Precertification Frequently Asked Questions

Transcription

1 Precertification Frequently Asked Questions 1. Which HMSA plans require precertification from Landmark? 2. How do I submit a Treatment Plan? 3. How do I print a copy of my completed e Form? 4. How do I know whether to submit the Fast Form or the standard Treatment Plan e Form? 5. How does Landmark determine when a Treatment Plan qualifies for the Fast Form? 6. Does a case qualify for Fast Form if I have been treating the patient without precertification for the first eight visits (for the Basic UM tier or OT)? 7. Does a case qualify for Fast Form if there is an authorization within the prior 90 days, if the new request is for a different practitioner (or diagnosis, or type of therapy)? 8. Can I use the e Forms for out of network services? 9. What provider ID number should I use on the Treatment Plan? 10. May I call in to request precertification? 11. How far in advance can I submit a Treatment Plan? 12. Can I change the Start Date of an authorization? 13. How do I extend the End Date of an authorization? 14. Can I request more visits after my authorization expires? 15. How do I request more visits within a previously authorized timeframe? 16. Is a new Treatment Plan required if a patient has surgery on the body part being treated in therapy? 17. How will I be notified of Landmark s review determination?

2 18. How quickly will Landmark review my Treatment Plan and get back to me? 19. What determines medical necessity? 20. What is short term therapy? 21. Why are authorizations limited to a 30 day treatment period? 22. I received a fax from Landmark stating that information was missing on my Treatment Plan. What should I do? 23. Is it okay to use non specific diagnosis codes? 24. Can I include DME supplies on a precertification request to Landmark? 25. How do I check the status of my Treatment Plan? 26. How do I appeal services not approved as medically necessary? 27. Who do I call to verify member benefits? 28. Where do I submit claims? 29. What if I did not obtain precertification and my claim was denied?

3 1. Which HMSA plans require precertification from Landmark? Landmark s utilization review services apply to physical and occupational therapies provided to patients in the following plans: HMO/PPO Fed 87 QUEST Akamai Advantage For all other HMSA groups (e.g., FEP and 65C Plus) please continue to follow applicable HMSA or group specific policies and procedures. Note that claims data from all of your HMSA members in the four plans above will be included in your PPS. 2. How do I submit a Treatment Plan? To maximize efficiency, precertification requests should be submitted electronically on Landmark Connect at Online e Forms are easy to use and ensure that requests include complete information. Also, because the Fast Form is available online through the e Form process, responses to initial treatment requests completed online are usually presented to you immediately. The Fast Form is a short, easy to use version of the e Form that offers immediate, online precertification for a patient s initial course of care. Alternatively, you may fax the Physical/Occupational Therapy Treatment Plan form to Landmark at (888) There is no paper version of the Fast Form. Faxed forms follow standard utilization management processes and turnaround times. Do not submit both an e Form and a faxed Treatment Plan for the same patient for the same dates of service. 3. How do I print a copy of my completed e Form? All submitted e Forms are available on Landmark Connect in a print friendly format. Landmark transfers the information you provide to a PDF document for you to view and print for your records. 4. How do I know whether to submit the Fast Form or the standard Treatment Plan e Form? There is no decision for you to make on the form you submit. The web site, Landmark Connect, will automatically display the appropriate form for your patient, depending on your patient s precertification history and eligibility for the Fast Form. 5. How does Landmark determine when a Treatment Plan qualifies for the Fast Form? Treatment Plans submitted electronically qualify for the Fast Form if the request is for the patient s initial treatment. Landmark considers the request to be for initial treatment if the patient has no precertifications on file within 90 days of the request. 1

4 6. Does a case qualify for Fast Form if I have been treating the patient without precertification for the first eight visits (for the Basic UM tier or OT)? Yes. The initial precertification request qualifies for the Fast Form, provided that there are no authorizations on file within 90 days of your request. 7. Does a case qualify for Fast Form if there is an authorization within the prior 90 days, if the new request is for a different practitioner (or diagnosis, or type of therapy)? No. A patient s care does not qualify for Fast Form if there are any physical and/or occupational therapy authorization within 90 days of your request. The existence of a authorization within 90 days, regardless of provider, results in the need for our clinical peer reviewers to evaluate more clinical information, as provided on the standard Treatment Plan. 8. Can I use the e Forms for out of network services? Yes. When an e Form is submitted for an HMO or QUEST member, provider network participation is verified and the request is processed accordingly. 9. What provider ID number should I use on the Treatment Plan? Independent practitioners should use their individual provider ID number whether practicing within a group or individually. Facility/hospital outpatient clinic providers should use the appropriate hospital ID number (usually contains the letter H). Data for PPS reports are based on the provider s ID number on the claim. In order for the data to aggregate properly, the correct ID number must be used. To verify or confirm your provider ID number, please call HMSA. 10. May I call in to request precertification? No. Treatment Plans must be either completed online via Landmark s secure web site or faxed utilizing Landmark s Treatment Plan to (888) How far in advance can I submit a Treatment Plan? Submit Treatment Plans no more than five days prior to the proposed Start Date. Requesting care too far in advance does not allow you to report up to date patient subjective complaints and examination findings. For a surgical patient, please hold your request until five days before the proposed Start Date of post operative treatment. To avoid a delay in receiving a review determination, include the current objective and subjective findings paying particular attention to the patient s progress for the services you have already provided. The Date of Assessment you report should be within seven days of your request. 2

5 12. Can I change the Start Date of an authorization? You may change the Start Date up to seven calendar days prior to the original Start Date of an authorization. Contact Landmark at (888) to request the adjustment. The Start Date of an authorization cannot be adjusted to a later date. 13. How do I extend the End Date of an authorization? Submit a Date Extension Request form using the Landmark Connect e Form, or download the Date Extension Request form and fax it to (888) The Date Extension policy applies to all precertification requests. We will approve one extension per treatment episode up to a maximum of 30 days. You must request your date extension within 30 days after the previously approved Treatment Plan End Date. 14. Can I request more visits after my authorization expires? Yes. If you believe a patient will require therapy after completing the authorized number of visits, submit an updated Treatment Plan to request continuing care. Keep in mind that Treatment Plan periods cannot overlap. Therefore be sure the Start Date of your request for continuing care is after the End Date of your previous authorized visits. 15. How do I request more visits within a previously authorized timeframe? If there is additional clinical information not previously submitted with a Treatment Plan, you may request additional visits within an authorized timeframe. To do so, you must explain how many and why additional visits are required and include all evaluations, progress summaries, daily treatment notes, and flow sheets for review. FAX the original precertification letter and supporting documentation to (888) Example: Six visits are authorized from 5/1 5/31. On 5/20, you determine that 2 more visits are necessary within this period. FAX additional clinical and supporting information with a copy of the authorization letter for 5/1/ 5/31. If care continues beyond 5/31, submit a new Treatment Plan for 6/1 and beyond. 16. Is a new Treatment Plan required if a patient has surgery on the body part being treated in therapy? Yes. If a patient has surgery on the body part being treated in therapy, and therapy is contemplated post surgery, submit a new Treatment Plan request. A new precertification request is required. 3

6 17. How will I be notified of Landmark s review determination? Written notifications of clinical review determinations are provided online on Landmark Connect. To view letters, login and access the Treatment Plans inquiry feature under the Patient Status menu. We will also fax or mail you a copy of each determination letter. 18. How quickly will Landmark review my Treatment Plan and get back to me? Landmark will generally review your Treatment Plan and respond with its precertification determination within three business days. If your Treatment Plan is not filled out correctly or information is omitted, the review process may be delayed. Additionally, the clinical reviewers on occasion will request additional information. If additional information is needed you will be notified in writing within three business days of receipt of your Treatment Plan. 19. What determines medical necessity? Therapy is medically necessary when required to achieve a specific diagnosis related goal that will (i) significantly improve impaired neurological and/or musculoskeletal function stemming from a congenital anomaly or (ii) restore neurological and/or musculoskeletal function that was lost or impaired due to an illness, injury or prior therapeutic intervention. Significant is defined as a measurable and meaningful increase (as documented in the patient's record) in the patient s level of physical and functional abilities that can be attained with short term therapy, usually within a two to three month period. In addition all therapists must follow these HMSA policies: The therapy Treatment Plan should be designed to transfer responsibility to the patient or patient caregiver through education and instruction so the patient or patient caregiver may continue therapy in the home setting. The patient must be under the care of a physician for a condition for which therapy is medically necessary, reasonable and appropriate. The services must be considered, under accepted standards of medical practice, to be a specific and effective treatment for the patient's condition. 20. What is short term therapy? Generally, short term is less than 90 days in length and all the therapy delivered during that period of time must be skilled and directed at restoring function. If the patient does not have a reasonable expectation of achieving significant improvement in a reasonable and predictable period of time, therapy is not a covered benefit. Significant is defined as a measurable and meaningful increase (as documented in the patient's record) in the patient s level of physical and functional abilities that can be attained with short term therapy, usually within a two to three month period. Short term therapy is defined as the number of visits necessary to improve or restore neurological or musculoskeletal function required to perform normal activities of daily 4

7 living, such as grooming, toileting, feeding, etc. Therapy beyond this is considered longterm and is not covered. Maintenance therapy, defined as activities that preserve present functional level and prevent regression, is not covered. 21. Why are authorizations limited to a 30 day treatment period? Authorization for a 30 day timeframe allows the therapist to assess the patient s response to treatment. If additional care is required, updated clinical information must be submitted along with a new precertification request. 22. I received a fax from Landmark stating that information was missing on my Treatment Plan. What should I do? You must fax back your original Treatment Plan submission to (888) along with the updated missing information. Please include the letter from Landmark after your cover sheet. Submitting your Treatment Plan online reduces the likelihood that your request will be delayed due to missing information. 23. Is it okay to use non specific diagnosis codes? No. Use the most specific ICD 9 codes available. It is to your advantage to code as specifically as possible as some codes are identified as more complex cases with higher risk adjustment factors. Proper specific coding will affect your Risk adjusted Visits per Episode (RAVE) and will result in more accurate reporting on your PPS. 24. Can I include DME supplies on a precertification request to Landmark? You may document that a patient requires specialized DME equipment; however, orthotics, DME and supplies will not be authorized by Landmark. Follow the normal HMSA process for all DME precertification requests. 25. How do I check the status of my Treatment Plan? You may check the status of a Treatment Plan review online through Landmark s secure web site, Landmark Connect, at (select Patient Status from the menu). Or call Landmark at (888) How do I appeal services not approved as medically necessary? You may appeal the precertification determination; the precertification determination letter provides appeal information. Or you may speak directly with a Landmark clinical peer reviewer. To discuss your case, call Landmark s customer service number (888) and ask to speak with a clinical peer reviewer. 27. Who do I call to verify member benefits? Member benefits for therapy can be verified by following the normal HMSA process for eligibility of benefits. 5

8 28. Where do I submit claims? There is no change in the claims process. Continue to submit claims directly to HMSA. 29. What if I did not obtain precertification and my claim was denied? If you did not request precertification for services and your claim was denied, you must submit a Treatment Plan to Landmark for retrospective review. Retrospective review requests must also include the initial evaluation and all periodic reassessments and daily progress notes for the services provided. Landmark has up to thirty (30) calendar days to process the request and provide a determination. Once you have received the determination letter from Landmark, and if the services have been approved, claims may be re submitted to HMSA for processing. 6