Service Authorization. February 2017

Service Authorization February 2017

Overview Service Authorizations Identifying Service Authorizations Requirements Requesting Service Authorizations 2

Service Authorizations 3

Service Authorization Certain services, procedures, and medications covered by Alaska Medical Assistance require service authorization (SA) An SA is an authorization to provide a service to a member Some services require an SA before those services can be rendered Refer to section II of the billing manuals Refer to fee schedule Complete request accurately and completely SA does not guarantee payment 4

Identifying Service Authorizations Requirements 5

When To Get a Service Authorization Service authorizations may be required for whole categories of service or individual services/items depending on the type of service. Examples of each include: Categories of Service Outpatient imaging Enhanced adult dental procedures Transportation Hospital stays longer than three days Hospice Home health Behavioral health Waiver and PCA Individual Service or Item Certain hospital stays three days and less Specific surgical procedures Chiropractic services for children under six years old Some services in the following service categories: Child dental services Audiology services Physician services 6

Billing Manual Authorization Information 7

Fee Schedules Fee schedules tell you: What services are covered Maximum allowed reimbursement Additional documentation requirements Other special considerations Fee schedules can be found on http://medicaidalaska.com in the Documents & Forms section under Fee Schedules. 8

Dental Fee Schedule Authorization Information 9

Authorization Requests 10

Authorization Request Coding Requirements Authorization Requests ICD-9 codes must be used for dates of service on or before 9/30/2015 ICD-10 codes must be used for dates of service on or after 10/1/2015 Service Authorization requests with service dates spanning 10/1/2015 must incorporate both ICD-9 and ICD-10 codes Behavioral Health Authorization Requests Treatment plan begin dates on or before 9/30/2015 must continue to be use DSM-IV-TR codes Treatment plan begin dates on or after 10/1/2015 must use ICD-10 diagnosis codes 11

Service Authorization Approving Agencies Each of the following agencies review and approve SA requests for specific services; refer to the appropriate billing manual for an explanation of the SA process: Conduent Magellan Medicaid Administration (MMA) Qualis Health Division of Senior and Disabilities Services (DSDS) 12

Services Authorized by Conduent Conduent authorizes these select professional/outpatient services: Air Ambulance (Medevacs and Backhauls) In-Office Injections (Some J-code drugs Behavioral Health Limited Surgical Procedures Chiropractic Care (Children Under 6) Maternal/Newborn Stays (Meeting Certain Criteria) Dental Nutrition Services Durable Medical Equipment/Supplies Private Duty Nursing Hearing Prosthetics and Orthotics Home Health Respiratory Therapy Home Infusion Services exceeding the established service limits Hospice Transportation (Emergency and Non-Emergent) Incontinence Supplies Vision 13

Services Authorized by Conduent Service authorizations can be requested through Conduent using the following options: Submitting an authorization request form by mail to: Service Authorization PO Box 240808 Anchorage, AK 99524-0808 Submitting an authorization request form by fax to: Behavioral health request forms - 866.653.1435 Dental request forms 907.644.9861 All other request forms - 907.644.8131 All services must be requested on the correct service authorization request form Conduent service authorization forms are available at http://manuals.medicaidalaska.com/docs/forms.htm Always follow the instructions for completion and submission given on the forms 14

Service Authorization Request 15

Service Authorization Request 16

Services Authorized by Conduent Behavioral Health Mental health physician and community behavioral health clinic providers must request service authorizations for behavioral health treatment when the amount of services indicated exceeds the annual service limitations set out by Alaska Medical Assistance The behavioral health provider is responsible for keeping track of service limits for their members and submitting SA requests when the member s behavioral health treatment plan identifies the need for frequency and duration of services in excess of the daily or annual service limits 17

Services Authorized by Conduent Behavioral Health Behavioral health authorization requests must: Be documented in the clinical record Include a listing of AK Medicaid reimbursable services and expected duration of services as set forth in the treatment plan Affirm that the appropriate parties have reviewed the treatment plan and agree that the requested services are medically necessary Be submitted on the correct form for the requested service Community Behavioral Health Clinic Services Mental Health Physician Clinic Services Residential Behavioral Rehabilitation Services 18

Community Behavioral Health Services Request Providers should continue to use this SA request form to request services under 12 hours per day 19

Community Behavioral Health Services Request 20

Community Behavioral Health Services Request 21

Community Behavioral Health Services Request Providers should use this new form to request services that go beyond the allowed limits of 12 hours per day. Refer to the accompanying guidance document for more details. 22

Community Behavioral Health Services Request 23

Community Behavioral Health Services Request 24

Community Behavioral Health Services Request 25

Mental Health Physician Clinic Request 26

Mental Health Physician Clinic Request 27

Residential Behavioral Rehabilitation Services Request 28

Residential Behavioral Rehabilitation Services Request 29

Residential Behavioral Rehabilitation Services Request 30

Services Authorized by Conduent Conduent and Qualis share responsibility for authorizing certain maternal and newborn admissions. 31

Services Authorized by Conduent CMN Use a Certificate of Medical Necessity (CMN) or CMN for Incontinence Supplies to request an authorization for the following services or items: Durable Medical Equipment / Supplies Hearing Aids / Accessories Home Infusion Incontinence Supplies Nutrition Services Prosthetics and Orthotics Respiratory Therapy (Oxygen Equipment, etc.) Any services exceeding the established or approved service limits if the initial authorization required a CMN 32

Services Authorized by Conduent CMN 33

Services Authorized by Conduent CMN 34

Services Authorized by Conduent CMN 35

Services Authorized by Conduent CMN 36

Services Authorized by Conduent Incontinence 37

Services Authorized by Conduent Incontinence 38

Services Authorized by Conduent Incontinence 39

Services Authorized by Conduent - Transportation Emergency Transportation Alaska Medical Assistance covers emergency medical transportation to the nearest medical facility capable of handling that medical emergency IHS beneficiaries may choose to travel to the nearest IHS or Tribal facility Authorization for emergent services are made retroactively Medevac Reimbursements Submit medical justification and all required flight documentation within two business days of the member s transport date Complete Air Ambulance Flight Summary and attach to claim form Available at http://manuals.medicaidalaska.com/docs/forms.htm 40

Services Authorized by Conduent - Transportation Non-emergent transportation and accommodation can be submitted by: Alaska Medicaid Health Enterprise Website or Calling 907.644.6800, option 5 or 800.770.5650, option 1, 2 Have member s information available for request: Alaska Medical Assistance ID number First name Last name Date of birth Address, including city, state and zip code Referring and receiving providers Reason for travel Diagnosis Origin and destination Escort information - first and last name, date of birth, reason escort is needed 41

Transportation Request 42

Transportation Request 43

Transportation Request 44

Services Authorized by Conduent Surgeries Most surgical procedures are authorized by Qualis Health Any surgical procedure requiring a service authorization that is not on the Qualis Health Pre-Certification list, such as rhinoplasty and blepharoplasty, is authorized by Conduent The surgeon and the facility must be enrolled with Alaska Medical Assistance 45

Services Authorized by Conduent Dental The following services require authorization requests for dental: All enhanced adult dental services Prosthodontics Orthodontia Certain children s and adult emergent dental services These are identified in the Dental Fee Schedule 46

Dental Service Authorization Request 47

Vision Service Authorization Request 48

Attachment Requirements Many authorization requests require additional supporting documentation before they can be approved. Examples of supporting documentation could be: Prescription Therapist assessment and/or plan of care Clinical notes or letter of medical need Pricing information Documentation requirements may be found in associated billing manuals and fee schedules Attach all relevant documentation to the initial request to expedite the authorization process 49

Updating Conduent Service Authorizations When the information on the SA does not match the services provided, you will need to update the SA before submitting your claim. Authorization Type Transportation Behavioral Health Dental All Others Actions Needed Fax Transportation Authorization Update Form or contact Travel SA Dept. Submit a new form with total needed units, check the Update to Existing SA block and include the SA number. Fax requested changes to Dental SA Dept. Submit original approved authorization form with needed changes and required justification. Dental authorization changes must include: Additional or adjusted services needed with supporting documentation Reason(s) treatment could not be completed within the original dates, if extending a longterm treatment plan (such as orthodontic services) New estimated date for completion and any documentation to support extending the length of treatment 50

Updating Conduent Service Authorizations 51

Dental SA Update Request 52

Service Authorization Request Processing When authorization requests are received, Conduent reviews: Member eligibility and provider enrollment Requested services and units Any medical justification and supporting documentation History of current and previous authorizations, including any service limits Authorization is approved, denied, or pended (if additional information is needed) Copy of authorization decision is forwarded to provider listed on the SA request 53

Services Authorized by Magellan Magellan Medicaid Administration (MMA) oversees the pharmacy program including service authorizations and billing. Certain medications require an authorization to be covered by Alaska Medical Assistance The Division of Health Care Services maintains the Prior Authorized Drug List and Interim Prior Authorized Drug List Drug lists and authorization forms are available online at http://dhss.alaska.gov/dhcs/pages/pharmacy/medpriorauthoriz.aspx SA forms can also be requested from MMA Only the prescriber may request medications, unless otherwise indicated on the either listing, by: calling the MMA Clinical Call Center at 800.331.4475 or faxing the appropriate completed request form to 888.603.7696 54

Prior Authorization Medication List by Category 55

Preferred Drug List 56

Services Authorized by Qualis Health Qualis Health authorizes certain facility stays, procedures, and outpatient imaging as part of utilization management for Alaska Medical Assistance. Inpatient acute care hospital admissions exceeding three days Long-term acute care facility admissions and continued stays Inpatient and Residential psychiatric services Outpatient imaging Magnetic resonance imaging (MRI) Positron emission tomography (PET) Magnetic resonance angiography (MRA) Single-photon emission computed tomography (SPECT) Select inpatient and outpatient diagnoses, procedures, and transplants, regardless of length of stay Identified in Select Diagnoses and Procedures Pre-certification List and Outpatient Imaging, available under Review Guidelines at http://www.qualishealth.org/healthcareprofessionals/alaska-medicaid-health-care-services/provider-resources 57

Services Authorized by Qualis Health Three-Day Stay Guidelines (Inpatient Hospital) A medical necessity review must be obtained if patient is not discharged by the third day (day of admission is day one) Review must occur on or before day four of the stay Only exception to standard three-day stay guidelines are maternal and newborn stays related to childbirth 58

Qualis Health Contact Qualis business hours are 6:30am 5:00pm AKST, Monday Friday, excluding scheduled holidays. Qualis Health Provider Portal (QHPP), a secured web-based utilization review system providers must use to submit review requests For more information, refer to www.qualishealth.org Utilization Review Phone: 888.240.0437 Fax: 800.826.3630 Physician Hotline (Peer-to-Peer Conversations) 877.292.2615 59

Qualis Health Review Submission Deadlines Providers must use the QHPP to submit review requests Untimely review requests will not be considered unless extenuating circumstances exist. Providers must adhere to the following submission deadlines: Review Type Pre-service Urgent review* Submission Deadline Within 1 working day of service begin date Pre-service Non-urgent review* Minimum 7 calendar days prior to scheduled service date and up to 4 weeks prior Concurrent Urgent review* (inpatient only) Concurrent Non-urgent review* (inpatient only) On or before 4 th day after admission and/or intervals determined by Qualis after initial concurrent review On or before 4 th day after admission; non-urgent concurrent reviews are generally limited to one extension up to 15 days as determined by Qualis Retrospective Review As soon as eligibility is established up to 365 calendar days from service begin date; contact Qualis for request instructions if greater than 365 days from service begin date *Deadlines still apply for weekend and holiday requests, including emergency admissions. 60

Qualis Health Review Determinations Review Type Pre-service Urgent review Pre-service Non-urgent review Concurrent Urgent review Concurrent Non-urgent review Retrospective Review Determination Timeframe 3 calendar days 15 calendar days 3 calendar days 3 calendar days 30 calendar days Timelines are based on reviews where all necessary clinical information has been received and no referral for clinical peer review is needed When additional information is required to complete the review, the timeline is adjusted accordingly Urgent reviews are performed when a case involves urgent care and the time required for non-urgent review could: Seriously jeopardize the member s life, health or their ability to regain maximum function Subject the member to severe pain that could not be adequately managed without requested treatment 61

Qualis Health Peer-to-Peer Conversation When a non-certification decision is made, providers may request a peer-to-peer conversation with Qualis staff Peer-to-peer conversation allows the attending provider the opportunity to discuss the request and possibly prevent the need to appeal The attending physician must call Qualis Health Physician Hotline at 877.292.2615 by 5:00 pm AKST the day following notification of the potential non-certification If not able to call within this timeframe, notify Qualis Health within the timeframe to request an extension 62

Division of Senior and Disabilities Services Long-term care admission and level of care determination Swing bed and administrative-wait beds Personal Care Attendant services Waiver services DSDS forms are available at http://dhss.alaska.gov/dsds/pages/info/approvedforms.aspx Contact for further information: Anchorage office at 907.269.3666 or 800.478-9996 (toll-free) Juneau office at 907.465.3372 or 800.465.3165 (toll-free) Fairbanks office at 907.451.5045 or 800.770.1672 (toll-free) 63

Authorization Request Common Errors Common errors made on SA requests include: No date(s) of service indicated Invalid procedure codes Missing attachments Insufficient details provided Failure to verify eligibility for the date of service Retroactive services do not meet criteria SA requested for service that does not require SA Incorrect form used 64

Additional Resources Alaska Medicaid Health Enterprise website at http://medicaidalaska.com Information necessary for successful billing Includes provider-specific Medicaid billing manuals and fee schedules You may also call: Eligibility only 907.644.6800, Option 1,2 or 800.770.5650 (toll-free), Option 1,1,2 All other inquiries 907.644.6800, Option 1,1 or 800.770.5650 (toll-free), Option 1,1,1 66

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