Mississippi Medicaid Diabetes Self-Management Training (DSMT) Provider Manual

Transcription

1 Mississippi Medicaid Diabetes Self-Management Training (DSMT) Effective Date: May 1, 2015

2 Introduction: eqhealth Solutions Diabetes Self-Management Training Utilization Management Program includes prior authorization of services that begin on or after April 1, Prior authorization for Diabetes Self- Management Training Services applies to Mississippi Medicaid eligible beneficiaries who are not enrolled in the Mississippi Coordinated Access Network (MSCAN). This manual should be used as a companion to the Mississippi Administrative Code and the Medicaid fee schedule. Table of Contents Section I What you need to know before examining a Medicaid beneficiary... 3 Checking Eligibility... 3 Medicaid Coverage Categories of Eligibility... 4 Getting to Know Mississippi Division of Medicaid (DOM) Diabetes Self-Management Training Services Coverage... 5 Section II Submitting a prior authorization request... 6 Types of Review Requests and Required Documentation... 7 Timeframes for Review Completion... 7 Section III What eqhealth looks for when reviewing your request... 8 The eqhealth Review Team, Who We Are....8 Administrative Screening....8 Clinical Reviewer (1 st Level) Screening of the Request....8 Screening for Compliance with Administrative Code....8 Clinical Information: Pending and Suspended Requests....8 First Level Medical Necessity Review Process... 9 Approval Notifications... 9 Referral to a Second Level Reviewer.10 Second Level Review Process 10 Approval Determinations and Pended Reviews Adverse Determinations Reconsideration Reviews Page: 1

3 Section IV - If You Need Information or Assistance Questions about the Diabetes Self Management Training Services Utilization Management Program...12 eqhealth Solutions Helpline Section VI Review Workflow Page: 2

4 Section I What you need to know before examining a Medicaid beneficiary: Did you check beneficiary eligibility? The plastic Medicaid card is not a guarantee of Medicaid eligibility. You must access the beneficiary s eligibility and service limit information through the eligibility verification options before submitting a prior authorization request to eqhealth Solutions. You are responsible for verifying a Medicaid beneficiary s eligibility each time the beneficiary appears for service. You are also responsible for confirming the person presenting the card is the person to whom the card is issued. You can verify eligibility by the Medicaid ID number or thesocial Security number of the beneficiary by either of the following services: Website verification: o Automated Voice Response System (AVRS) at Provider/Beneficiary Services Call Center at Medicaid Eligibility Verification Services (MEVS) transaction using personal computer (PC) software or point of service (POS) swipe card verification device. Page: 3

5 Medicaid Coverage Categories of Eligibility (COE) eqhealth Solutions Utilization Management of Diabetes Self-Management Training Services is applicable for Mississippi Medicaid beneficiaries in the following eligibility categories: Fee-for-service eligible beneficiaries The following beneficiaries are not eligible for Diabetes Self-Management Training Services or do not require prior authorization by eqhealth: Beneficiaries enrolled in Mississippi Coordinated Access Network (MSCAN) or Children Health Insurance Program (CHIP) Beneficiaries in COE 029, Family Planning Waiver Beneficiaries with no Medicaid coverage for the date of service Beneficiaries covered by both Medicare and Medicaid Please check eligibility at each visit. Page: 4

6 Getting to Know Mississippi Division of Medicaid (DOM) Diabetes Self- Management Training Services Coverage Comprehensive information about Diabetes Self-Management Training Services covered, limitations, and exclusions can be found on the Division of Medicaid s website: Mississippi Administrative Code: Title 23: Division of Medicaid, Part 200 General Provider Information; Chapter 5: Rule 5.6: Diabetes Self- Management Training (DSMT) Diabetes Self Management Training codes requiring prior authorization Service Description Procedure Code Maximum Units Initial Assessment G hour = 2 units Group Sessions Individual Sessions (Note 1: if the ordering physican determines and documents the beneficiary would benefit from individual sessions instead of group sessions due to a medical condition.) Follow-up Training (Note 2: must be ordered by the physician actively managing the beneficiary s diabetes, including documentation in the medical record of the specific medical condition that the follow-up must address.) G0109 G0108 (see Note 1) G0109 (see Note 2) 6 hours= 12 units 7 hours = 14 units (see Note 1) 2 hours = 4 units (see Note 2) Page: 5

7 Section II Submitting a prior authorization request Review Information When a beneficiary requires, the following information must be submitted with your request to eqhealth Solutions. The table below details information which must be submitted for codes G0108 and G0109. Note: A printable version of the request form can be found at Diabetes Self- Management Training Completed Request eqhealth Solutions Diabetes Self- Management Training Services form Plan of Care Certificate of accreditation by o American Diabetes Association, or the o American Association of Diabetes Educators Forms are available at eqhealth Solutions website Completed forms and supporting documentation should be faxed to eqhealth Solutions at fax number Page: 6

8 Types of Review Requests New Service/Admission All services are submitted for PA a minimum of three (3) business days prior to the planned date. Extension of TAN End Date Request Extension requests are submitted via fax. Retrospective: For beneficiaries who are determined to be retroactively eligible, and have been discharged from care. Submit the review request as soon as eligibility is confirmed and within one (1) year of the retroactive eligibility determination date. If services are in progress when the retroactive eligibility is determined, submit an admission review request. For extenuating circumstances please call eqhealth Solutions eqhealth Solutions completes requests for services within specific timeframes. Admission review: 2 business day from receipt. Retrospective eligibility review requests: 20 business days from receipt. Page: 7

9 Section III What eqhealth looks for when reviewing request The eqhealth Review Team, who we are: eqhealth is a multidisciplinary team. Diabetes Self-Management Training Services reviews are conducted by registered nurses and physicians. Administrative Screening When the review request is faxed to eqhealth Solutions, the intake staff screens the request to ensure all Medicaid eligibility requirements are satisfied. If there is an eligibility issue or the services are not subject to review, the review will be cancelled and the provider will be notified. Clinical Reviewer (1st Level) Screening of the Request The first level reviewer evaluates the entire request for compliance with Mississippi Admin Code and for compliance with documentation requirements. Screening for Compliance with Administrative Code If the first level reviewer identifies an issue with the request related to Medicaid requirements, a technical determination (TD) is rendered and the review will not proceed. The requesting provider is notified by phone. Since a technical determination is rendered for an administrative reason (not a clinical or medical necessity reason) it is not subject to reconsideration. If all required information is not received with the request, the first level reviewer pends the request. Clinical Information: Pended and Suspended Requests Pended and Suspended Review Requests When the clinical reviewer pends a review request: You will receive a phone call and a written notification containing details of the missing information and response instructions. The requested information must be submitted within ten (10) business days for an admission, extension, or retrospective review. If eqhealth does not receive the information within ten (10) business days for an admission or retrospective review from date of notification, the review request is suspended and no further review Page: 8

10 processing occurs until the additional information has been received. Written notification is issued when the request is suspended. If the information is submitted at a later date, eqhealth Solutions re-opens the request and reviews the services beginning from the date the complete information was received. eqhealth cannot backdate the request. First Level Medical Necessity Review Process When all information has been submitted and the clinical information screening is completed, the first level reviewer performs the medical necessity review. When performing the review, the first level reviewer evaluates all clinical information recorded in eqsuite and evaluates all submitted information. Clinical Guidelines eqhealth Solutions uses Administrative Code as a tool when making clinical determinations concerning the medical necessity of care. Approvals First level reviewers apply Medicaid approved clinical guidelines to determine whether the services are medically necessary or otherwise allowable under Medicaid regulations. If the criteria are satisfied, the clinical reviewer renders an approval determination for each line item, for the number of units requested and for the requested time frame or regulations maximum. Approval Notifications Approval notifications are generated for all services determined to be medically necessary. Electronic notifications are generated to the treating practitioner/provider which will contain: o the authorized service(s), the number of units, the authorization period, and the Treatment Authorization Number (TAN). o eqhealth transmits the Treatment Authorization Number (TAN) to the Medicaid fiscal agent. Referral to a Second Level Reviewer (SLR) First level reviewers may not render an adverse determination. Any requests which they cannot approve are referred to a SLR. Page: 9

11 Second Level (Physician) Review Process The SLR uses clinical experience and knowledge of generally accepted professional standards of care and judgment. Approval Determinations and Pended Reviews For each service the first level reviewer was unable to approve, the SLR determines the medical necessity of the service and the number of units and service duration requested. Approval on the basis of available information - When the available information substantiates the medical necessity of the service(s), units and service duration, the SLR approves them as requested and the review is completed. Notifications are issued as described under First Level Medical Necessity Review Process: Approval Notifications. You may receive a pend if additional information is required: If a SLR is not able to approve the service(s) on the basis of the available information, the SLR may attempt to speak with the treating practitioner to obtain additional or clarifying information. If the treating practitioner is not available when the SLR calls, the SLR may issue a pend determination at that time. Any information obtained telephonically or via pend is documented in the review record. If the SLR is able to authorize the service(s) on the basis of the additional or clarifying information obtained, an approval determination is rendered. The review is complete and notifications are issued as described under First Level Medical Necessity Review Process: Approval Notifications. SLR pended review requests - If the treating practitioner is not available when the SLR calls, the SLR may issue a pend determination at that time. Any additional information received telephonically or via fax is documented in the review record. o The information must be provided within ten (10) business days. o If the requested information is not received within ten (10) business days, the review is suspended until additional information requested by the physician is obtained. Page: 10

12 Adverse Determinations Only a SLR may render an adverse determination (denial). As noted in the preceding section, prior to rendering an adverse determination the SLR may attempt to discuss the request with the treating practitioner. Denial The SLR may render a (full) medical necessity denial of one or more line items. eqhealth will notify the provider by phone when there is a denial decision Within one (1) business day of the determination, the final written notification of the denial is generated and mailed. Written denial notifications also are mailed to the beneficiary or the beneficiary s parent or legal guardian/caretaker. The written notification includes information about reconsideration rights for providers and beneficiaries. Notifications are issued to the parties as described in the preceding section, Denial. For the services that are approved, the approval information is provided to the fiscal agent. Reconsideration Reviews The provider, the ordering physician or the beneficiary (or his or her parent/guardian/caretaker) may request a reconsideration of an adverse determination. Denial notices contain instructions for requesting reconsideration. The request must be received at eqhealth Solutions within 30 calendar days of the date of the denial notification. Additional information may be found in our Reconsideration Manual. Page: 11

13 Section IV IF YOU NEED INFORMATION OR ASSISTANCE eqhealth Solutions offers a variety of ways to obtain information or assistance when submitting prior authorization requests. Questions about the Utilization Management Program For questions or information about the Diabetes Self-Management Training Services Utilization Management Program, the following resources are available: Resources available on our Web site: o eqhealth. eqhealth s HELPLINE Toll free number To pre-schedule a time and date to speak with someone from the eqhealth Education Staff, you may submit a Microsoft Calendar meeting request to Education@eqhs.org eqhealth Solutions HELPLINE For general inquiries, or questions about specific requests, or if you have a complaint, or a compliment, contact our HELPLINE Toll free number available 8:00AM 5:00PM Central Time, Monday through Friday. If you call during non-business hours, there is the the option to leave a message. If you prefer to write to us, there are two options. Fax the information to our toll free Quality Concerns fax number: or mail the information to: eqhealth Solutions- Mississippi Division Attention: Quality Concerns 460 Briarwood Drive, Suite #300 Jackson, MS Page: 12

14 REVIEW WORKFLOW Request for Certification Technical Denial is issued Provider receives electronic/ written notification No Is Beneficiary EPSDT eligible? Yes Refer for Second Level (Physician) Review No First Level Reviewer determines if clinical information is complete. Yes No First Level Reviewer Request Additional Information (Pend) Second Level (Physician) Review Meets Clinical Guidelines? Yes Information received Suspend Review *See Note below Provider receives electronic/ written notification No Approved May contact rendering provider to ask for additional information Information received Yes Clinical determination by Second Level (Physician) Reviewer Yes Data Entry of Determination, Item, Timeframe Assigned and Treatment Authorization Number (TAN) assigned. Provider receives outcome notification. Yes No Suspend Review *See Note below Provider receives electronic/written notification. Information Received Data Entry of Determination, Item, Timeframe Assigned and Treatment Authorization Number (TAN) assigned. Denied Treatment Authorization Number (TAN) transmitted to fiscal agent (MMIS). Provider receives electronic/written & verbal notification. Data Entry of Determination. Treatment Authorization Number (TAN) transmitted to fiscal agent (MMIS). Provider receives electronic/written and verbal notification which includes reconsideration instructions. Medicaid beneficiary receives written denial notice, and reconsideration instructions. Note: eqhealth holds request indefinitely. If the provider has not responded within 45 business days, the request is suspended. This means the request remains pended waiting for the provider to complete deficits in the clinical information but is removed from active eqhealth work queues. However if appropriate the request may be reactivated by the requestor/provider and processed if appropriate. Page: 13