Regulations on Medical Necessity, Acute Rehab Hospital Screening Criteria in RFA, Current ICD Coding Rules Review Results: Approve, Deny or Re-review 10
12 Postpayment Review Transition: Permedion-HMS begins with claims selection paid by MassHealth starting on 7/1/09 and actual postpayment review begins January 1/31/10 (Masspro will complete their reviews by 1/31/10) Includes: Inpatient, Outpatient and Acute Rehab Reviews Perform desk review Courtesy phone calls for medical record on day 15 Criteria: InterQual Criteria, MassHealth Regulations on Medical Necessity, Acute Rehab Hospital Screening Criteria in RFA, Current ICD Coding Rules Review Results: Approve, Deny or Re-review 11
13 Timeframe for Pre and PostPayment Review Calendar Day Activity 1 Request medical records from hospitals for the sample claims 17 Medical records are due to Permedion HMS. Follow up call after 15 days from date of medical record request 19 Absolute deadline for receipt ofmedical records orcase is deferred 75 All reviews are complete and the initial determinations are made 108 The last day the hospital has to submit documentation to dispute Initial Determinations of denial. All re reviews are complete and Final Determinations are sent to 123 the hospitals. 12
14 Hearings Other Activities t Permedion-HMS will participate in all Acute Hospital Utilization Management Hearings as scheduled by the Board of Hearings (including reviews completed by Masspro) Quality Assurance Maintain QA process, review manual, clinical QC panel 13
15 Permedion-HMS Contact Information Phone: (877) Fax: (877) address: Address: Permedion HMS Government Services 510 Rutherford Avenue, 3 rd Floor Charlestown, MA Provider Relations Laura Ferreira : (617)
16 Open Discussion and Questions s 15
PERMEDION, INC., AN HMS COMPANY. Questions & Answers. Massachusetts Hospital Association Presentation October 27, 2009
PERMEDION, INC., AN HMS COMPANY Massachusetts Hospital Association Presentation Preadmission Screening (PAS) 1. Please provide clarification of which Rehab Hospitals will require PAS from Permedion. Only
Presentation Overview
RETROSPECTIVE PREPAYMENT REVIEW & BILLING ERRORS Presentation Overview eqhealth s Role as QIO What is Retrospective Review? Selection and notification process HFS Retrospective Review Requirements Scope
POLICY AND PROCEDURE DEPARTMENT:
PAGE: 1 SCOPE: Coordinated Care (Plan) Department. PURPOSE: To evaluate members for admission to a Post-Acute Facility (Skilled Nursing, Inpatient Rehabilitation or Long Term Acute Care) including support
HOME HEALTH CARE TABLE OF CONTENTS. OVERVIEW TRANSITIONAL... CARE... SERVICES . MEMBERS... MANAGED... BY... EVICORE
TABLE OF CONTENTS. OVERVIEW............................................................................................. 452..... TRANSITIONAL................. CARE...... SERVICES......................................................................
KDHE-DHCF: Kansas Department of Health and Environment - Division of Health Care Finance. UM Retrospective Review Services.
KDHE-DHCF: Kansas Department of Health and Environment - Division of Health Care Finance UM Retrospective Review Services Provider Manual August 2017 This page intentionally blank Table of Contents KDHE-DHCF:
Section VII Provider Dispute/Appeal Procedures; Member Complaints, Grievances, and Fair Hearings
Section VII Provider Dispute/Appeal Procedures; Member Complaints, Grievances, and Fair Hearings Provider Dispute/Appeal Procedures; Member Complaints, Grievances and Fair Hearings 138 Provider Dispute/Appeal
Presentation Overview
MISSING VITALS: IMPORTANT INFORMATION FOR UTILIZATION REVIEW 2011/2012 Presentation Overview Utilization Review HFS Requirements Vital Information for Review Clinical information necessary Completeness
National Imaging Associates, Inc. (NIA) 1 Medical Specialty Solutions
National Imaging Associates, Inc. (NIA) 1 Medical Specialty Solutions Provider Training/Presented by: Name: Kevin Apgar 1 National Imaging Associates, Inc. (NIA) is a subsidiary of Magellan Healthcare,
Dean Health Plan Physical Medicine Overview
Dean Health Plan Physical Medicine Overview Provider Training / Presented by: Leta Genasci Above and throughout this document, NIA Magellan refers to National Imaging Associates, Inc. Dean Health Plan
Passport Advantage Provider Manual Section 5.0 Utilization Management
Passport Advantage Provider Manual Section 5.0 Utilization Management Table of Contents 5.1 Utilization Management 5.2 Review Criteria 5.3 Prior Authorization Requirements 5.4 Organization Determinations
UTILIZATION MANAGEMENT AND CARE COORDINATION Section 8
Overview The focus of WellCare s Utilization Management (UM) Program is to provide members access to quality care and to monitor the appropriate utilization of services. WellCare s UM Program has five
SECTION 9 Referrals and Authorizations
SECTION 9 Referrals and Authorizations General Information The PAMF Utilization Management (UM) Program is carried out by the Managed Care department. The UM Program is designed to ensure that all Members
Appeals Policy. Approved by: Tina Lee Approval Date: 3/30/15. Approval Date: 4/6/15
Appeals Policy Department: Compliance Policy Number: C205 Attachments: Attachment A- Attachment B- Effective Date: 1/1/14 Revision Date: 5/19/14, 3/17/15, 3/30/15 Title of Policy: Reference(s): NCQA UM
Appeals and Grievances
Appeals and Grievances Community HealthFirst MA Special Needs Plan (HMO SNP) Community HealthFirst MA Plan (HMO) Community HealthFirst Medicare MA Pharmacy Plan (HMO) Community HealthFirst MA Extra Plan
Molina Healthcare MyCare Ohio Prior Authorizations
Molina Healthcare MyCare Ohio Prior Authorizations Agenda Eligibility Medicare Passive Enrollment Transition of Care Definition Submission Time Frame Standard vs. Urgent How to Submit a Prior Authorization
Section 4 - Referrals and Authorizations: UM Department
Section 4 - Referrals and Authorizations: UM Department Primary Care Referral Process 1 Referrals to In-Network Specialists 1 Referrals to Out-Of-Network Specialists 2 Consultation Referral Forms 2 Consultation
Utilization Review in Illinois (attorney presentation)
Utilization Review in Illinois (attorney presentation) Presented by: Mary Ellen Kozeluh,, UR Manager Jennifer Weber, UR Supervisor August, 2011 1 Overview Utilization Review - history State of Illinois
Magellan Healthcare 1 Medical Specialty Solutions
Magellan Healthcare 1 Medical Specialty Solutions Horizon NJ Health 1 National Imaging Associates, Inc. is a subsidiary of Magellan Healthcare, Inc. Magellan Healthcare Training 2 Magellan Healthcare Agenda
Chapter 4 Health Care Management Unit 4: Denials, Grievances and Appeals
Chapter 4 Health Care Management Unit 4: Denials, Grievances and Appeals In This Unit Topic See Page Unit 4: Denials, Grievances And Appeals Member Grievances/Appeals 2 Filing a Grievance/Appeal on the
NIA Magellan 1 Medical Specialty Solutions
NIA Magellan 1 Medical Specialty Solutions CeltiCare of Massachusetts Health Provider Training 1 - NIA Magellan refers to National Imaging Associates, Inc. NIA Magellan Training Program 2 NIA Magellan
Chapter 4 Health Care Management Unit 3: Requesting an Authorization
Chapter 4 Health Care Management Unit 3: Requesting an Authorization In This Unit Topic See Page Unit 3: Requesting An Authorization Overview 2 Requesting an Authorization 3 Treatment Plan Submissions
Blue Medicare Private-Fee-For-Service SM (PFFS) 2008 Medicare Advantage Terms and Conditions
Blue Medicare Private-Fee-For-Service SM (PFFS) 2008 Medicare Advantage Terms and Conditions Medicare Advantage Table of Contents Page Plan Highlights...2 Provider Participation The Deeming Process...2
UTILIZATION MANAGEMENT Section 4. Overview The Plan s Utilization Management (UM)
Overview The Plan s Utilization Management (UM) Program is designed to meet contractual requirements and comply with federal regulations while providing members access to high quality, cost effective medically
State of Montana. Department of Public Health and Human Services CHILDREN S MENTAL HEALTH BUREAU PROVIDER MANUAL AND CLINICAL GUIDELINES
State of Montana Department of Public Health and Human Services CHILDREN S MENTAL HEALTH BUREAU PROVIDER MANUAL AND CLINICAL GUIDELINES FOR UTILIZATION MANAGEMENT January 31, 2013 Children s Mental Health
Hospital Appeals. December 6, Adrienne Mims, MD MPH Medical Director, Medicare Quality Improvement
Hospital Appeals December 6, 2012 Adrienne Mims, MD MPH Medical Director, Medicare Quality Improvement Objectives Review process for appeals for termination of Medicare services in the hospital setting
THE INVISIBLE DENIAL: A Closer Look at Commercial Denials and Appeals Strategies
THE INVISIBLE DENIAL: A Closer Look at Commercial Denials and Appeals Strategies Marc Tucker, DO, FACOS, MBA Sr. Medical Director ACE AHA Solutions, Inc., a subsidiary of the American Hospital Association,
Home Health Program Integrity Prior Authorization Process for Home Health Services
Home Health Program Integrity Prior Authorization Process for Home Health Services March 16, 2016 Goal: Increase understanding of PA Process Regulations Documentation 2 Presenters Kerri Ikenberry, BSN,
ABOUT AHCA AND FLORIDA MEDICAID
Section I Introduction About AHCA and Florida Medicaid ABOUT AHCA AND FLORIDA MEDICAID THE FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION The Florida Agency for Health Care Administration (AHCA or Agency)
Joining Passport Health Plan. Welcome IMPACT Plus Providers
Joining Passport Health Plan Welcome IMPACT Plus Providers Agenda Passport Behavioral Health Services Overview Steps to Joining Passport Health Plan s Network Getting a Medicaid Number Enrolling in the
State of Montana. Department of Public Health and Human Services CHILDREN S MENTAL HEALTH BUREAU PROVIDER MANUAL AND CLINICAL GUIDELINES
State of Montana Department of Public Health and Human Services CHILDREN S MENTAL HEALTH BUREAU PROVIDER MANUAL AND CLINICAL GUIDELINES FOR UTILIZATION MANAGEMENT October 1, 2012 Children s Mental Health
Keystone First Provider Training
Keystone First Provider Training NIA Program Agenda Introduction to National Imaging Associates (NIA) Our Program 1. Authorization Process 2. Other Program Components 3. Provider Tools and Contact Information
IPA. IPA: Reviewed by: UM program. and makes utilization 2 N/A. Review) The IPA s UM. includes the. description. the program. 1.
IPA Delegation Oversight Annual Audit Tool 2011 IPA: Reviewed by: Review Date: NCQA UM 1: Utilization Management Structure The IPA clearly defines its structures and processes within its utilization management
Priceless Partners: Common Patients, Common Goals
Priceless Partners: Common Patients, Common Goals Erin Hodson, RN, BSN, ACM Senior Director Case Management Inova Fairfax Hospital Pamela Andrews, RN, MSW, MBA, CCM, ACM Director Medical Management INTotal
Subject to change. Summary only; does not supersede manuals and formal notices and publications. Consult and appropriate Partners
Subject to change. Summary only; does not supersede manuals and formal notices and publications. Consult www.partnersbhm.org and appropriate Partners for most recent information or with questions. Gain
Massachusetts Partnership for Correctional Healthcare. Provider Manual
Massachusetts Partnership for Correctional Healthcare Provider Manual Version 1.1 July 2013 Table of Contents MPCH Overview... 5 MPCH Guiding Principles... 5 MPCH Approach... 5 MPCH Summary... 6 Working
DIVISION OF MEDICAID Provider Workshop 2016 MSCAN & CHIP
DIVISION OF MEDICAID Provider Workshop 2016 MSCAN & CHIP Magnolia Health MississippiCAN Overview 2011 30,000 Members December 2012 77,000 Members December 2014 98,000 Members January 2015 115,000 Members
HMSA s Interventional Pain Management and Spine Surgery Program
HMSA s Interventional Pain Management and Spine Surgery Program Presented by: Laurie Kim, Director, Provider Relations and Account Management Hawai i Magellan Healthcare 1 Training Program 1 National Imaging
Medical Management Program
Medical Management Program Introduction Molina Healthcare maintains a medical management program to ensure patient safety as well as detect and prevent Fraud, Waste and Abuse in its programs. The Molina
State of Alaska Department of Health and Social Services. Community-Based Youth Residential Behavioral Health Services Review Provider Manual
State of Alaska Department of Health and Social Services Community-Based Youth Residential Behavioral Health Services Review Provider Manual February 2018 TABLE OF CONTENTS Section 1: Qualis Health Care
Appeals and Grievances
Appeals and Grievances Community HealthFirst MA Special Needs Plan (HMO SNP) As a Community HealthFirst Medicare Advantage Special Needs Plan enrollee, you have the right to voice a complaint if you have
Best Practice Recommendation for
Best Practice Recommendation for Standard Notification Timeframes for Pre-Authorization Requests Version 4.6 Admin Simplification: A program of the Washington Healthcare Forum operated by OneHealthPort
Participating Provider Manual
Participating Provider Manual Revised November 2012 TABLE OF CONTENTS 1. INTRODUCTION Page 5 Psychcare, LLC s Management Team Mission statement Company background Accreditations Provider network 2. MEMBER
Aetna/Coventry Pennsylvania and West Virginia Physical Medicine Overview for Providers
Aetna/Coventry Pennsylvania and West Virginia Physical Medicine Overview for Providers Aetna Physical Medicine Overview What: When: Who: Aetna will initiate a Utilization Management Prior Authorization
FALLON TOTAL CARE. Enrollee Information
Enrollee Information FALLON TOTAL CARE- Current Edition 12/2012 2 The following section provides an overview on FTC enrollee rights and responsibilities, appeals and grievances and resources available
HOW TO GET SPECIALTY CARE AND REFERRALS
THE BELOW SECTIONS OF YOUR MEMBER HANDBOOK HAVE BEEN REVISED TO READ AS FOLLOWS HOW TO GET SPECIALTY CARE AND REFERRALS If you need care that your PCP cannot give, he or she will refer you to a specialist
IHCP bulletin INDIANA HEALTH COVERAGE PROGRAMS BT AUGUST 30, 2016
IHCP bulletin INDIANA HEALTH COVERAGE PROGRAMS BT201648 AUGUST 30, 2016 2016 IHCP Annual Provider Seminar scheduled for October 18-20 in Indianapolis The Indiana Family and Social Administration (FSSA)
Managed Care Referrals and Authorizations (Central Region Products)
In this section Page Overview of Referrals and Authorizations 10.1 Referrals 10.1! Referrals: SelectBlue only 10.1! Definition of referrals 10.1! Services not requiring a referral 10.1! Who can issue a
General Who is National Imaging Associates, Inc. (NIA)?
National Imaging Associates, Inc. (NIA) Frequently Asked Questions (FAQ s) For Managed Health Services (MHS) Providers Post Service Therapy Review Program Question Answer General Who is National Imaging
TABLE OF CONTENTS. Therapy Services Provider Manual Table of Contents
Table of Contents TABLE OF CONTENTS Table of Contents...1 About AHCA...2 About eqhealth Solutions...2 Accessibility and Contact Information...5 Review Requirements and Submitting PA Requests...9 First
* NEW PROCESS FOR ADVISING MEDICARE ADVANTAGE MEMBERS OF THEIR RIGHTS AS INPATIENTS AND AT DISCHARGE *
* NEW PROCESS FOR ADVISING MEDICARE ADVANTAGE MEMBERS OF THEIR RIGHTS AS INPATIENTS AND AT DISCHARGE * JUNE 22, 2007 MSFB-HOSP-2007-004 TO: FROM: (1) CHIEF EXECUTIVE OFFICER (2) CHIEF FINANCIAL OFFICER
State of Alaska Department of Health and Social Services. Behavioral Health Inpatient Psychiatric Review Provider Manual
State of Alaska Department of Health and Social Services Behavioral Health Inpatient Psychiatric Review Provider Manual Revised October 2015 Alaska Medicaid Inpatient Psychiatric Review Provider ManualTable
Section 7. Medical Management Program
Section 7. Medical Management Program Introduction Molina Healthcare maintains a medical management program to ensure patient safety as well as detect and prevent fraud, waste and abuse in its programs.
Home Health & HP Provider Relations
Home Health & Hospice HP Provider Relations October 2010 Agenda Session Objectives Home Health Benefit Coverage Billing Overhead Multiple Visits Most Common Denials Hospice Benefit Coverage Election/Revocation/Discharge
LifeWise Reference Manual LifeWise Health Plan of Oregon
11 UB-04 Billing Description This chapter contains participation, claims and billing information for providers who bill on a UB-04 (CMS 1450) claim form. This chapter supplements information contained
National Imaging Associates, Inc. (NIA) Frequently Asked Questions (FAQ s) For NH Healthy Families Providers Post Service Therapy Review Program
National Imaging Associates, Inc. (NIA) Frequently Asked Questions (FAQ s) For NH Healthy Families Providers Post Service Therapy Review Program Question Answer GENERAL Who is National Imaging Associates,
10.0 Medicare Advantage Programs
10.0 Medicare Advantage Programs This section is intended for providers who participate in Medicare Advantage programs, including Medicare Blue PPO. In addition to every other provision of the Participating
PA/MND Review of Spine Surgery services Questions & Answers
PA/MND Review of Spine Surgery services Questions & Answers 1. What is the Musculoskeletal Program? Horizon BCBSNJ has expanded our Pain Management Program with evicore to include Pain Management and Spine
HOW TO GET SPECIALTY CARE AND REFERRALS
THE BELOW SECTIONS OF YOUR MEMBER HANDBOOK HAVE BEEN REVISED TO READ AS FOLLOWS HOW TO GET SPECIALTY CARE AND REFERRALS If you need care that your PCP cannot give, he or she will REFER you to a specialist
MassHealth Provider Billing and Services Updates & Upcoming Initiatives. Massachusetts Health Care Training Forum July 2011
MassHealth Provider Billing and Services Updates & Upcoming Initiatives Massachusetts Health Care Training Forum July 2011 Agenda I. MassHealth Updates/Resources & Upcoming MassHealth Initiatives II. Paper
OUTLINE OF MEDICARE SUPPLEMENT COVERAGE
A Medicare Supplement Program Basic, including 100% Part B coinsurance A B C D F F * G Basic, including Basic, including Basic, including Basic, including Basic, including 100% Part B 100% Part B 100%
ColoradoPAR Program Durable Medical Equipment. August 2015
ColoradoPAR Program Durable Medical Equipment August 2015 Agenda Introduction to eqhealth Solutions Scope of Services Overview of the PAR process eqsuite Contacts and resources at eqhealth Solutions Key
A complaint is an expression of dissatisfaction with some aspect of the Public Mental Health System (PMHS).
CHAPTER 9 GRIEVANCES AND APPEALS The grievance procedure is set forth in Maryland Law (COMAR 10.09.70.08). This chapter of the provider manual describes the process for complying with COMAR regulations.
CareFirst ICD-10 Claim Submission Guidelines
CareFirst ICD-10 Claim Submission Guidelines Introduction The U.S. Department of Health and Human (HHS) has released a HIPAA administration simplification mandate requiring all HIPAA entities to adopt
NCQA Corrections, Clarifications and Policy Changes to the 2018 HP Standards and Guidelines
This document includes the corrections, clarifications and policy changes to the 2018 HP standards and guidelines. NCQA has identified the appropriate page number in the printed publication and the standard
INPATIENT Provider Utilization Review and Quality Assurance Manual. Short Term Acute Care
INPATIENT Provider Utilization Review and Quality Assurance Manual Short Term Acute Care Revised December 15, 2014 Table of Contents Section A: Overview... 2 General Information... 3 1. About eqhealth
Accountable Care in Infusion Nursing. Hudson Health Plan. Mission Statement. for all people. INS National Academy of Infusion Therapy
Accountable Care in Infusion Nursing INS National Academy of Infusion Therapy November 14 16, 2014 Atlanta, GA Margaret (Peggy) Leonard, MS, RN-BC, FNP Senior Vice President Clinical Services Hudson Health
IV. Additional UM Requirements/Activities...29
I. HMO Responsibilities...2 A. HMO Program Structure... 2 B. Physician Involvement... 3 C. HMO UM Staff... 3 D. Program Scope... 3 E. Program Goals... 4 F. Clinical Criteria for UM Decisions... 4 G. Requirements
Medical Management. G.2 At a Glance. G.2 Procedures Requiring Prior Authorization. G.3 How to Contact or Notify Medical Management
G.2 At a Glance G.2 Procedures Requiring Prior Authorization G.3 How to Contact or Notify G.4 When to Notify G.7 Case Management Services G.10 Special Needs Services G.12 Health Management Programs G.14
Medical Management. G.2 At a Glance. G.3 Procedures Requiring Prior Authorization. G.5 How to Contact or Notify Medical Management
G.2 At a Glance G.3 Procedures Requiring Prior Authorization G.5 How to Contact or Notify Medical Management G.6 When to Notify Medical Management G.11 Case Management Services G.14 Special Needs Services
CHAPTER 6: CREDENTIALING PROCEDURES
We want to help you become or continue as a participating in-network provider for our members. Please refer to this chapter for information about: Provider credentialing Provider recredentialing Provider
Residential Rehabilitation Services (RRS) Part 1
Residential Rehabilitation Services (RRS) Part 1 Registration and Billing Process for MBHP January 2018 1 Objectives Overview of Billing Codes and Modifier requirement used by MBHP Verifying Member Eligibility
Molina Healthcare Michigan Health Care Services Department Phone: (855) Fax: (800)
Utilization Management Program Molina Healthcare of Michigan s Utilization Management (UM) program utilizes a care management approach based upon empirically validated best practices, where experience
SNF Determinations of Non-Coverage Denial Letters, ABNs & Expedited Determinations
SNF Determinations of Non-Coverage Denial Letters, ABNs & Expedited Determinations for clients of: www.teamtsi.com 800.765.8998 Content developed and presented by: 3030 N. Rocky Point Drive, Suite 240
NP or PA as Billing Provider
NP or PA as Billing Provider Claire Agnew, CPA MBA CHC Vice President of Financial Operations Phoenix Children s Medical Group Phoenix Children s Hospital Arizona s only children s hospital recognized
2017 Quality Improvement Work Plan Summary
Project Member Service and Satisfaction Commercial Products: Commercial Project Description: To improve member service and satisfaction and increase member understanding of how the member s plan works.
eqsuite User Guide for Electronic Review Request Acute Inpatient Medical/Surgical DRG Reimbursed
eqsuite User Guide for Electronic Review Request Acute Inpatient Medical/Surgical DRG Reimbursed CONTENTS OVERVIEW OF SYSTEM FEATURES... 3 ACCESSING THE SYSTEM... 4 USER LOG IN - GETTING STARTED... 5 SUBMITTING
Louisiana Medicaid Hospital Precertification for Acute Care. On Line Webinar November 12 13, 2009
Louisiana Medicaid Hospital Precertification for Acute Care On Line Webinar November 12 13, 2009 2 OVERVIEW OF TRAINING SESSION Summary of Changes Acute Care Admissions and Extensions Adult or Pediatric
Referrals, Prior Authorizations, Medical Management, and Appeals
Referrals, Prior Authorizations, Medical Management, and Appeals 1 An Independent Licensee of the Blue Cross Blue Shield Association 044506 (12-21-2017) 2017 Premera. Proprietary and Confidential. Referrals
Outpatient Behavioral Health Basics 1
7/5/2018 1 Outpatient Behavioral Health Basics July 2018 Webinar 1 Description: This class will review the SoonerCare Outpatient Behavioral Health Program. It will include an overview of commonly asked
NIA Magellan 1 Medical Specialty Solutions
NIA Magellan 1 Medical Specialty Solutions Provider Training 1 NIA Magellan refers to National Imaging Associates, Inc. NIA Magellan Training Program 2 NIA Magellan Program Agenda Introduction to NIA Magellan
Health Utilization Management Standards
Health Utilization Management Standards Version 5.0 URAC, an independent, nonprofit organization, is well-known as a leader in promoting health care quality through its accreditation and certification
ABOUT FLORIDA MEDICAID
Section I Introduction About eqhealth Solutions ABOUT FLORIDA MEDICAID THE FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION The Florida Agency for Health Care Administration (AHCA or Agency) is the single
Outpatient Behavioral Health Basics 1
6/6/2018 1 Outpatient Behavioral Health Basics 2018 Spring Workshop 1 Description: This class will review the SoonerCare Outpatient Behavioral Health Program. It will include an overview of commonly asked
8/6/2013. More than a Century of Legal Experience. Agenda
Swing Bed Services: 3 Day Qualifying Stays, Medically Necessary Admissions, and Observation Services Oh My!!! August 13, 2013 Presented by: Jennifer McManis More than a Century of Legal Experience This
Credentialing Standards
Credentialing Standards Presenters: Mei Ling Christopher Veronica Harris Royal Agenda Definitions vs. 2017 Regulatory Updates Understanding the Standards SB 137 Provider Directories Reminders Questions
Partnering with Managed Care Entities A Path to Coordination and Collaboration
Partnering with Managed Care Entities A Path to Coordination and Collaboration Presented by: Caroline Carney Doebbeling, MD, MSc Chief Medical Officer, MDwise May 9, 2013 Agenda Are new care models on
General Who is National Imaging Associates, Inc. (NIA)?
National Imaging Associates, Inc. (NIA) Frequently Asked Questions (FAQ s) For the Post Service Therapy Review Program For Home State Health Plan Providers Question Answer General Who is National Imaging
Utilization Management (UM) Quality Management (QM) Review Manual Nebraska Medicaid South 13 th Street, Suite 100 Lincoln, NE 68508
Utilization Management (UM) Quality Management (QM) Review Manual Nebraska Medicaid 1 206 South 13 th Street, Suite 100 Lincoln, NE 68508 Utilization and Quality Review Manual Nebraska Medicaid March 2014
Health Alliance. Utilization Management Changes Overview. Maxine Wallner Director Provider Services. February 2017
Health Alliance Utilization Management Changes Overview February 2017 Maxine Wallner Director Provider Services Agenda Decision Overview Utilization Management Program Changes Expansions and modifications
Utilization Review Determination Time Frames
Utilization Review Time Frames The purpose of this chart is to reference utilization review (UR) determination time frames. It is not meant to completely outline the UR determination process. Refer to
Florida Comprehensive Medicaid Utilization Management Program. Inpatient Services Presentation April 2011
Florida Comprehensive Medicaid Utilization Management Program Inpatient Services Presentation April 2011 eqhealth Key Personnel Chief Executive Officer Gary Curtis, MSW Chief Medical Officer Ron Ritchey
PROVIDER APPEALS PROCEDURE
PROVIDER APPEALS PROCEDURE 1. The Provider or his/her designee may request an appeal in writing within 365 days of the date of service 2. Detailed information and supporting written documentation should
Regulatory Compliance Risks. September 2009
Rehabilitation Regulatory Compliance Risks September 2009 1 Agenda - Rehabilitation Compliance Risks Understand the basic requirements for Inpatient Rehabilitation Facilities (IRFs) and Outpatient Rehabilitation
The California Medical Treatment Utilization Schedule: SB 1160, New Treatment Guidelines, and Formulary
1 The California Medical Treatment Utilization Schedule: SB 1160, New Treatment Guidelines, and Formulary CC VI Ray Meister, MD, MPH Executive Medical Director Division of Workers Compensation Ellen Sims
Centurion of Vermont, LLC Provider Manual
Centurion of Vermont, LLC Provider Manual Version 1.1 November 2015 Table of Contents Centurion of VT Overview... 5 Centurion of VT Guiding Principles... 5 CENTURION OF VT Approach... 5 CENTURION OF VT
Recovery Audit Contractors: AHA Perspective. Elizabeth Baskett, Policy, AHA February 23, 2012
Recovery Audit Contractors: AHA Perspective Elizabeth Baskett, Policy, AHA February 23, 2012 Agenda Lay of the Land = Audit Overload RACs (Medicare & Medicaid) MACs ZPICs and OIG and DOJ, oh my! AHA and
Engaging Providers in Integrated Care Programs
Engaging Providers in Integrated Care Programs November 6, 2014 4:00 PM Eastern The Integrated Care Resource Center, an initiative of the Centers for Medicare & Medicaid Services Medicare-Medicaid Coordination
Illinois Treatment Authorization Requests
Illinois Treatment Authorization Requests Behavioral Health Services Providers IlliniCare Health has contracted with the following provider types: Hospitals offering acute psychiatric care and detoxification
MEDICAL ASSISTANCE BULLETIN
MEDICAL ASSISTANCE BULLETIN COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE ISSUE DATE EFFECTIVE DATE NUMBER September 8, 1995 September 8, 1995 1153-95-01 SUBJECT Accessing Outpatient Wraparound
Hospital Refresher Workshop. Presented by The Department of Social Services & HP Enterprise Services
Hospital Refresher Workshop Presented by The Department of Social Services & HP Enterprise Services 1 Training Topics Provider Bulletins Outpatient Claim Billing Changes Explanation of Benefit Codes Web