KanCare All MCO Training Physicians and Specialists Spring 2018

Transcription

1 KanCare All MCO Training Physicians and Specialists Spring 208

2 Welcome, Introductions, & Agenda ACCESS TO CARE REQUIREMENTS LOCK IN PROGRAM PROVIDER PANEL & DEMOGRAPHIC UPDATES RECREDENTIALING HEDIS MUE/NCCI 2

3 PCP and Specialists Primary Care Provider (PCP) a participating provider who has the responsibility for supervising, coordinating, and provide primary health care to their members, initiating referrals for specialist care, and maintain the continuity of member care. PCPs include, but are not limited to pediatricians, family practitioners, general practitioners, internists, geriatricians, obstetrician/gynecologist (OB/GYN) or nurse midwives (for women when they are pregnant), specialist (as determined by health risk appraisal and an Amerigroup network provider), Federally Qualified Health Centers (FQHC)/Rural Health Clinics (RHC) and Indian Health Providers. Specialty Care Providers A specialty care provider is a network physician responsible for providing specialized care for members, usually upon appropriate referral from member s PCP. High volume specialists are defined by the Quality Management Program and determined by exceeding a threshold of annual member encounters. These will include at least the following specialists: OB/GYN, cardiologists, psychiatrists (of both adult and child/adolescent psychiatry), allergists, neurology, hematology, urology, dermatologist, gastroenterologist, general surgery, ophthalmologist, orthopedic surgeons, oncologists, endocrinologists, otolaryngologists, neonatologists, nephrologists, neurosurgeons, and plastic and reconstructive surgeons. 3

4 Access Requirements - Primary Care Provider Emergency = Immediately Urgent Care = Within 48 Hours Routine or Preventive Care = Within 3 Weeks In-office wait time for scheduled appointments should not routinely exceed 45 minutes, including time in the waiting room and examining room. The provider must offer 24-hour-a-day, 7-day-a-week telephone access for members. A 24-hour telephone service may be used. The service may be answered by a designee such as an: On-call physician Physician extender Answering service or a pager system; however, this must be a confidential line for member information and/or questions. If an answering service or pager system is used, the call must be returned within 30 minutes. An answering machine is not acceptable. 4

5 Access Requirements Mental Health Providers Post-Stabilization = Within hour from referral for post-stabilization services (both inpatient and outpatient) in an emergency room. Emergent = Within 3 hours for outpatient MH services, and; within hour from referral for an emergent concurrent utilization review screen. Urgent = 48 hours from referral for outpatient MH services, and; within 24 hours from referral for an urgent concurrent utilization review screen. Planned Inpatient Psychiatric = Referral within 48 hours; assessment and/or treatment within 5 working days from referral. Routine Outpatient = Referral within 5 days; assessment and/or treatment within 9 working days from referral and/or 0 working days from previous treatment. 5

6 Access Requirements Substance Use Disorder Providers Emergent Treatment = Members are asked to go directly to an emergency room for services if individual is either unsafe or their condition is deteriorating. Urgent = A service need that is not emergent and can be met by providing an assessment within 24 hours of the initial contact, and services delivered within 48 hours from initial contact without resultant deterioration in the individuals functioning or worsening of his or her condition. If the member is pregnant, she is to be placed in the urgent category. Routine = A service need that is not urgent and can be met by receiving an assessment within 4 calendar days of the initial contact, and treatment within 4 calendar day of the assessment, without resultant deterioration in the individual s functioning or worsening of his or her condition. IV Drug Users = If a member has used IV drugs within the last six months, and he or she does not fall into the emergent or urgent categories because of clinical need, the member will need to be placed in this category. Members who have utilized IV drugs within the last six months need to be seen for treatment within 4 calendar days of initial contact. There is not a time standard requirement for the assessment, nor is there an IV drug user category in the KCPC. These members are categorized as routine but are to receive treatment within 4 days of their initial contact, not within days of the their assessment. 6

7 Access Requirements Other Specialists All Other Specialty Care: Emergency = Immediately Urgent Care = Within 48 Hours Routine or Preventive Care = Within 3 Weeks Routine Lab, Radiology, & Optometry = Within 3 Weeks 7

8 Lock-In Program The lock-in physician is the primary prescribing physician. Narcotics and controlled substances should only be prescribed by the lock-in physician or approved by his or her specific referral. Lock-In providers will be notified via written communication of those members who have been assigned to them. Lock-in providers are never required to provide services or medications not supported by medical necessity. The member is expected to actively share in the lock-in responsibility by only receiving health care, prescription medications and hospital outpatient services from the assigned lock-in providers. If the locked-in member fails to follow medical advice, the lock-in providers are not required to provide requested referrals or treatment. 8 If the assigned provider is dissatisfied with the member assignment and would like to be removed, the provider, pharmacy or hospital for nonemergent services may contact the MCO.

9 Panel and Demographic Updates Data integrity is a critical component in effectively managing our provider network and supporting our KanCare members. To assist in this process, the MCOs ask that providers continue to update us as changes are made in your practice. Some of these updates may include: Change in address Change in phone number Provider leaving the practice Changes to your panel capacity Panel closures Please follow up with the individual MCO s on tools available to submit the above changes, as well as tools available to manage provider panels (i.e. online reporting). 9

10 Recredentialing Recredentialing is required every three years by the National Committee for Quality Assurance (NCQA). Rights of Providers During Credentialing/Recredentialing Processes: Request a status of your application via phone, fax, or mail. Review information submitted to support your credentialing application. Explain information obtained that may vary substantially from what you provided. Provide corrections to any erroneous information submitted by another party. MCO s will use Credentialing Committee(s) and/or Medical Director review during the credentialing/recredentialing process. Decisions will be communicated in writing and denials may be appealed. Please refer to the individual MCO Provider Manuals for details. 0

11 HEDIS Healthcare > Effectiveness > Data > Information > Set HEDIS is a performance measurement tool that is coordinated and administered by NCQA (National Committee for Quality Assurance) and used by Centers for Medicare & Medicaid Services (CMS) for monitoring the performance of managed care organizations. All managed care companies who are NCQA accredited perform HEDIS reviews the same time each year. HEDIS is a retrospective review of services and performance of care. Results are used to measure performance, identify quality initiatives and provide educational programs for providers and members.

12 What is your role in HEDIS? We appreciate your cooperation and timeliness in submitting the requested medical record information. You play a central role in promoting the health of our members. You and your office staff can help facilitate the HEDIS process improvement by: Providing the appropriate care within the designated time frames Documenting all care in the patient s medical record Reviewing Gaps in Care reports Accurately coding all claims Responding to our requests for medical records within 0 business days The records you provide us during this process help us to validate the quality of care provided to our members. Note: Using CPT Category II Codes can help reduce the number of medical records. Adding these codes to a claim will help us identify additional information about the visit and improve the accuracy of reporting quality measures. 2

13 Medicaid HEDIS measures: ABA Adult body mass index assessment AWC Adolescent well-care visits CBP Controlling high blood pressure CCS Cervical cancer screening CDC Comprehensive diabetes care CIS Childhood immunization status FPC Frequency of ongoing prenatal care HPV Human papillomavirus vaccine for female adolescents IMA Immunizations for adolescents LSC Lead screening in children PPC Prenatal and postpartum care WCC Weight assessment/counseling for nutrition and physical activity for children/adolescents W5 Well-child visits in the first 5 months of life W34 Well-child visits in the 3rd, 4th, 5th and 6th years of life 3

14 MUE / NCCI What is the CMS National Correct Coding Initiative (NCCI)? The National Correct Coding Initiative (NCCI) was implemented to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. An MUE is a maximum number of Units of Service allowable under most circumstances for a single Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) code billed by a provider on a date of service for a single beneficiary. 4

15 Accessing Edits To access the CMS NCCI/MUE Edit: html 5

16 Column Descriptions for NCCI Edits Column Column 2 Column 3 Column 4 Column 5 Column 6 Indicates the payable code Contains the code that is not payable with this particular Column code, unless a modifier is permitted and submitted Indicates the effective date of the edit Indicates the deletion date of the edit Indicates if use of a modifier is permitted. This number is the modifier indicator for the edit 0, 9 or Provides the underlying basis for each edit 6

17 COLUMN / COLUMN 2 SAMPLE VIEW Column Column 2 Effective Date Deletion Date Modifier Indicator PTP Edit Rationale Standard Preparation / Monitoring Services for Anesthesia Standard Preparation / Monitoring Services for Anesthesia Misuse of column two code with column one code Misuse of column two code with column one code Standard Preparation / Monitoring Services for Anesthesia 7

18 MODIFIERS Modifiers may be appended to HCPCS/CPT codes only if the clinical circumstances justify the use of the modifier. A modifier should not be appended to a HCPCS/CPT code solely to bypass a code pair edit if the clinical circumstances do not justify its use. Indicator 0 = NOT ALLOWED: There are no modifiers associated with NCCI allowed to be used with this PTP pair Indicator = ALLOWED The modifiers associated with NCCI are allowed with this PTP code pair when appropriate. Indicator 9 = NOT APPLICABLE An NCCI edit does not apply to this PTP code pair. The edit for this PTP Code pair was deleted retroactively. 8

19 MUE, Medically Unlikely Edit An MUE (Medically Unlikely Edit) for a HCPCS/CPT code is the maximum Units of Service that a provider would report under most circumstances for a single member on a single date. Not all HCPCS/CPT codes are subject to MUE edits. Most MUEs are visible to providers on the website. However, some MUEs are considered confidential by CMS and are not released. Claims processing contractors may have edits that are more restrictive than MUEs. MCOs are required to use the KDHE limits, but because the MCOs are required to also follow the NCCI/MUE rules, if KDHE s limits are less restrictive, we go by NCCI/MUE unless the State has made an exception. 9

20 2 0 MUE TABLE

21 Additional Resources Kansas Medical Assistance Program: CMS Tables: index.html MLN (Medicare Learning Network): Learning-Network-MLN/MLNProducts/Downloads/How-To-Use- NCCI-Tools.pdf 2

22 Kansas Medicaid Opioid Products Indicated for Pain Management PA Effective (tentatively 06/0/208) Criteria will apply to all patients covered under Kansas Medicaid. Information on the Kansas Medicaid Opioid Products Indicated for Pain Management PA is available on the following links: PA Criteria PA Form clinical_pa_forms.htm 22 22

23 Kansas Medicaid Opioid Products Indicated for Pain Management PA Short-Term/Acute Pain Opioid User (patients who have received opioid prescription(s) for < 90 days in a look back period of 4 months): Limit of 7 day supply of short acting opioid (e.g. immediate release formulation). Up to 4 day supply is allowed within a 60 day look back period. Must be no more than 7 day supply per prescription. Daily limit of 90 MME (morphine milligram equivalent). 23 PA required for All long-acting opioid prescriptions (e.g. extended release formulations). Any short-acting opioid prescriptions exceeding the shortterm/acute pain 23 use day supply or 90 MME limits.

24 Kansas Medicaid Opioid Products Indicated for Pain Management PA Chronic Opioid User (patients who have received opioid prescription(s) for 90 day in a look back period of 4 months): Prior Authorization required (for any duration) Patients with cancer, sickle cell, or hospice/palliative care diagnosis in paid medical claims will be EXEMPT from the 7 day supply and MME limits and long-acting PA edit. Buprenorphine products for opioid dependence (e.g. Suboxone) are NOT affected by this policy

25 Thank You! Any Questions? 25 25