Specialty Therapy & Rehab Services (STRS) Requesting an Authorization

Transcription

1 Specialty Therapy & Rehab Services (STRS) Requesting an Authorization

2 Partnership Celticare Health/ Cenpatico Providers Members Improving Lives 2

3 STRS Clinical Services Utilization Management Clinical Provider Training Care Coordination 3

4 Getting Started Benefit Coverage/Limitations CarePlus covers outpatient PT, OT and ST services for members age Cenpatico is not delegated for EPSDT or ECI requests Benefit coverage: There are no limits, requests must meet Medical Necessity Criteria. Home Health: Cenpatico is now delegated for home health review for the Celticare Health -CarePlus members. See the following slides for instructions for home health therapy authorizations. 4

5 Getting Started Prior Authorization Prior Authorization is required for all Physical (PT),Occupational (OT), and Speech Therapy (ST) services. Exceptions are as follows: Evaluations: 1 initial evaluation per provider, per discipline, per 12 months without authorization for PAR providers. Re-evaluations: 1 re-evaluation per provider, per discipline, per 12months without authorization for PAR providers. Non-PAR providers: Prior authorization required for all evaluations and re-evaluations. Post-Surgical Requests: With a verbal/written doctor s order we can approve up to 5 post-surgical visits telephonically for urgent therapy needs. 5

6 Requesting Therapy Services Home Health PT,OT and ST therapy As of January 1, 2016 Celticare Health will be updating the Authorization process for Home Health Services. All PT, OT and ST home health services will be authorized through Cenpatico. Fax all PT, OT and ST requests to Cenpatico at All PT, OT and ST notification or therapy requests should use the Cenpatico Outpatient Treatment Request form: 6

7 Requesting Therapy Services Home Health PT,OT and ST therapy Cont d Home Health Services and Prior Authorizations At-A-Glance The first six (6) Home Health visits to include evaluation and treatment are automatically approved Cenpatico requires notification prior to completion of the sixth visit. Providers should fax the following documents to (855) : Cenpatico Outpatient Authorization Form(OTR) Physician s written order, verbal order, or 485 form All subsequent requests will require prior authorization and required clinical documentation. 7

8 Requesting Therapy Services Required Documentation A complete request includes: Outpatient Treatment/Home Health Request Form (OTR) Therapy Evaluation/ Plan of Care (POC) Evaluation should include: Medical/therapy history Assessment of patient s abilities and deficits Standardized testing/clinical observations Current & previous level of function Plan of Care should include: Short/long term goals Baseline function for goals Home exercise plan Specific frequency/duration Additional narrative explanation if needed for consideration 8

9 Required Documentation Therapy Orders Prescriptions are accepted if: Signed by prescribing provider o o o Must be physically or electronically signed Rubber stamped signatures will not be accepted Verbal orders for home health have special conditions that must be met (see next slide) Prescribing provider is one of the following: MD, DO, PA, ARNP, APRN Dates of service on prescription are current 9

10 Required Documentation Therapy Orders Cont d Outpatient therapy: Prescriptions are valid for 1 year from the initial evaluation unless a shortened duration is indicated in the order. Home Health Services: Verbal orders Initial requests - signed by RN from a physician and valid for 30days Subsequent requests signed by RN acceptable if submitted along with copy of MD signed 485 from previous request Manuscript or electronic prescription Valid for 60 days 10

11 Evaluation/Assessment Key Elements Diagnosis with date of onset or exacerbation should be included Assessment should include, but is not limited to: Standardized and functional evaluation scores Clinical observations to support the identified functional deficits Standard Score when appropriate for the Member s diagnosis/disability Informal assessment & narrative Medical/Developmental history Previous level of function Summary of results achieved 11

12 Plan of Care Key Elements Current Plan Of Care(POC) is required for all authorizations The written plan of care must include all of the following, but is not limited to: Short and long term functional treatment goals that are realistic, specific and measurable Treatment techniques and interventions to be used to include frequency, and duration required to achieve measurable goals Home Education/Exercise program for the member and/or primary caregiver Summary of results achieved during previous periods of therapy, if applicable 12

13 Plan of Care Objective & Measurable Goals Objective Goals are SMART, not Vague (be SMART) SPECIFIC Goals/Interventions MEASURABLE ATTAINABLE REALISTIC TIMELY Goals must address ADL Functional Needs and meet Medical Necessity Guidelines 13

14 Clinical Documentation Common Errors Standardized developmental scores are within 1.5 standard deviations from the norm or less than 20% delay Standardized evaluations utilized for inappropriate population No objective measurements of deficits No objective measurements of improvement All objective measurements have not been administered to rule out concomitant diagnoses 14

15 Clinical Documentation Common Errors Clinical information or severity of deficits submitted does not support the frequency or duration of requested services No updated clinical information or progress submitted to support reauthorization of services Goals are written for deficits that are not documented Plan of Care does not address the documented deficits 15

16 OTR Essential Elements Member Information Member Name Copy exact name as ID card Include hyphenated names Be certain the first name is not a nickname Medicaid ID Copy exact number as ID card Date of Birth/Address Complete member section in full to avoid delays or incomplete requests 16

17 OTR Essential Elements Provider Information Treating Provider Information Facility/Provider NPI Tax ID Physical address Contact phone number Fax number Prescribing Provider Physician name (MD or healthcare practitioner who prescribed therapy) Contact phone number 17

18 OTR Essential Elements Diagnosis/Disorder Primary Diagnosis Condition(s) referred for therapy Dictated by physician Treating Diagnoses: Condition(s) therapist is providing rehabilitation or care Utilize ICD-10 codes Please provide an actual ICD-10 code in the Primary Diagnosis box 18

19 OTR Essential Elements Common Errors: Provider Section/Diagnosis Provider Section Incorrect NPI Number used for provider Prescription not updated Incorrect Prescribing Provider information Prescribing Provider phone number listed inaccurately Diagnosis Improper diagnosis Diagnosis on the OTR doesn t match the referring diagnosis Diagnosis changes with new request for same condition 19

20 OTR Essential Elements Retro Dates of Service Start and End Dates: Authorizations will not be retroactive, with the exception of extraordinary circumstances Ex: inaccurate information received from Celticare Health Plan or Cenpatico; retro eligibility; new insurance coverage Start date should be no earlier than the date faxed/submitted Retain a copy of fax confirmation sheet with the time/date stamp 20

21 OTR Essential Elements Requesting Treatment Determining a treatment start: enter the date the member will begin therapy (this date should be after the initial evaluation) Frequency: Capture it in times per month or week; cannot be a range of frequency, i.e. 2-3 times per week Duration and/or frequency on OTR must match with plan of care Total Visits Requested: give a total number of visits for the span of the authorization 21

22 OTR Essential Elements Requesting Additional Treatment Plan of Care(POC) requirements for additional visits beyond the initial therapy request (i.e. subsequent requests): Outpatient Services: POC cannot exceed 6 months Updated POC required with every subsequent request Home Health Services: POC cannot exceed 60 days Updated Therapy POC required with every subsequent request 22

23 OTR Essential Elements Requesting an extension: Dates of Service extensions: The Dates of Services can be extended for missed visits as long as: The current authorization has not expired The script on file will include the extended dates of service The plan of care covers the newly requested dates of service To request an extension: 1 week extension: Call (855) to make the request Requesting more than a 1 week extension: Fax in a completed Outpatient Treatment Request Form (OTR) to (855) to our Utilization Management Department with the new end date of services and the reason for the extension. Include a Fax Cover sheet that indicates: "Date extension requested. Be sure to include information on the reason for the date extension request. (Additional information may be requested in order to approve the extension. 23

24 OTR Essential Elements Common Errors Multiple Initial Evaluations billed by same Provider Frequency or duration on OTR is different than on the POC Prior Authorization not obtained for a 2 nd initial evaluation/reevaluation per discipline within a rolling year Authorization Start Date section filled in with date that is prior to date submitted Initial evaluation date listed as the date treatment started. In MA a provider is not able to bill an evaluation and treatment on the same day Frequency or duration on OTR is significantly different than on the POC and there is no explanation Frequency/Duration on POC and OTR are not followed once treatment has begun Dates of service on OTR do not match the dates on the POC Frequency documented as a range (e.g. 1-3/week) 24

25 Provider Communications The Following are types of communication a provider may receive from Cenpatico Utilization Management: Feedback Letter: This type of letter will outline what is needed with any future therapy requests to help justify medical necessity. This will be sent along with an approval notice. Problem Letter: This letter will communicate an outright rejection of the authorization request based on one of the following reasons): Member eligibility could not be verified Provider could not be found Plan of Care missing or illegible Prescription/Order missing Retro dates were requested (the prospective dates will be processed) Medicaid is the secondary payer Your request will not be processed if you receive a problem letter 25

26 Provider Manual The Celticare Health Provider Manual offers information on our policies and procedures for serving our Members. This Manual is part of your Agreement with us and will help you ensure compliance with all regulatory authorities and program requirements. The Provider Manual covers: Claims Program Authorization Process Eligibility Verification Credentialing Policies Medically Necessary Criteria Clinical Practice Guidelines Appeals/Denials Process Utilization Management Guidelines Quality Improvement Guidelines Forms A copy of the provider manual can be found online at 26

27 Authorization Request Process Outpatient Treatment Request Physician's Rx or Referral Plan of Care 27

28 Requesting Authorization Frequently Asked Questions Q: WHAT is needed? A: OTR form, Evaluation/Plan of Care, Prescription Q: WHEN do I send in the request? A: Requests should be sent in after completing an initial evaluation, or at end of an existing authorization period(before initial evaluation if a non-contracted provider). Q: WHERE do I send it? A: A completed Cenpatico/STRS: Outpatient Treatment Request Form(OTR) and supplemental clinical documentation should be faxed to(855) Q: HOW long will it take? A: Once Cenpatico is in receipt of all required documentation, our internal goal is to turnaround each request within 5 Business days, but providers will get a determination letter no later than fourteen (14) calendar days after the request was received. 28

29 Additional Information STRS Contacts and Resources Health Plan Website: Medical Necessity Criteria: CeltiCare Health Phone Number (CarePlus): (855) Cenpatico Fax Number: (855) Claims Phone Number: (855) Claims Address: PO Box 3080, Farmington, MO

30 Questions? 30