Section Contents. PCPs and Specialist Authorization Information 5-9

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1 Section Contents Introduction 5-3 Authorization Department Information 5-3 Types of Referrals/Authorizations 5-3 Frequently Asked Questions 5-4 Authorization Process Overview 5-6 Prior Authorizations Reminders 5-7 Additional Important Information 5-8 PCPs and Specialist Authorization Information 5-9 Using the Web to Submit and View Authorizations 5-10 Basic Instructions for Submitting Requests Using the Web 5-11 Authorization Procedures PCPs, Specialist and Ancillary Providers 5-12 Emergency Services 5-12 Authorization Request Review 5-13 Criteria for Determination 5-13 Determination Notification (to Provider) 5-13 Member Notification 5-14 Medical Director Availability 5-14 Authorization Request Notification Report 5-15 Correspondence Approval Letters 5-16 Denial Letters 5-16 Cancel Letters 5-16 Denial Process 5-17 IPA Provider Manual EXCEL MSO, LLC

2 Medi-Cal 5-18 A. Covered by Medi-Cal Managed Care (HMO) 5-19 Contracts with IPAs B. Covered through Fee-For-Service Medi-Cal 5 22 (not through IPA contracts with health plans) C. Covered through Fee-For-Service Medi-Cal 5-22 D. Exclusions 5-22 Medi-Cal Obstetrical Care 5-24 Appendix IPA Authorization Process Overview Authorization Request Form (Sample Form for faxing) Diagnostic Authorization Information Web Authorization User Instructions IPA Provider Manual EXCEL MSO, LLC

3 INTRODUCTION Authorization requests may be submitted using the standard Authorization Request Form or using the Web Auth System located on The Web Authorization System (available through pmgmd.com) is available for Physicians offices to submit and view status of a referral request. A report is also faxed (in the morning) to each office with recent authorization request status history. IPA Authorization Department Information Authorizations Department Phone (408) Fax: (408) Types of Referral/Authorizations Routine authorizations are for services that are not-urgent. Retrospective authorizations are medical services provided without prior authorization. Retro authorizations must be submitted within two business days for review. Urgent means services that are required in order to prevent serious deterioration of a member s health that results from an unforeseen illness or injury. Emergency - A medical or psychiatric condition manifesting itself by acute symptoms of sufficient severity such that a prudent layperson would expect the absence of immediate medical attention to result in jeopardizing health, serious impairment of body function or dysfunction of any bodily organ or part. Generally, authorizations are required for all services except for PCP-capitated services, Ob/Gyn visits, and some exceptions made by the IPA such as ancillary services performed at IPA contracted facilities. IPA Provider Manual EXCEL MSO, LLC

4 What requires an authorization? Frequently Asked Questions PCP services beyond office visits Initial referral to a Specialist for Services (consultation) Follow-up visits for Specialist Services Outpatient surgical services, ambulatory surgery, endoscopy, etc. Inpatient services Physical Therapy, Occupational Therapy, Speech Therapy, Nutritioanal Services, Chemotherapy Adult Hep A and Hep B, Synagis, high cost drugs Bone Density, CT Scans, Diagnostic Infertility Studies, MRIs, and Nuclear Medicine REQUIRE an authorization for all members at all facilities. Treadmill, Stress Echo, and Holter Monitor, Apnea monitor, Sleep Testing HHC, DME, Orthotics Out of network or non-contracted providers or facilities The following do NOT require an authorization EKGs Orthpaedics: Participating orthopedic physicians may perform X-rays in their office and are not limited to fractures only. Lab and X-ray (Routine X-rays do not need an authorization through IPA designated Providers) Routine OB/Gyn Care, including well woman visits. (OB delivery still requires prior authorization.) Physician inpatient visits for approved inpatient stays Routine immunizations IPA Provider Manual EXCEL MSO, LLC

5 Please refer to the Appendix for the Diagnostic Authorization Information listing for additional info (i.e. All par OB/Gyns may perform up to two ultrasounds for pregnancies without an auth. Any additional ultrasounds must be prior authorized). Please call for unlisted services. IPA Provider Manual EXCEL MSO, LLC

6 Authorization Process Overview You may submit referral authorizations using a standard Authorization Request Form or electronically through our online Web Auth system. Contact Provider Services at (408) to request additional copies of Authorization Request Forms. The Authorizations Department fax number is (408) Updating a request? To update recently approved authorization requests, please fax EXCEL a written request with the referral number and the requested change. We will be happy to assist you. Once an Authorization Request is received, how long does authorization determination take? Routine requests with adequate information are completed within five business days from receipt of request. Urgent requests with adequate information are completed within 3 days from receipt of request. How will we be notified of the determination? A report will be faxed to the fax number we have on file for your office. It is important to keep your fax machine on 24 hours a day, since we fax back daily notifications to you after typical business hours. Remember to check your incoming fax report before calling our office to inquire about status. You can also check our Web Authorization system on-line at pmgmd.com. Notification letters of determination will be sent to members only. Prior Authorization Requests Fax Number If you send us Prior Authorization Request by fax, please send to (408) Sending to other fax numbers may delay your request. IPA Provider Manual EXCEL MSO, LLC

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8 DO: Prior Authorizations Reminders Check fax notification DAILY for status and authorization number. This is typically sent the day after the determination is made. (Keep fax machine ON!) Fill in the diagnosis (code), procedure (code), member name and ID on each request, and adequate clinical information. Combine requests if the requested services are for the same provider at the same site. Refrain from calling for status of request, unless it is urgent or an emergency. Respond to a request for additional information from our medical review staff as soon as possible so that a determination can be made. Include clinical information pertinent to the request. Include/enter the Facility when appropriate (i.e. hospital, ambulatory surgery center, SNF, etc.) Use the on-line PMG web system to verify status of requests. Send two separate authorization/referral requests for office and hospital procedures PCPs: A referral to an Ob/Gyn is not required. DO NOT: Send an additional request to add a code. Contact us by phone or fax to modify an already approved authorization. Call for the authorization number unless it is urgent. Routinely send requests as URGENT OR EMERGENCY. Urgent or emergency requests are based on medical conditions as outlined on the top of the request form. (paper form) Send multiple copies of the same request. Send a retro-authorization after 48 hours OR after a claim has been denied. No authorization will be given. This is considered an appeal. IPA Provider Manual EXCEL MSO, LLC

9 PCPs: Send a referral to an OB/GYN as prior authorization is not required. See Claims section for additional information. Additional Important Information With the electronic Web Authorization request system, an Evaluation & Management code level has to be entered. Therefore, a level xxxx3 is automatically entered into the system. You may bill the appropriate level, and the Claims Department will pay the level according to the PMG guidelines. Please submit medical notes with claim if you are upcoding to a higher level. As a rule, requests for surgical supplies and trays, will not be prior authorized. These will be reviewed on a case-by-case basis by the Claims Department. Specialists should request follow-up visits and surgical procedures directly. If specialist has not seen member in last 3 months and is not under active treatment, member needs to redirect back to PCP for evaluation first. Web Authorization System - Reminders Make sure the appropriate diagnosis codes and procedure codes are entered. Check the status of the requests daily in order to respond to request for information quickly. Providers who are RANK 5 in the system are out-of-network providers. If you want to refer to a Rank 5 provider, be sure to enter the reason for such a referral; otherwise there will be a delay. IPA Provider Manual EXCEL MSO, LLC

10 PCPS AND SPECIALIST AUTHORIZATIONS The following describes basic information about authorizations for PCPs and Specialists. Important: Authorizations are NOT required for a referral from a PCP to a contracted Ob/Gyn Specialist for Ob/Gyn visits. Be sure to inform your patients! This information is KEY in coordinating timely care for your patients. Ob/Gyns: You do not need to ask for a referral authorization for an office visit related to Ob/Gyn care when a member self refers. Continue to submit referral authorizations for anything beyond office visits, including procedure(s) and delivery. Specialists: When you receive an initial referral from a PCP, it is good for the initial consult only. YOUR Specialist office may request continued care and treatment authorizations for the member. It is not necessary for the PCP to request follow-up visits, unless member does not have a recent history with specialist (not under active treatment). In these cases, PCP should evaluate member first to determine need for referral to specialist. IPA Provider Manual EXCEL MSO, LLC

11 USING THE WEB TO SUBMIT AUTHORIZATIONS There are a number of benefits and advantages to using a paperless process. Not only are your requests received instantly by the UM Department, you are able to: Check the status of any request any time. Check eligibility. Receive the referral/reference number immediately. Check history of a referral related to the member. If you don t have a User ID, call Provider Services at (408) to request a User ID, password and training. IPA Provider Manual EXCEL MSO, LLC

12 Basic Instructions for Submitting Referral Authorizations Using the Web For additional detailed instructions, please logon to pmgmd.com. Launch your Internet connection, Internet Explorer browser and go to Click PMG ONLINE. Enter your User name (userid) and Password. Reminder: Always type the User name and Password in CAPITAL LETTERS. Click Add Referral. A data entry screen will appear. Complete the required fields on the form. Enter Clinical Notes to illustrate medical necessity. Example: Patient in first trimester with abnormal vaginal bleeding and abdominal cramps. Needs urgent ultrasound. Click Add Referral at the bottom of the screen. Detailed instructions and learning materials are available on Click web instructions for the latest version. The most recent version of these instructions (at the time of printing) are included in the Appendix of this section. IPA Provider Manual EXCEL MSO, LLC

13 AUTHORIZATION PROCEDURES Primary Care Physicians, Specialist Physician Offices and Ancillary Providers Providers are responsible for verifying the eligibility of the member before services are delivered and the validity of an authorization before performing the services. Submitting New Referrals/Request for Authorizations Verify eligibility of the member. Submit Authorization Request using one of these methods: Web Authorization System or by fax. By FAX using the standard Authorization Request Form. Fax to (408) Important! If any required information is missing, a request may be returned for clarification. Emergency Services Primary Care Physicians are requested to notify EXCEL immediately of all Emergency Department visits, including member visits to out-of-network facilities. ER services are periodically reviewed by EXCEL s UM department and/or the IPA s UM Committee. When ER services have been authorized by the PCP or other authorized representative of the IPA, but were later found through the UM review process not to meet medical necessity criteria, this information may be incorporated into targeted provider utilization history. IPA Provider Manual EXCEL MSO, LLC

14 Authorization Request Review All authorization request reviews will be made according to standard time frames, provided appropriate information is submitted or available to make a determination. Turn around times are: URGENT: NON-URGENT: within 72 hours within 5 business days Criteria for Determination Eligibility, medical appropriateness, and standard criteria/guidelines are routinely used: Milliman & Robertson Apollo Member s Health Plan Specialty Society Guidelines Physicians Medical Group Guidelines All denial determination for lack of medical necessity is made by the IPA s Medical Director or designated physician reviewer. *Physicians may request copies of criteria and/or guidelines by calling the UM Department at (408) Determination Notification (to Provider) EXCEL will notify the referring provider, requested provider and the Primary Care Physician (if PCP is not the requesting provider) of all authorization decisions via fax (decisions are currently faxed in the mornings for requests made the previous day). Determination status is APPROVED, PENDED, CANCELLED or DENIED. See also details on the Authorization Request Notification Report. IPA Provider Manual EXCEL MSO, LLC

15 Member Notification EXCEL notifies the member in writing for all decision determinations. This confirmation letter is sent to the member by mail within 48 hours of the decision determination. Medical Director Availability The IPA Medical Director is available to discuss any case with the physician/provider. Please call the UM department Monday through Friday between the hours of 8:30 AM and 4:30 PM at (408) IPA Provider Manual EXCEL MSO, LLC

16 AUTHORIZATION REQUEST NOTIFICATION REPORT The following illustrates the details in the report that is faxed to your office on a daily basis with the activities related to authorization referrals. Report sections include: Your Authorization Requests (referrals from you) Referrals to you For your information as a PCP (PCPs only) SAMPLE TO DAVID WILLIAMS, M.D., Fax #: (408) W. JACKSON AVENUE SAN JOSE, CA (408) Subject: Authorization Request Verification Your Authorization Requests This section itemizes the authorization requests from you to another Physician or Facility. Report lists Date Received, Track #, Member #, Name/Sex/DOB, PCP/Comment, Referred By, ProcCode/Description, Qty, Processed, Expire, and Status. Referrals to you This section lists the referrals (from other Physicians) to you. It typically lists members who belong to another PCP. For your information as a PCP This section displays a summary of activity for your members (if you are a PCP). This includes referrals originated by another Physician to another Physicians, Specialists, and Facilities. Disclaimer: This report is subject to enhancement and is intended as a sample only. IPA Provider Manual EXCEL MSO, LLC

17 CORRESPONDENCE Approval Letters The approval letter notifies the member regarding the specific request (for service for a specific provider/physician) has been approved. Denial Letters The denial letter notifies the member regarding the specific request (for service for a specific provider/physician) has been denied. The letter also explains they have the right to appeal the decision by filing a grievance with their health plan. In addition, Health plan submission guidelines, including the number of days the member has to file an appeal is described. The denial letter is sent to the member with copies to the requesting provider and PCP. Cancel Letters An Authorization request maybe cancelled because provider requests cancellation; it is a duplicate; health plan financial responsibility; or a carved out benefit. Given the complex nature of medical group contracts, there are many occasions when the requested services will be the financial responsibility of the health plans; in which case, the requests maybe cancelled and may need to be authorized directly by the health plan. One example is the member request for out of network second opinion. Carved out benefits are services that are covered by the health plans but administered by other entities or vendors other than the medical group. The best examples are vision, mental health, dental, and, in the case of Medi-Cal plans, California Children Service (CCS). When authorization requests are being cancelled, the providers and the members will be notified with the exception of duplicate requests. IPA Provider Manual EXCEL MSO, LLC

18 DENIAL PROCESS The Utilization Management (UM) staff coordinates with other departments such as Quality Management and Claims, to ensure that accurate information is given to the members and providers when a denial for a service is processed. It is medical group policy that: All denial determinations are made by the IPA s Medical Director or Physician designee. Utilization Management staff will send denial confirmation letters to PCPs, requesting providers and members. All denials of service will be handled in a timely manner according to health plan guidelines, and will be documented and tracked. All appeals will be handled in an efficient manner according to IPA/Health plan approved procedures. Process A denial letter is sent to member, PCP and requesting providers by the UM staff, and copied to the member s Health Plan. The requesting provider will be notified within one business day of the denial determination by fax. Confirmation denial letters are sent within 2 business days after the decision determination. In addition to the explanation for the denial, all letters will provide instructions for initiating an appeal in compliance with health plan and regulatory requirements. Requests for service authorization commonly are denied for the following reasons: The provider requested is not contracted with the IPA. The service is not a covered benefit. The service is not medically necessary/medically appropriate. The member is not eligible. The member s benefits for that service have been exhausted. The services can be provided by the primary care physician. IPA Provider Manual EXCEL MSO, LLC

19 MEDI-CAL Medi-Cal COVERED Services The following pages describe: A. Covered by Medi-Cal Managed Care Contracts (HMO) with B. Covered through Fee-For-Service Medi-Cal (not through IPA contracts with health plans) C. Covered through Fee-For-Service Medi-Cal (conditions triggering disenrollment from health plan and return to fee-for service coverage) D. Exclusions. NOT COVERED by Fee-For-Service Medi-Cal OR by Medi-Cal Managed Care (HMO) Billing Notes: Use standard form based on CMS 1500 form. Notation of authorization number on the claim form is required for prompt and proper payment. Use standard CPT codes. Payment to participating IPA specialists for authorized professional services to members will be based on Medi-Cal Fee-for-Service or RBRVS rates. Send these claims to EXCEL within 90 days of date of service. Disclaimer: Services covered by Medi-Cal and Medi-Cal Managed Care (HMO) are subject to change by the State Department of Health Services and by contracted health plans. The description below is provided as an overview only. The Utilization Management Department will keep current with any State or health plan changes, subsequent to this printing. Physician offices are advised to verify benefits through the UM Department. IPA Provider Manual EXCEL MSO, LLC

20 A. Covered by Medi-Cal - Contracts with IPAs These services are covered by the IPA or Health Plan if services are considered medically necessary and the member is eligible at the time of service. Allergy testing and desensitization therapy Audiology (does not apply to State s Medi-Cal members 21 years old when services rendered by an audiologist) Comprehensive hearing examinations Hearing aids Chemotherapy: covered in inpatient, outpatient and home settings. (No experimental/investigative drugs) Dental Services: Inpatient dental surgery for (accidental) injury as necessary for construction of non-dental structures. Routine dental care covered through State s Medi-Cal (Denti-Cal) program. Detox Services (medically necessary): Not covered by Blue Cross; SCFHP covers inpatient only. Durable Medical Equipment: from contracted vendor(s). Emergency Services: covered in participating and non-participating facilities. Use of Regional Medical Center of San Jose strongly preferred. Notes: 1 -- Physicians offices should encourage members to call PCP office to make urgent care appointments, and to use the 24-hour nurse advice 800# s provided by their health plans. 2 Routine & Urgent medical conditions occurring during business hours should be handled by the members personal physician (PCP). IPA Provider Manual EXCEL MSO, LLC

21 Experimental Procedures limited coverage IPA Provider Manual EXCEL MSO, LLC

22 Covered by Medi-Cal Contracts with IPAs (continued) Family Planning Services Insertion of IUD, subcutaneous device (Norplant) Injection of Depo provera Sterilization (with informed consent) HIV/AIDS counseling and testing services in conjunction with family planning services. For the Family Planning Services listed above, members may selfrefer (within the IPA network) without authorization. Note: Abortions do not require prior authorization for participating IPA providers. For non-participating providers, prior authorization is EXCLUSIONS (Not covered by Medi-Cal): IVF, Sperm banking, Artificial insemination, Infertility Diagnosis/Treatment, Sterilization Reversal. Hemodialysis, Peritoneal Dialysis (acute): covered in IP, OP, and Home settings. Home Health Services from a contracted agency: (if medically necessary) Skilled nursing Home health aide services Social work services Medical supplies, equipment Rehabilitation therapies (PT, Speech, OT) Home infusion, including chemotherapy Inpatient Hospital Care includes: Medically necessary surgery (including outpatient surgery) Medications Diagnostic services IPA Provider Manual EXCEL MSO, LLC

23 Anesthesia Operative care Blood Products (Exclusion: autologous blood donation) AUTHORIZATION PROCESS Laboratory/Pathology Services: Use QUEST DIAGNOSTICS (Unilab) for inpatient laboratory services or Regional Pathology (Dr. Freedman) for outpatient pathology. (Contracted providers.) Note: Office-based routine lab work will not be reimbursed. Pregnancy test (with or without PCP authorization) Routine blood chemistry tests Pap Smears Testing for medication levels HIV testing Long Term Care: Skilled Nursing Facility (if medically necessary) covered up to 60 days (after 60 days, coverage would be arranged through state Medi-Cal program). Mammography: Per guidelines. Maternity Care/Prenatal Services. (See OB/GYN Services ) Member may access IPA OB/GYN provider without PCP referral OB must offer access to CPSP services IPA does not currently offer midwifery services If ordered by OB provider, covered services include: Related lab tests must be done at QUEST DIAGNOSTICS Related diagnostic tests Sonograms All medically necessary hospital services Organ Transplants refer to Health Plan guidelines. Physical Therapy Refer to contracted ancillary providers. Podiatry Radiation Therapy: Inpatient, Outpatient Radiology See Authorization Information listing in Appendix. Skilled Nursing Facility (SNF): Short term (up to 60 days) IPA Provider Manual EXCEL MSO, LLC

24 B. Covered through Fee-For-Service Medi-Cal (not through IPA contracts with Med-Cal Managed Care health plans) Medi-Cal beneficiary remains a health plan member with IPA, uses BIC card to access the following services: Acupuncture Chiropractic California Children Services - CCS - (diagnosis-specific) Detoxification - outpatient Drug and Alcohol Rehabilitation Mental Health Services (inpatient and outpatient) Prayer and Spiritual Healing Routine Vision Care (Optometry Vision Services) C. Covered through Fee-For-Service Medi-Cal (conditions triggering disenrollment from Med-Cal Managed Care health plan and return to fee-for-service coverage): Long Term Care (SNF/Nursing Home) >60 days Major Organ Transplants (once member is put on transplant list EXCEPT RENAL) D. Exclusions: NOT COVERED by Fee-For-Service Medi-Cal OR by Medi-Cal Managed Health Care (HMO) Artificial Insemination Biofeedback Circumcision (routine) Employment/pre-employment physical exams Infertility diagnosis/treatment Travel injections and inoculations IPA Provider Manual EXCEL MSO, LLC

25 MEDI-CAL GUIDELINES FOR OBSTETRICAL CARE (BASED ON ACOG & CPSP STANDARDS) 1. Member may self-refer for direct access to Sensitive Services (e.g., pregnancy testing, sexually transmitted disease testing and counseling, HIV testing and counseling, and family planning services). 2. If confirmed pregnancy: Member must receive prenatal care and must be offered CPSP services. See the following page for additional maternity care information. The PCP and IPA UM Dept. can help with selection/referral to an OB for prenatal care and to CPSP services, if OB is not CPSP provider. If member is high risk, the PCP/OB should communicate this information to the IPA s Case Management. OB must be part of the IPA Medi-Cal panel. OB must notify the IPA (EXCEL MSO) of the expected date of confinement/delivery. CPSP available through (Regional Medical Center of San Jose s) Natividad Women s Clinic of San Jose. (408) x2145 If the mother refuses CPSP services, OB must document refusal in chart. IPA Provider Manual EXCEL MSO, LLC

26 Medi-Cal Guidelines for Obstetrical Care (based on ACOG & CPSP Standards) - continued First Trimester Week 1-28 (first 28 weeks) Weeks After 36 weeks Post delivery Home Care Post-partum visit Other care Initial assessment, within 7 days of request for appointment. Office visits every 4 weeks. Office visits every 2-3 weeks. Weekly office visits until delivery. Nursing visits may be authorized based upon medical necessity and extent of Medi-Cal benefit. Should occur within 4-6 weeks after delivery. To be coordinated by member s OB during prenatal care period in conjunction with member s PCP relationship Other care includes: - Dental care (separate benefit, dentist bills Medi-Cal fee-for-service). - Health Education - Nutritional counseling, including referral to WIC Program. IPA Provider Manual EXCEL MSO, LLC