Ohio Medicaid Utilization Review Program

Transcription

1 Ohio Medicaid Utilization Review Program Precertification Program Revised March 3, 2011 Prepared for: Ohio Department of Job and Family Services Prepared by: 350 Worthington Road, Suite H Westerville, Ohio

2 TABLE OF CONTENTS INTRODUCTION TO THE PRECERTIFICATION PROCESS... 1 WHAT S NEW?... 1 New precertification list effective 10/1/ WHO TO CALL?... 5 INFORMATION TO HAVE ON HAND WHEN YOU CALL:... 5 OHIO MEDICAID CONTACT REFERENCE GUIDE... 6 OVERVIEW OF PROCESS... 7 REQUESTS FOR RECONSIDERATION... 8 ODJFS ADMINISTRATIVE REVIEW... 9 DEFINITIONS (PER ODJFS) Elective Admission Elective Care Emergency Admission Hospital Medical Admission Medically Necessary Services Observation Services Outpatient Services Preadmission Testing Precertification Same Day Surgery Surgical Admission EXEMPT CATEGORIES FREQUENTLY ASKED QUESTIONS What is the difference between precertification and prior authorization? What information should I have available when I call for precertification? Who do I call when a precertification has been denied? What is the penalty for not calling for precertification before the procedure is performed? Is there an appeals process when a precertification is not called in time before the procedures? Who is responsible to obtain a precertification? What if the CPT code for the procedure I plan to perform is not listed in Section II? LIST OF PRECERTIFICATION PROCEDURES INPATIENT AND OUTPATIENT (HYSTERECTOMIES ARE THE ONLY OUTPATIENT PROCEDURE REQUIRING PRECERTIFICATION) Hysterectomy INPATIENT ONLY (ALL PROCEDURES FROM PAGE ARE ONLY NEEDING PRECERTIFICATION IF THEY ARE BEING SCHEDULED AS AN INPATIENT PROCEDURE) Cervical Laminectomy Esophagogastroduodenoscopy (EGD) Injection or infusion of cancer chemotherapeutic substance Laparoscopic Cholecystectomy Laparoscopy - Diagnostic Lumbar Laminectomy - Posterior Percutaneous Angioplasty - Noncoronary Vessel PTCA-Coronary Angioplasty DETAILED REVIEW PROCESS DETAILED REVIEW PROCESS, STEP-BY-STEP... 33

3 UTILIZATION REVIEW RECONSIDERATION PROVIDER ADMINISTRATIVE APPEAL RESOURCES/CONTACT INFORMATION Permedion Ohio Department of Job and Family Services (ODJFS) - Policy Related Questions URAC GUIDELINES ODJFS RULES : ELIGIBLE PROVIDERS : GENERAL PROVISIONS: HOSPITAL SERVICES : APPEALS AND RECONSIDERATION OF DEPARTMENTAL DETERMINATIONS REGARDING HOSPITAL INPATIENT AND OUTPATIENT SERVICES : PRE-CERTIFICATION REVIEW

4 INTRODUCTION TO THE PRECERTIFICATION PROCESS WHAT S NEW? The Ohio Medicaid is monitored to identify trends in utilization and show patterns and profiles for Ohio Medicaid consumers and providers. Permedion was acquired by HMS as a wholly owned subsidiary in October, 2007 and continues to work jointly with the Ohio Department of Job and Family Services (ODJFS) to evaluate the usefulness of the program. New precertification list effective 10/1/2006 Changes to the list of elective procedures requiring precertification were made October 1, Following are the procedures requiring precertification. Please note that only Hysterectomy procedures require precertification in both the inpatient and outpatient setting. A detailed description of the procedures will follow in Section II. Inpatient and Outpatient Hysterectomy Inpatient Only Cervical laminectomy Esophagogastroduodenoscopy (EGD) Injection or infusion of cancer chemotherapeutic substance Laparoscopic cholecystectomy Laparoscopy diagnostic Lumbar laminectomy posterior Percutaneous angioplasty non coronary vessel PTCA coronary angioplasty SECTION I VERSION 1.7, January 2010 INTRODUCTION TO THE PRECERTIFICATION PROCESS Page 1

5 Section II of this manual includes a comprehensive list of procedures, corresponding ICD-9 codes, and CPT codes. If a procedure is not on this list, it does not require precertification. Milliman Care Guidelines will be utilized to determine the medical necessity for the requested elective procedure. It will also provide valuable information as to the preferred setting for a procedure whether it is the inpatient or outpatient (observation) setting. The Milliman Care Guidelines are nationally accepted, copy protected guidelines that are founded on the use of evidence-based research methodology. The clinical criteria are updated on a regular basis with input from health care providers in active clinical practice. SECTION I VERSION 1.7, January 2010 INTRODUCTION TO THE PRECERTIFICATION PROCESS Page 2

6 Precertification Via the Web Precertification via the Web supplements the other existing options available for precertification which include telephone ( ) and fax ( ). As a provider contact person, in order to initiate precertification requests via the Web, you will first need to register and receive a password that will allow access to the secure area of Permedion s Web site. Once logged into the secure area, the person making the precertification request will be asked to provide information that is very similar to that provided on the current fax form. After the request is submitted, an will be sent to the person making the request confirming Permedion's receipt of the precertification request. Permedion will process Web-initiated precertification requests in the same manner as other requests and will issue a letter along with an assigned precertification number once the request has been approved. Also, Permedion's nurse reviewer staff will continue to call the provider with the assigned precert number. Providers can continue to expect a timely response to their precertification requests if they choose to use the Web application for precert. User Registration To become a registered user of precertification on the web: 1. Go to 2. Click on the link "Ohio Medicaid" in the left column. 3. Once on the Ohio Medicaid page, click on the "Precert Registration" button in the upper right portion of the page or CLICK HERE. 4. Enter and submit the information requested on the Precertification Registration Form. 5. Within one business day, Permedion will provide you with the login and password information you need to submit requests. If you do not receive this information within one business day, please contact us at SECTION I VERSION 1.7, January 2010 INTRODUCTION TO THE PRECERTIFICATION PROCESS Page 3

7 Precertification Request To request a precertification via the web: 1. Go to 2. Click on the "Login" link in the left column or CLICK HERE. 3. Enter the Username and Password provided to you as a registered user. 4. Click on the "Generate a Precertification Request" link. 5. Enter and submit the requested information. For more information, please contact the Ohio Medicaid Precertification Center at A detailed review process is located in Section IV. This section also includes a copy of the Precertification Fax Form, an explanation of URAC Accreditation, utilization review reconsideration process, provider administrative appeal process, and resources/contact information. Ohio Administrative Code (OAC) Rules that apply to precertification are located in Section V. Look for OAC rule 5101: that applies to precertification. The rules can also be found at the ODJFS web site: click on Ohio Health Plans Provider, and then click on Hospital Handbook. SECTION I VERSION 1.7, January 2010 INTRODUCTION TO THE PRECERTIFICATION PROCESS Page 4

8 WHO TO CALL? Requests for Ohio Medicaid precertifications are called or faxed to: Permedion Attn: Ralene McNeal 350 Worthington Road, Suite H Westerville, Ohio Phone or Fax or INFORMATION TO HAVE ON HAND WHEN YOU CALL: Medicaid consumer demographic information Physician demographic information Facility demographic information Clinical information and procedure codes Section IV of this manual details what is included in these categories. SECTION I VERSION 1.7, January 2010 INTRODUCTION TO THE PRECERTIFICATION PROCESS Page 5

9 OHIO MEDICAID CONTACT REFERENCE GUIDE Bureau of Community Access Phone (614) Ohio Medicaid Drug List for covered drugs that are available without prior authorization. Bureau of Consumer and Program Support (614) Pharmacy Point of Sale (POS) Program General Information: (877) Prior Authorization Help Desk: (877) Bureau of Health Plan Policy (614) Health Care Excel - Precertification for Psychiatric Admissions (800) (614) Bureau of Home and Community Services Ohio Home Care (614) Ombudsman/Technical Assistance Unit (614) Bureau of Long Term Care Facilities (614) Out of State Provider Assistance (800) Bureau of Managed Health Care (614) Bureau of Plan Operations ODJFS Online Provider Network Management (800) Medicaid Consumer Line (800) (Includes Ohio Children Health Insurance Program-CHIP) (800) (TDD) in and out-of-state Used for consumer complaints, billing, benefits, application, access to providers, coordination of benefits and to request information on state hearing process. Provider Enrollment (800) Prior Authorization (800) Surveillance and Utilization Review Section (614) Interactive Voice Response System (800) Third Party Health Insurance Questions (800) Medicaid Managed Care Plans (614) Ohio Department of Job and Family Services (614) Special Review on Non-Covered Services (800) Prenatal Wellchild/Help Me Grow In and out-of state (800) Care-Source SECTION I VERSION 1.7, January 2010 INTRODUCTION TO THE PRECERTIFICATION PROCESS Page 6

10 OVERVIEW OF PROCESS Requests for precertification of procedures will be monitored for both medical necessity and level of care for the requested services. Registered nurse reviewers will evaluate the clinical information, obtained by fax or phone, against established, nationally recognized Milliman Care Guidelines. Sources of information for all Care Guidelines include medical literature and textbooks, nationally recognized guidelines published in all fields of medicine, practice observation, and database analysis. These guidelines provide a range of best demonstrated practices and help to reduce unnecessary variation in health care practice. They encourage participation in the practice of evidence-based medicine. Each set of criteria requires medical information clinically specific to the procedure requested. Additional information regarding complicating signs and symptoms may be necessary. Clinical Comorbidities, pertinent laboratory and radiology reports, and consults can affect the level of care authorized. Setting may also be impacted by the type, route, and time of anesthesia. When the medical information provided does not meet the standards of this criteria, the information will be sent to an Ohio-based, specialty-related physician reviewer. A physician-to-physician review will be accomplished prior to any notification of denial. Providers will be notified of the determination within 24 hours of the receipt of the complete medical information. SECTION I VERSION 1.7, January 2010 INTRODUCTION TO THE PRECERTIFICATION PROCESS Page 7

11 REQUESTS FOR RECONSIDERATION If a procedure, or setting for a procedure, is denied, a request for reconsideration may be submitted in writing within 60 days of the date of the original determination. This request for reconsideration is sent to: Permedion Attn: Ralene McNeal 350 Worthington Road, Suite H Westerville, Ohio Fax or Requests must include: Copy of initial determination letter from Permedion Patient s medical record Additional supporting documentation Requests for reconsideration of any determination will be sent to a different specialty-related, peer-matched physician. Physician reviewers have up to 30 days to render a decision. Providers will be notified of a decision within one day of reconsideration determination. SECTION I VERSION 1.7, January 2010 INTRODUCTION TO THE PRECERTIFICATION PROCESS Page 8

12 ODJFS ADMINISTRATIVE REVIEW If the procedure or setting is still denied after reconsideration, the facility/physician has 30 days from the Permedion notification date of the reconsideration determination to appeal to ODJFS for an administrative review. Providers will be notified of the administrative review determination within 30 days of the date ODJFS receives the request for administrative review. Mail requests for administrative review to: OFMS - Bureau of Auditing and Consulting Services. P.O. Box Columbus, OH SECTION I VERSION 1.7, January 2010 INTRODUCTION TO THE PRECERTIFICATION PROCESS Page 9

13 DEFINITIONS (PER ODJFS) Elective Admission Any admission that does not meet the emergency admission definition. Elective Care Medical or surgical treatment that may be postponed for at least 48 hours without causing the patient unbearable pain, physical impairment, serious bodily injury or death. Emergency Admission Hospital An admission to treat a condition requiring medical and/or surgical treatment within the next 48 hours when, in the absence of such treatment, it can reasonably be expected that the patient may suffer unbearable pain, physical impairment, serious bodily injury or death. A provider eligible under Rule 5101: of the Ohio Administrative Code (OAC). SECTION I VERSION 1.7, January 2010 INTRODUCTION TO THE PRECERTIFICATION PROCESS Page 10

14 Medical Admission Non-surgical, non-psychiatric, and non-maternity admission. Medically Necessary Services Services as defined in Paragraph (B) of Rule 5101: of the OAC. Observation Services "Observation services" are those services furnished on a hospital's premises, including use of a bed and periodic monitoring by a hospital's nursing or other staff, which are reasonable and necessary to evaluate an outpatient's condition or determine the need for possible admission to the hospital as an inpatient. Outpatient Services "Outpatient services" - Diagnostic, therapeutic, rehabilitative, or palliative treatment or services furnished by or under the direction of a physician or dentist which are furnished to an outpatient by a hospital as defined in rule 5101: of the Administrative Code. Outpatient services do not include direct-care services provided by physicians, podiatrists and dentists. Outpatient services exclude direct-care physician services except as provided in rule 5101: of the Administrative Code. Preadmission Testing Testing that can be completed prior to an admission. SECTION I VERSION 1.7, January 2010 INTRODUCTION TO THE PRECERTIFICATION PROCESS Page 11

15 Precertification Process whereby ODJFS (or its contractual designee) assures that covered medical and psychiatric services and covered surgical procedures are medically necessary and are provided in the most appropriate and costeffective setting. Since it may be determined that an inpatient stay is not required for the provision of that covered medical or covered surgical care, the location of the service delivery may be altered as a result of precertification. Precertification must be obtained prior to the procedure for non-psychiatric procedures. The payment of that non-psychiatric treatment or procedure is contingent upon the acceptance of Permedion s recommendation on the appropriate location of service and medical necessity of the admission and/or procedure. For psychiatric precertification, contact Health Care Excel/First Mental Health at Same Day Surgery Surgery scheduled and completed on the day of admission with inpatient postoperative days required. Surgical Admission Admission to a hospital in which surgery is performed as part of the treatment plan. SECTION I VERSION 1.7, January 2010 INTRODUCTION TO THE PRECERTIFICATION PROCESS Page 12

16 EXEMPT CATEGORIES Emergency services, with the exception of emergency psychiatric services. Substance abuse services. Maternity services. Medicaid consumers enrolled in Health Maintenance Organizations (HMOs) under contract with ODJFS for provision of health services to Medicaid consumers. Physicians and hospitals located in noncontiguous states. Elective care that is performed in a hospital inpatient setting on a patient that is already hospitalized for a medically necessary condition unrelated to the elective care or when an unrelated procedure which does not require precertification is being performed simultaneously (inpatient only). Persons whose eligibility is pending at the time of service or who make application for Medicaid subsequent to admission. Patients who are jointly eligible for Medicare and Medicaid who are being admitted under the Medicare Part A benefit. Patients who are eligible for benefits through third party insurance as the primary payer for the services subject to precertification. SECTION I VERSION 1.7, January 2010 INTRODUCTION TO THE PRECERTIFICATION PROCESS Page 13

17 Transfers from one hospital to another hospital with the exception of those hospitals identified for inappropriate transfers. Elective procedures or diagnoses not found on the Precertification List. Patients not identified as Medicaid consumers at the time of elective admission or procedure. However, every effort should be made by both the attending and/or admitting physicians and hospital providers to identify Medicaid consumers before the admission or procedures that required precertification are performed. SECTION I VERSION 1.7, January 2010 INTRODUCTION TO THE PRECERTIFICATION PROCESS Page 14

18 FREQUENTLY ASKED QUESTIONS What is the difference between precertification and prior authorization? Most people think that these are the same, and in some arenas they are. In Ohio, however, precertification procedures are targeted procedures that are part of the Medicaid benefit package and are commonly used. These procedures are updated and changed according to practice patterns and medical standards. Precertification for procedures is provided through Permedion in Westerville, Ohio at or Prior authorization is obtained from the ODJFS for procedures that are not considered a benefit under Ohio Medicaid. For prior authorization of procedures, call What information should I have available when I call for precertification? Patient s Medicaid ID (billing number). Patient s demographic information. Name Address Responsible party, if patient is a minor Date of birth SECTION I VERSION 1.7, January 2010 INTRODUCTION TO THE PRECERTIFICATION PROCESS Page 15

19 Physician demographic information. Physician s name Medicaid provider number Address Telephone number Fax number Specialty Procedure to be done Date of procedure Name of procedure CPT code Patient clinical information. Signs/symptoms ICD-9 diagnosis codes Duration of signs/symptoms Treatment received so far (medications, PT, etc.) Family history, if applicable Other tests done Reason why physician is ordering procedures Who do I call when a precertification has been denied? Follow the appeals procedures described in your hospital letter of notification. The appeals procedures will give you the name of the appeals contact person, the address to mail your appeal, and the deadline for receipt of the appeal. SECTION I VERSION 1.7, January 2010 INTRODUCTION TO THE PRECERTIFICATION PROCESS Page 16

20 What is the penalty for not calling for precertification before the procedure is performed? When precertification is required for a procedure, there will be no financial reimbursement to the hospital if precertification is not obtained, in accordance with OAC Rule 5101: Is there an appeals process when a precertification is not called in time before the procedures? There is no appeals process for untimely precertification, in accordance with OAC Rule 5101: Who is responsible to obtain a precertification? While the information required is provided by both the hospital and the patients physician, the hospital is ultimately responsible and receives no payment if precertification is not obtained. What if the CPT code for the procedure I plan to perform is not listed in Section II? Only the CPT codes listed require precertification. SECTION I VERSION 1.7, January 2010 INTRODUCTION TO THE PRECERTIFICATION PROCESS Page 17

21 LIST OF PRECERTIFICATION PROCEDURES INPATIENT AND OUTPATIENT (HYSTERECTOMIES ARE THE ONLY OUTPATIENT PROCEDURE REQUIRING PRECERTIFICATION) Hysterectomy Service: Hysterectomy ICD-9 Code Laparoscopic supracervical hysterectomy Other subtotal abdominal hysterectomy nos Total abdominal hysterectomy Laparoscopically assisted vaginal hysterectomy (LAVH) Other vaginal hysterectomy CPT Codes Closure of vesicouterine fistula; with hysterectomy Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s) Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystopexy (e.g., Marshall-Marchetti-Krantz, Burch) Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s) Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube(s), with or without removal of ovary(s) Vaginal hysterectomy, for uterus 250 grams or less; Vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s), and/or ovary(s) Vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s), and/or ovary(s), with repair of enterocele Vaginal hysterectomy, for uterus 250 grams or less; with colpourethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control Vaginal hysterectomy, for uterus 250 grams or less; with repair of enterocele Vaginal hysterectomy, with total or partial vaginectomy (CONTINUED ON NEXT PAGE) SECTION II LIST OF PRECERTIFICATION PROCEDURES Page 18

22 Service: Hysterectomy CPT Codes (CONTINUED) Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less With removal of tube(s) and/or ovary(s) Laparoscopy surgical, with vaginal hysterectomy, for uterus 250 grams or less Laparoscopy surgical, with vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s) and/or ovary(s) Resection of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy SECTION II LIST OF PRECERTIFICATION PROCEDURES Page 19

23 INPATIENT ONLY (ALL PROCEDURES FROM PAGE ARE ONLY NEEDING PRECERTIFICATION IF THEY ARE BEING SCHEDULED AS AN INPATIENT PROCEDURE) Cervical Laminectomy Service: Cervical Laminectomy ICD-9 Code CPT Codes Other cervical fusion, anterior technique Other cervical fusion, posterior technique Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C Cervical below C2, each additional interspace (List separately in additional to code for separate procedure) (OLD CODES) Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other than for decompression) cervical below C Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other than for decompression) cervical below C2; thoracic Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other than for decompression) cervical below C2; lumbar (OLD CODES) Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other than for decompression) cervical below C2; each additional interspace (List separately in addition to code for primary procedure) (Use in conjunction with codes 22554, 22556, 22558) Arthrodesis, posterior technique, craniocervical (occiput-c2) Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment; thoracic (with or without lateral transverse technique) Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment; lumbar (with or without lateral transverse technique) (CONTINUED ON NEXT PAGE) SECTION II LIST OF PRECERTIFICATION PROCEDURES Page 20

24 Service: Cervical Laminectomy CPT Codes (CONTINUED) Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment; each additional vertebral segment (List separately in addition to code for primary procedure) (Use in conjunction with codes 22600, 22610, 22612) Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), threaded bone dowel(s), methylmethacrylate) to vertebral defect or interspace (OLD CODES) (OLD CODES) Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace; cervical, each additional interspace (List separately in addition to code for primary procedure) (Use in conjunction with code 63075) SECTION II LIST OF PRECERTIFICATION PROCEDURES Page 21

25 Esophagogastroduodenoscopy (EGD) Service: Esophagogastroduodenoscopy (EGD) ICD-9 Code CPT Codes Other endoscopy of small intestine Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with transmural drainage of pseudocyst Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with transendoscopic intraluminal tube or catheter placement Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with endoscopic ultrasound examination, including the esophagus, stomach and either the duodenum and/or jejunum as appropriate Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with transendoscopic stent placement (includes predilation) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with transendoscopic stent placement (includes predilation) Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; with biopsy, single or multiple SECTION II LIST OF PRECERTIFICATION PROCEDURES Page 22

26 Service: Esophagogastroduodenoscopy (EGD) ICD-9 Code Multiple segmental resection of small intestine CPT Codes Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), esophagus (includes endoscopic ultrasound examination limited to the esophagus) Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum and/or jejunum as appropriate) Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum and/or jejunum as appropriate) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with biopsy, single or multiple SECTION II LIST OF PRECERTIFICATION PROCEDURES Page 23

27 Injection or infusion of cancer chemotherapeutic substance Service: Injection or infusion of cancer chemotherapeutic substance ICD-9 Code CPT Code Injection or infusion of cancer chemotherapeutic substance Insertion of arterial and venous cannula(s) for isolated extracorporeal circulation including regional chemotherapy perfusion to an extremity, with or without hyperthermia, with removal of cannula(s) and repair of arteriotomy and venotomy sites Bladder instillation of anticarcinogenic agent (including detention time) Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic Chemotherapy administration; intralesional, up to and including 7 lesions Chemotherapy administration; intralesional, more than 7 lesions Chemotherapy administration; intravenous, push technique, single or initial substance/drug Chemotherapy administration; intravenous, push technique, each additional substance/drug Ingrid Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug Chemotherapy administration, intravenous infusion technique; each additional hour, 1 to 8 hours Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour Chemotherapy administration, intra-arterial; push technique (CONTINUED ON NEXT PAGE) SECTION II LIST OF PRECERTIFICATION PROCEDURES Page 24

28 CPT Code (CONTINUED) Chemotherapy administration, intra-arterial; infusion technique, up to one hour Chemotherapy administration, intra-arterial; infusion technique, each additional hour up to 8 hours Chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion (more than 8 hours), requiring the use of a portable or implantable pump Refilling and maintenance of portable pump Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic (eg, intravenous, intra-arterial) SECTION II LIST OF PRECERTIFICATION PROCEDURES Page 25

29 Laparoscopic Cholecystectomy Service: Laparoscopic Cholecystectomy ICD-9 Code Laparoscopic cholecystectomy Laparoscopic partial cholecystectomy CPT Codes Laparoscopy, surgical; with guided transhepatic cholangiography, without biopsy; cholecystectomy Laparoscopy, surgical; with guided transhepatic cholangiography, without biopsy; cholecystectomy with cholangiography Laparoscopy, surgical; with guided transhepatic cholangiography, without biopsy; cholecystectomy with exploration of common duct SECTION II LIST OF PRECERTIFICATION PROCEDURES Page 26

30 Laparoscopy - Diagnostic Service: Laparoscopic - Diagnostic ICD-9 Code Laparoscopy CPT Codes Laparoscopy, abdomen, peritoneum and omentum; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Laparoscopy, surgical; with biopsy (single or multiple) Laparoscopy, surgical; with aspiration of cavity or cyst (e.g., ovarian cyst) (single or multiple) Laparoscopy, surgical; with drainage of lymphocele to peritoneal cavity Unlisted laparoscopy procedure, abdomen, peritoneum and omentum SECTION II LIST OF PRECERTIFICATION PROCEDURES Page 27

31 Lumbar Laminectomy - Posterior Service: Lumbar Laminectomy - Posterior ICD-9 Code Excision of intervertebral disc Lumbar and lumbosacral fusion, posterior technique CPT Codes Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment; thoracic (with or without lateral transverse technique) Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment; lumbar (with or without lateral transverse technique) Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment; each additional vertebral segment (List separately in addition to code for primary procedure) (Use in conjunction with codes 22600, 22610, 22612) Arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace (other than for decompression), single interspace; lumbar Arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace (other than for decompression), single interspace; lumbar; each additional interspace (List separately in addition to code for primary procedure) (Use in conjunction with code 22630) Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments) Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (CONTINUED ON NEXT PAGE) SECTION II LIST OF PRECERTIFICATION PROCEDURES Page 28

32 Service: Lumbar Laminectomy - Posterior CPT Codes (CONTINUED) Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 8 or more vertebral segments Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), threaded bone dowel(s), methylmethacrylate) to vertebral defect or interspace Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar (including open or endoscopically-assisted approach) Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure) Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, reexploration, single interspace; lumbar Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, reexploration, single interspace; each additional lumbar interspace (List separately in addition to code for primary procedure) Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (eg, spinal or lateral recess stenosis)), single vertebral segment; lumbar SECTION II LIST OF PRECERTIFICATION PROCEDURES Page 29

33 Percutaneous Angioplasty - Noncoronary Vessel Service: Percutaneous Angioplasty-Non Coronary Vessel ICD-9 Code Angioplasty or atherectomy of non-coronary vessel CPT Codes Transluminal balloon angioplasty, percutaneous; tibioperoneal trunk or branches, each vessel Transluminal balloon angioplasty, percutaneous; tibioperoneal trunk or branches, each vessel; renal or visceral artery Transluminal balloon angioplasty, percutaneous; tibioperoneal trunk or branches, each vessel; aortic Transluminal balloon angioplasty, percutaneous; tibioperoneal trunk or branches, each vessel; iliac Transluminal balloon angioplasty, percutaneous; tibioperoneal trunk or branches, each vessel; femoral-popliteal Transluminal balloon angioplasty, percutaneous; tibioperoneal trunk or branches, each vessel; brachiocephalic trunk or branches, each vessel Transluminal balloon angioplasty, percutaneous; tibioperoneal trunk or branches, each vessel; venous SECTION II LIST OF PRECERTIFICATION PROCEDURES Page 30

34 PTCA-Coronary Angioplasty Service: PTCA-Coronary Angioplasty ICD-9 Code Percutaneous transluminal coronary angioplasty [PTCA] or coronary atherectomy CPT Codes Percutaneous transluminal coronary balloon angioplasty; single vessel Percutaneous transluminal coronary balloon angioplasty; each additional vessel (List separately, in addition to code for primary procedure) (Use in conjunction with codes 92980, 92982, 92995) Percutaneous transluminal coronary atherectomy, by mechanical or other method, with or without balloon angioplasty; single vessel Percutaneous transluminal coronary atherectomy, by mechanical or other method, with or without balloon angioplasty; each additional vessel (List separately in addition to code for primary procedure) (Use in conjunction with code(s) 92980, 92982, 92995) SECTION II LIST OF PRECERTIFICATION PROCEDURES Page 31

35 DETAILED REVIEW PROCESS Overview of Telephone/Fax/Web Form Review Process Demographic Information Clinical Information Evaluation of Medical Necessity Physician Panel Request for Reconsideration Patient/Provider Notification Reporting SECTION III DETAILED REVIEW PROCESS Page 32

36 DETAILED REVIEW PROCESS, STEP-BY-STEP Participating Medicaid Facility, Attending Physician, or Physician Office Staff will telephone or fax the Utilization Management RN. The Utilization Management RN at Permedion will: Answer telephone or review fax/web form request. Input demographic information. Medicaid consumer demographic data Name Address Sex Date of birth Medicaid consumer ID number Physician demographic data Name Address Telephone number Fax number Medicaid provider number Physician specialty Facility demographic data Name Address Telephone number Medicaid provider number (billing number) SECTION III DETAILED REVIEW PROCESS Page 33

37 The Utilization Management RN will: Input clinical information Primary and/or secondary diagnosis Planned procedure(s) Service date(s) Severity indicators Supporting labs, radiology, and consults Treatment plan/intensity indicator Contact person Review clinical information against criteria Severity Clinically specific to procedure requested Complicating signs and symptoms Acute clinical compromise Chronic clinical symptoms Abnormalities as identified by lab testing Pathology as noted by radiology and/or surgical intervention Clinical specialty consults denoting clinical pathology Psycho-social factors impacting patient s episode of care Clinical comorbidities Pertinent laboratory, radiology, and consults SECTION III DETAILED REVIEW PROCESS Page 34

38 Intensity Diagnostic procedures to establish cause or nature of severity indicators Therapeutic treatment indicators Anesthesia-impact of type, route, and time Post-procedure monitoring Therapeutic management of diagnoses and comorbidities Does clinical information support medical necessity based upon the application of clinical criteria? If no: RN Reviewer refers to Ohio Physician Panel. Ohio Physician Reviewer calls attending physician for peer-to-peer case discussion (minimum two calls per business day). OR If yes: RN Reviewer certifies procedure and provides certification number. Notification is sent to facility, physician, and patient. Electronic notification is forwarded to ODJFS. SECTION III DETAILED REVIEW PROCESS Page 35

39 Is medical necessity and appropriateness validated by Ohio Physician Reviewer? Ohio Physician Reviewer recommends non-certification for lack of established medical necessity and notifies attending physician within one business day of decision. Notification of determination and details regarding the reconsideration and appeal process is forwarded within one business day to physician, facility, and patient. OR Ohio Physician Reviewer recommends certification. Notification is sent to physician, facility, and patient. Electronic notification is forwarded to ODJFS. SECTION III DETAILED REVIEW PROCESS Page 36

40 The Utilization Management RN will: Approve procedure or refer to Ohio Physician Panel Ohio Physician Panel Ohio based physicians in active practice Speciality peer-matching Confidence in appropriateness of decisions Timeliness in rendering decisions Accessibility which facilitates interaction between the panel and key participants An educational, non-adversarial approach to the review process Appeals handled by different sub-specialty, peer-matched physician Specialties, e.g. Gastroenterology ENT Family Practice Cardiology Surgery Neurosurgery Orthopedic surgery Pediatrics Oncology/Hematology Podiatry Ophthalmology Anesthesiology Psychiatry Obstetrics/Gynecology Physical/Rehabilitation Medicine Otolaryngology Cardio Thoracic Surgery SECTION III DETAILED REVIEW PROCESS Page 37

41 The Utilization Management RN will: If approved, communicate certification via phone and fax, as applicable Forward notification to patient, provider and facility Precertification determinations within 24 hours of receipt of information Availability and process for appeal of denials Appeal decision within one day of determination Availability and process of administrative appeals Permedion address Permedion Attn: Ralene McNeal 350 Worthington Road, Suite H Westerville, Ohio Phone or Fax or SECTION III DETAILED REVIEW PROCESS Page 38

42 Permedion/ODJFS Precertification Fax Form PERMEDION OHIO MEDICAID or (phone) FAX PRECERTIFICATION FORM or (fax) CONTACT PERSON: CONTACT S PHONE #: PATIENT NAME: MEDICAID ID #: PT. ADDRESS: CITY, STATE, ZIP: PHY: PHY PHONE: PHYS ADDRESS: PHY OH MEDICAID PROV # : CITY, STATE, ZIP: SITE OF PROCEDURE: SITE ADDRESS: INPT, OBS, OUTPT (CIRCLE ONE) DOB: CITY, STATE, ZIP: CPT PROC CODE: ICD9 CODE: DATE OF PROC: IS MEDICAID THE ONLY INSURANCE? (CIRCLE) YES NO CLINICAL DOCUMENTATION (include symptoms, length of time patient has been experiencing symptoms, tests performed and results, pertinent family history and any other pertinent information) SECTION III DETAILED REVIEW PROCESS Page 39

43 UTILIZATION REVIEW RECONSIDERATION Submit to Permedion within 60 days of the date of the determination Permedion Attn: Ralene McNeal 350 Worthington Road, Suite H Westerville, Ohio Fax or Request must be in writing and include: Copy of written determination Patients medical record Additional supporting documentation SECTION III DETAILED REVIEW PROCESS Page 40

44 PROVIDER ADMINISTRATIVE APPEAL If a request for reconsideration is denied, the provider requesting precertification may request an administrative review pursuant to OAC Rule 5101: Facility/Physician has 30 days from Permedion notification date to appeal to ODJFS. ODJFS will provide administrative review Determination to certify If No: Non-certification decision upheld If Yes: Non-certification decision reversed Notification of determination made in writing to appellant and to the hospital utilization review unit (30 days from ODJFS received date) Mail request for administrative review to: OFMS Bureau of Audit and Consulting Services P.O. Box Columbus, Ohio SECTION III DETAILED REVIEW PROCESS Page 41

45 RESOURCES/CONTACT INFORMATION Permedion Ralene McNeal, RN, Review Supervisor, Permedion Maureen Riley, RN, BSN, UR Service Line Manager, Permedion Phone or Fax Ohio Department of Job and Family Services (ODJFS) - Policy Related Questions Autumn Darnell, Bureau of Health Plan Policy Phone Fax SECTION III DETAILED REVIEW PROCESS Page 42

46 URAC GUIDELINES The American Accreditation Healthcare Commission (URAC) accreditation standards support the necessary structures and processes to promote high quality care and preserve patient rights. Ohio Medicaid s has been under the leadership of the Permedion Contract Manager since In November, 2007 Permedion received full URAC reaccreditation in utilization management. This precertification program monitors and complies with all Ohio Medicaid legislative and certification requirements. Permedion s review personnel meet or exceed all training and qualification requirements in the URAC guidelines. SECTION III DETAILED REVIEW PROCESS Page 43

47 ODJFS RULES 5101: ELIGIBLE PROVIDERS. (A) A hospital must have a currently valid provider agreement in order to participate in the Medicaid program. A "provider agreement" is a contractual agreement whereby the provider agrees to adhere to conditions of participation as outlined in rule 5101: of the Administrative Code. All hospitals, except those excluded below, which are certified by the Ohio department of health for participation under Medicare (Title XVIII) are eligible to participate in the Ohio Medicaid (Title XIX) program upon execution of a provider agreement. Also considered to be eligible is a hospital which is currently determined to meet the requirements for Title XVIII participation and has in effect a hospital utilization review plan applicable to all patients who receive medical assistance under Title XIX. The following hospitals are excluded from participation: (1) Tuberculosis facilities, and (2) Facilities that have fifty per cent or more of their beds registered pursuant to Chapter of the Administrative Code as alcohol and/or drug abuse rehabilitation beds, and have no beds licensed as psychiatric beds pursuant to Chapter of the Administrative Code. Copyright 2002 Anderson Publishing Co. Complete text of all rules, including full appendices, certified to the Legislative Service Commission and the Secretary of State, with an effective date on or before August 28, SECTION IV ODJFS RULES Page 44

48 (B) Limitations of participation The following facilities with more than sixteen beds shall be eligible to participate in Title XIX only for the provision of inpatient psychiatric services to recipients age sixty-five or older in accordance with paragraph (C) of this rule and to recipients under age twenty-one in accordance with paragraph (D) of this rule. (1) A hospital with fifty per cent or more of its beds registered as alcohol and/or drug abuse rehabilitation beds that also has beds licensed as psychiatric beds pursuant to Chapter of the Administrative Code. (2) Hospitals which have at least half of their beds licensed as psychiatric beds pursuant to Chapter of the Administrative Code or operated under the authority of the state mental health authority in accordance with section of the Revised Code. (3) Hospitals which have half or more of their discharges in any six-month time period reviewed by the Ohio department of job and family services and determined to be for psychiatric and/or substance abuse treatment. (C) Hospitals that are eligible to participate only for the provision of inpatient psychiatric services in accordance with paragraph (B) of this rule and are rendering inpatient psychiatric services to recipients age sixty-five or older must be certified by medicare for reimbursement of services, and must be licensed by the Ohio department of mental health in accordance with Chapter of the Administrative Code or operated under the authority of the state mental health authority in accordance with section of the Revised Code, and must provide services in accordance with Chapter of the Administrative Code. Hospitals shall operate pursuant to the provisions of Title 42, Subsection 441, Subpart C of the Code of Federal Regulations. Copyright 2002 Anderson Publishing Co. Complete text of all rules, including full appendices, certified to the Legislative Service Commission and the Secretary of State, with an effective date on or before August 28, SECTION IV ODJFS RULES Page 45