HPHConnect for Providers Habilitative & Rehabilitative Therapies Notifications User Guide December 2017
HPHCONNECT HOME REHABILITATIVE THERAPIES NOTIFICATIONS USER GUIDE Table of Contents A. HABILITATIVE & REHABILITATIVE THERAPIES NOTIFICATIONS OVERVIEW Introduction................................................................. 1 When to Use HPHConnect......................................................1 When Not to Use HPHConnect...................................................1 Notification/Authorization Requirements..........................................1 Submission Process............................................................1 Requesting Provider...........................................................1 Servicing Provider.............................................................2 B. SUBMITTING THE HABILITATIVE OR REHABILITATIVE THERAPY TRANSACTION Outpatient Services Form....................................................... 3 Required Fields............................................................... 4 C. SUBMISSION TIPS Diagnosis Codes............................................................... 5 Provider Information........................................................... 5 Remarks..................................................................... 5 D. THE TRANSACTION RESPONSE Key Information.............................................................. 6 Electronic Transaction Processing................................................ 6 Approved Rehabilitative Transaction (for condition-based benefits).................... 7 Print Referral Form: Approved Transaction NO ACTION REQUIRED Habilitative or Rehabilitative Therapy Transaction (for visit-limit benefits)......................... 8 No Action Required............................................................ 9 Pended for Review...........................................................10 Pended Habilitative or Rehabilitative Therapy Transaction..........................11 E. REVISIONS TO AN OT, PT, OR ST TRANSACTION Guidelines..................................................................12 F. CANCEL THE TRANSACTION When to Cancel a Transaction..................................................13 How to Cancel a Transaction...................................................13 APPENDIX HPHConnect Habilitative & Rehabilitative Therapies (PT, ST, OT) Initial Transaction Quick Reference Guide HPHConnect Outpatient Tab Habilitative & Rehabilitative Therapies (PT, ST, OT) HPHConnect Habilitative & Rehabilitative Therapies (PT, ST, OT) Online Transactions Quick Reference Guide Harvard Pilgrim Health Care HPHConnect iii December 2017
Occupational Therapy Physical Therapy Speech Therapy Habilitative & Rehabilitative Therapies Overview Introduction To submit transactions online, the provider must be contracted with Harvard Pilgrim and have a status of participating for the member s product. The user s access list determines which referral/authorization (RA) transactions can be viewed. Access to RA transactions is limited to those for providers on the user s access list who are the requesting provider, servicing provider or the patient s PCP. When to Use HPHConnect HPHConnect for Providers users can submit RA transactions and access two years of RA transaction history for Harvard Pilgrim HMO, POS, and PPO members online. You can also submit RA transactions and view RA transaction history for Harvard Pilgrim Choice Plus and Harvard Pilgrim Options members. When Not to Use HPHConnect HPHConnect for Providers is not used for transactions for members with the Choice or Choice Plus products offered through Passport Connect SM. For UnitedHealthcare s related policies/procedures, please go to www.harvardpilgrim.org or call 800-708-4414, option 2. Notification/Authorization Requirements Submit the notification to Harvard Pilgrim up to the first date of treatment or no later than the next business day, when physical therapy, occupational therapy, or speech therapy treatment is scheduled (following initial evaluation). Reminder: Failure to comply with Harvard Pilgrim Health Care authorization requirements will result in an administrative denial of the claim payment. Members cannot be held liable for claims denied for failure to meet these requirements. Submission Process Go to www.harvardpilgrim.org/providers. Click on log into HPHConnect and sign in. 1. Verify patient eligibility and benefits. Is the patient active with Harvard Pilgrim? If no, contact the patient for information. 2. Verify if referral/authorization is required. The Ref/Auth Required column indicates Y for authorization required and N for authorization not required. Note: If Rehabilitative Per Condition Benefit is displayed in the Additional Information column, benefit limits will not be displayed. Harvard Pilgrim Health Care HPHConnect 1 December 2017
Habilitative & Rehabilitative Therapies Overview, continued 3. Check Referrals/Auth status to see if a transaction is already in the system. If yes, review the Service Request Record Detail. 4. If the patient is eligible and no transaction exists, enter the Outpatient request. Requesting Provider Only providers with the specialties listed can submit occupational therapy, physical therapy and speech therapy transactions: Occupational Therapist Physical Therapist Speech Therapist Acute Care Facility Skilled Nursing Facility Rehabilitation Facility Servicing Provider One servicing provider is required on transactions for occupational therapy, physical therapy and speech therapy treatment and can be any of the following specialties: Occupational Therapist Physical Therapist Speech Therapist Acute Care Facility Skilled Nursing Facility Rehabilitation Facility The provider s name or NPI is required. If the servicing provider is not contracted with Harvard Pilgrim, the transaction pends for review. Harvard Pilgrim Health Care HPHConnect 2 December 2017
How to Submit the Habilitative & Rehabilitative Therapies Transactions Outpatient Services Form Harvard Pilgrim Health Care HPHConnect 3 December 2017
HPHConnect for Providers Habilitative Rehabilitative Therapies Notifications User Guide Submitting the Habilitative/Rehabilitative Therapies Transaction, continued Required Fields All required fields display a blue dot, and must be completed in order to process the request. In addition to the standard required fields, the requesting provider must supply contact information and auto-accident information, when applicable. All other fields are optional. Field Patient Requirement Name (pre-filled when the transaction is entered via Patient Management). Requesting Provider Contact Name / Contact Number Diagnosis Servicing Provider Requested Service Requested Units Start Date and End Date Related Cause Release of Information Select from the drop-down list, if not pre-filled. This is helpful for the Harvard Pilgrim Case Manager when additional information is needed. At least one diagnosis code is required. Up to 12 can be submitted. Enter all that are indicated on the physician s orders. Only one. Can also be the requesting provider. Occupational Therapy, Physical Therapy, or Speech Therapy. Enter the total number of visits needed. Select Visits from the drop-down list. Start date should be no more than one business day after the first date of treatment. If the service requested is due to an automobile accident: Check Auto Specify the date of the accident and the state/province or country Select Signed statement/claims. Note: Procedure codes are not required on PT, OT, or ST requests. When entering text in the Remarks field, enter letters and/or numbers only; do not use punctuation marks or other keyboard characters. Harvard Pilgrim Health Care HPHConnect 4 December 2017
Submission Tips Diagnosis Codes You can enter up to 12 diagnoses. If the patient is receiving care for multiple conditions, be sure to enter all diagnoses that apply. This information is important for the Harvard Pilgrim reviewer to know, when the authorization request requires review. Provider Information Users can enter referrals and authorizations using the requesting and servicing providers National Provider Identifier (NPI) or the provider s name. Remarks As the diagnosis may not fully describe what the therapist is treating, more specific information can be submitted in the Remarks field. The more information that you can provide electronically at the time of submission, the less additional information you may be asked to supply manually before receiving your determination. The type of information and level of detail to submit includes the following: Identify which side of the body is to be worked on, right or left If the treatment will be bilateral, note this If the request is directly linked to post-operative care: - Indicate the date of the most recent surgery - Specify what the surgery was For example, if the service to be performed is status post for arthroscopic surgery on the left shoulder on August 1, 2014, you need only enter: s p shoulder scope 030106 L - If submitting a revision request - When an additional condition is being added, indicate the first date of treatment for the second diagnosis Reminder: When entering text in the Remarks field, enter letters and/or numbers only; do not use punctuation marks or other keyboard characters. Harvard Pilgrim Health Care HPHConnect 5 December 2017
The Transaction Response Key Information In the title bar, you will find the: Transaction number (e.g., HPA12345) Status of the transaction: approved, modified, pended, or denied Member s name and member s ID# The requesting provider s and servicing provider s National Provider Identifier (NPI) display on both the transaction detail screen and the print referral. On approved and modified rehabilitative therapy transactions, the end date and # of units approved, that is, the number of visits approved, display. The Remarks field displays a summary explanation of the status of the transaction. The Edit button only displays on approved transactions. The Cancel button displays on pended and approved transactions. Electronic Transaction Processing Initial requests for Physical Therapy and Occupational Therapy for commercial members is as follows: Transaction All commercial initial requests for PT, OT, and ST Revised electronic requests for additional visits. Response Will return a NO ACTION REQUIRED response when the member has a visit-limit benefit. Reminder: Confirm member visit limit and current remaining visits in the member s eligibility and benefits response. Payment is subject to available benefit. Will approve and assign the entirety of the benefit when the member has a condition-based benefit. A pended status may be returned when the member has a combined benefit. Payment is subject to available benefit. Revisions to PT, OT, or ST transactions are not allowed via the portal. Providers should submit a new request if they want to render additional services. Harvard Pilgrim Health Care HPHConnect 6 December 2017
The Transaction Response, continued Approved Rehabilitative Therapy Transaction (For Condition-Based Benefits) When the initial rehabilitative therapy authorization request approves automatically, it is not necessary to supply supporting documentation. Modified status displays on a transaction that has been approved but not as requested, that is, the approved units, the end date, etc. may have changed from what the requestor submitted. JOHN DOE HP0012034O1 John Doe M54.42 LUMBAGO WITH SCIATICA, LEFT SIDE 1203452133 1203452133 Note: Payment is based on member eligibility, availability of benefits, and Harvard Pilgrim Health Care provider contractual agreement. Authorization does not guarantee payment. Harvard Pilgrim Health Care HPHConnect 7 December 2017
The Transaction Response, continued Print Referral Form: Approved Transaction To print a copy of the response for your records, use the browser print option or the Print Referral link. When you access this screen, your printer dialogue window displays automatically. Click on Print to print the form. John Doe John Smith 10 Mar 1952 AA12345 0192837465 NPI HP 283746500 605000 2192837463 NPI M54.42 LUMBAGO WITH SCIATICA, LEFT SIDE 605000 2192837463 NPI Harvard Pilgrim Health Care HPHConnect 8 December 2017
The Transaction Response, continued No Action Required Habilitative or Rehabilitative Therapy Transaction (for Visit Limit Benefits) When the initial habilitative or rehabilitative therapy request results in a NO ACTION REQUIRED status, it means that prior authorization is not required within the member s benefit. JOHN J DOE HP 283746500 John Doe M54.42 LUMBAGO WITH SCIATICA, LEFT SIDE Susan Blacke (12345) (0192837465 NPI) Mary Smith (54321) Note: Payment is based on member eligibility, availability of benefits, and Harvard Pilgrim Health Care provider contractual agreement. Authorization does not guarantee payment. Harvard Pilgrim Health Care HPHConnect 9 December 2017
The Transaction Response, continued Pended for Review The most common reasons why transactions pend are: The servicing provider is not contracted with Harvard Pilgrim. The servicing provider is contracted with Harvard Pilgrim but is not considered a participating provider for the member s product. The member s benefit is per-condition and a subsequent transaction is submitted that has the same diagnosis code as was previously submitted on a similar authorization in the calendar year. Susan Blacke HP004857601 Susan Blacke M54.42 LUMBAGO WITH SCIATICA, LEFT SIDE 0192837465 NPI 0192837465 NPI Harvard Pilgrim Health Care HPHConnect 10 December 2017
The Transaction Response, continued Pended Habilitative or Rehabilitative Therapy Transaction Susan Blacke M54.42 LUMBAGO WITH SCIATICA, LEFT SIDE 0192837465 NPI 0192837465 NPI The Approved Units and End Date are blank pending completion of the review. The Additional Information section on the transaction detail screen indicates what information is needed and the fax number of the rehabilitative therapies reviewer. Fax all the requested information to the number indicated: - Progress Report - Functional Goals - Plan of Treatment It is important to note that the Print Referral form does not display the Additional Information segment. To keep a copy of the needed information and fax number, print the Detail screen. Action Required for a Pended Transaction When a transaction pends for review, clinical notes are needed to make a determination. The Additional Information section lists the required documentation. The Remarks indicate where to send the information. The requestor can use the referral printout as the coversheet and indicate which side (right or left) he/she is seeking treatment for in the case of a bilateral body part. The Harvard Pilgrim Rehabilitative Therapies reviewer updates the outpatient record to reflect the final status, Approved or Denied, within two business days of receiving all information needed to complete the review. The requesting provider, servicing provider and PCP will receive electronic notification of the changed status of the transaction via the Activity Summary, if enabled. Note: If more information is needed, the provider will be contacted for more information. Harvard Pilgrim Health Care HPHConnect 11 December 2017
Revisions to an OT, PT or ST Transaction Guidelines The only edit supported is to cancel a transaction. Edits to days and visits are not supported. Only the requestor or the servicing provider can cancel a transaction. Only approved or pended transactions can be canceled. Harvard Pilgrim Health Care HPHConnect 12 December 2017
Cancel the Transaction When to Cancel a Transaction The requestor or the servicing provider can cancel a pended or approved transactions at any time, if: The record was entered for the wrong patient. The wrong service type was selected in the original request (e.g., physical therapy instead of occupational therapy, or speech therapy instead of physical therapy, etc.) To correct this error, it is necessary to cancel the original record and enter a new one for the appropriate service. The wrong type of request was submitted (e.g., Specialist or Admission rather than Outpatient, etc.) How to Cancel a Transaction To cancel the transaction: 1. Click on the Cancel button at the bottom of the detail screen. 2. When the Verification screen displays, click Yes to submit the cancellation request. 3. The transaction re-displays and the Status indicates Approved (Canceled), that is, the request to cancel the transaction was approved. Harvard Pilgrim Health Care HPHConnect 13 December 2017
Appendix Harvard Pilgrim Health Care HPHConnect 14 December 2017
HPHConnect Habilitative & Rehabilitative Therapies (PT, ST, OT) Initial Transaction Quick Reference Guide Prior to submitting a Rehabilitative Therapy Transaction: 1 Check member eligibility and benefits. 2. When you are sure that you have the correct member, click on Select to add the member to the Patient list. 3. Check to see if a Rehabilitative Therapy authorization is already in place (See To search for Rehabilitative Therapy Transactions below). 4. Have your provider number (NPI). 4. Have the servicing provider s NPI, which you can find via the Office Management/Provider Directory. 5. Have the diagnosis code(s), which you can pre-select from the Office Management/Code Lookup. To search for Specialist Referrals: 1. In Patient Management, select the member from the Patient list. 2. Click on the Referrals/Auths link to access the Service Request Search Results screen that displays a list of the member s referrals/authorizations. 3. (Optional) To sort the data on the Requested Service Search Results screen, click on the column-heading link: single click for ascending order or double click for decending order. 4. Click on the Number link in the Service Request Number column to access the Detail of an existing record. 5. If no record exists for the service in question, click on Add to enter a new referral. Troubleshooting problems: 1 If you receive an error message and need to correct data in one or more fields, click the Return to previous page link to correct the mistake(s) and resubmit the request. 2. If you receive the message, Your request has not been returned from the server. You will receive a communiqué shortly., click your browser Back button to resubmit the request. 3. If you have not used HPHConnect for 15 minutes, you will need to Sign In again before you can create a new admission transaction. To submit a Rehabilitative Therapy Transaction: 1. Select the Outpatient tab. 2. Complete the required information for the Patient, Requesting Provider, and Servicing Providers (Name or NPI). 3. Provide Contact Name/Number and Requested Service information. 4. Enter the diagnosis code. 5. Provide Start and End Dates. (The start date must indicate the date when the member will begin treatment.) 6. Select Release of Information and complete any applicable additional optional fields. 7. Use the Remarks section to submit additional information to describe the condition to be treated, such as, right or left side, bilateral, date and type of most recent surgery/injection, etc. 8. Click on Submit. The response will be returned to you directly and display the status. 9. To print a copy or the response for your records, use the Print Referral link. Helpful Hints: 1 Indicates required field. 2. To advance from field to field, use the TAB key instead of using your mouse. Do not hit Enter unless you need to search for the information for a field. 3. To move the cursor back a field, use the SHIFT + TAB keys together. 4. Pended transactions display a list of the additional information needed to review the request and the fax number to use to transmit the information. Transactions that status as NOHPHCACTION do not require prior authorization www.harvardpilgrim.org Harvard Pilgrim Health Care HPHConnect i December 2017
HPHConnect Outpatient Tab Habilitative & Rehabilitative Therapies (PT, ST, OT) 1. Patient Name Auto-populates from the Current Patient selected on today s list. 2. Requesting Provider Any Harvard Pilgrim contracted provider with the following specialties may submit the Habilitative or Rehabilitative Therapy transaction: Occupational Therapist Physical Therapist Speech Therapist Acute Care Facility Skilled Nursing Facility Rehabilitation Facility Entering the name of the provider: If 1 provider is on the access list 2-20 providers are on the access list More than 20 providers are on the access list Then The name of the provider auto populates. Select the name of the requesting provider from the drop-down list. A menu will not appear. Enter the name of the provider in the field. 3. Enter Contact Name and Contact Number in the two corresponding fields. 4. Diagnosis You can enter up to 12 diagnoses. Search by code or by name. Be sure to include the decimal point if the diagnosis code requires one. If you know the correct codes, you can submit multiple entries at one time, separated by a semi-colon. If you do not know the correct codes, you can search for them. 1 To add notes to explain the diagnosis, refer to Remarks on this page. 5. Servicing Provider Only one servicing provider should be entered and must be one of these specialties. Enter the correct name or NPI. www.harvardpilgrim.org 6. Requested Service Select from the drop down menu: Occupational Therapist Physical Therapist Speech Therapist 7. Requested Units Enter the number of visits requested. 8. Location Not required. 9. Procedure Code Not required. 10. Enter both Start Date and End Date of service. 11. Delay Reason Optional A Delay Reason may be selected if the request is submitted late. 12. Related Causes Check one or more boxes as appropriate. If an automobile accident is indicated, the date of the accident must be given. Select the state in which the accident occurred from the drop down menu. 13. Release of Information Select Informed Consent/Med or Signed Statement/Claims. 14. Additional Information Optional Additional information that the provider may submit for review. Note: When a transaction pends, the record automatically indicates what information Harvard Pilgrim needs. 15. Remarks This is a message board to communicate specific information between the Requesting Provider and Harvard Pilgrim to support the need for treatment (e.g., right shoulder pain or left shoulder pain, etc.) Note: Enter text only, that is, letters and/ or numbers; do not use punctuation marks or other keyboard characters. 1 When Entering Multiple Diagnoses: If you don t know the correct names or terms for a field, you must search for each entry individually. Enter a partial name or number in the appropriate field. Click on the Search button at right. A list, beginning with the characters you entered, will appear. Select the correct item from the list provided. Repeat this process for each entry. Harvard Pilgrim Health Care HPHConnect December 2017
HPHConnect Habilitative & Rehabilitative Therapies (PT, ST, OT) Online Transactions Quick Reference Guide Habilitative & Rehabilitative Therapy Online Transactions Payment is based on member eligibility and benefit limitation at the time the service is rendered, as well as Harvard Pilgrim Health Care provider contractual agreement. All services will be subject to applicable copays, co-insurance, and deductibles. Transaction Scenario All commercial initial requests for PT, OT, and ST Revised electronic requests for additional visits on approved transactions for members with 60 consecutive day benefits Response Will return a NO ACTION REQUIRED response when the member has a visitlimit benefit. Reminder: Confirm member visit limit and current remaining visits in the member s eligibility and benefits response. Payment is subject to available benefit. Will approve and assign the entirety of the benefit when the member has a condition-based benefit. A pended status may be returned when the member has a combined benefit. Payment is subject to available benefit. Revisions to PT, OT, or ST transactions are not allowed via the portal. Providers should submit a new request if they want to render additional services Harvard Pilgrim Health Care HPHConnect iii December 2017