Provider Portal Hints & Tips Frequently Asked Questions 1
Medical Review-Claim Appeal Hints & Tips Claim Appeals The Dean Health Plan Medical Affairs Department reviews the claim and associated medical records to determine one or more of the following decisions: Is the procedure, service, or medication medically necessary as defined in DHP Medical Policies? Is the procedure or service, including the level of care, and the length of stay medically appropriate? Is there reimbursement coverage under the terms of the member s benefit certificate? Are the medical records or information submitted adequate to make a determination or is additional information needed? Key Considerations When Submitting Medical Records: Do the medical records support the level of service billed and are the records for the correct date of service? A Medical Director will review medical records if services are deemed to be not medically necessary. Physician s signature should include the physician s typed name or electronic signature with the date signed Documentation to Include: Therapy Appeals -Initial therapy evaluation -Therapy notes for the entire course of treatment are required Lack of Prior Authorization -Medical Records which support why the services were urgent or emergent Experimental or Investigational -Research and/or medical journal articles to support why the services should not be considered experimental or investigational Observation Services -A signed physician s order for Admission to Observation -Medical records which support the services provided during the hours billed 2
Durable Medical Equipment (DME) -Signed physician s prescription -Certificate of Medical Necessity -Documentation which supports the type of equipment provided -Member s receipt of equipment Unlisted Codes-Claim Appeal Justification for Separate Reimbursement Provide a narrative as to why the service should be separately payable. This may include: -Whether the procedure was performed independent from other services provided, or if it was performed at the same surgical site or through the same surgical opening. -Any extenuating circumstances which may have complicated the service or procedure. -Time, effort, and equipment necessary to provide the service. -The number of times the service was provided. -Approach used for service, example open/ laparoscopic Not Otherwise Classified (NOC) code An unlisted code represents an item, service, or procedure for which there is no specific CPT or Level II alphanumeric HCPCS code. The Current Procedural Terminology (CPT) code book lists a number of unlisted service or procedure codes, which can be found at the end of a section or subsection. Alternatively, a summary list of the unlisted CPT codes can be found in the Guidelines section for each chapter of the CPT code book. The long descriptors for these codes start with the term Unlisted and the last two digits of the codes often end in 99. Similar Procedure Code A like code for price comparison. Example: Provider is billing an unlisted code for a laparoscopic surgery where no specific code exists. The provider can list the code for a similar open approach procedure. Specific Description of Unlisted Procedure/Diagnosis Because unlisted and unspecified procedure codes do not describe a specific procedure or service, it is necessary to submit further explanation when filing the claim. The CPT code description itself is not enough. An example of this is code 81479. The CPT description of unlisted molecular pathology procedure does not sufficiently explain what service was performed. The 3
description should include a clear description of the nature, extent, method used. Attachments-Claim Appeals When submitting supporting documentation, underline the portion of the note or op report that identifies the test or procedure associated with the unlisted procedure code. Please do not use highlight markers as this does not show on scanned images. Required information must be legible and clearly marked. (Refer to the guideline below for documentation requirements.) Suggested Documentation Procedure Code Category Surgical procedures: all unlisted codes within the range of 10021 69990 Radiology/imaging procedures: all unlisted codes within the range of 70010 79999 Laboratory and pathology procedures: all unlisted codes within the range of 80047 89398 Medical procedures: all unlisted codes within the range of 90281 99607 Unclassified drug codes Unlisted DME HCPCS codes Example CPT 19499 unlisted procedure, breast CPT 76496 unlisted fluoroscopic procedure (e.g., diagnostic, interventional) CPT 84999 unlisted chemistry procedure CPT 89240 unlisted miscellaneous pathology test CPT 92499 unlisted ophthalmological service or procedure HCPCS J3490 Unlisted drugs A4641 radiopharmaceutical, diagnostic, Provide narrative on the claim Documentation Requirements Operative or procedure report Imaging report Laboratory or pathology report Office notes and reports NDC number with full description/name and strength of the drug Provide narrative on the claim 4
Authorizations Authorization Number Sequence The authorization number generated consists of three parts. 1 digit alpha prefix Example: H 6 digit Julian date (YYMMDD) Example: 150907 3 = digit sequence number Example: 002 Future Dates of Service Authorizations with future dates of services greater than 90 days can be saved then submitted closer to the member s appointment. Refer to the Provider Portal User Guide under View Authorizations for assistance on saving an authorization. Servicing Provider The Servicing Provider on an Authorization should not reflect a clinic name but rather the name of an individual practitioner or hospital. The address where the member is receiving the services should be reflected. If the servicing provider s name is not known, Dean health Plan will accept the name of one of the practitioners with the same specialty, department and clinic location the member is being referred to even though the member s appointment may be with a different practitioner within that specialty. Example: The University of Wisconsin Pediatric Endocrinology Department. If the Servicing Provider is not found, such as a Non Contracted Provider, use the SEARCH function under Provider Search. Refer to the Authorization Section of the Provider Portal User Guide. For the University Hospitals and Clinics use the following address and phone number. 600 Highland Ave Madison, WI 53792 (608) 263-6400 Specialty Requests Separate authorizations are required for each specialty requested on an authorization. Priority The Priority refers to the urgency or status with which the authorization requires processing. There are five (5) types of priority statuses; two (2) are specific to inpatient authorizations and three (3) are specific to outpatient authorizations. 5
Medically Urgent/Expedited This status is used when a member s medical condition requires urgent attention. Such as the loss of life or limb to the member if the services are not provided within 72 hours. For medical urgent prior authorizations, the physician s signature is required. The authorization paper form does not have to be completed in full but rather just indicate the authorization number in Essette along with attaching the form with physician s signature. Administratively Urgent This status is used for requests which do not meet the definition of Medically Urgent however, are deemed to be time-sensitive by one or more affected parties. Such as no loss of life or limb to the member. The authorization would be reviewed within 7 days in most cases but can take up to 15 days. Non-Urgent/Standard This status is used for future dates of service within the next 90 days or less. Such as pre-service, elective and routine outpatient requests. These requests can take up to 15 days to process. Concurrent This status is used for same day-next business day admission notifications. Such as inpatient or observation admission to a facility. Post-Service This status is used for requests that are received after the member s services have already been rendered. The Dean Health Plan Utilization Management (UM) does not allow backdating of authorization requests. These requests will be returned to the provider with a note that indicates that UM does not backdate. An Exception maybe if the patient is admitted to a SNF/Home Health/Home Infusion/ hospice/ IP rehab or hospital. This information should be submitted to the Dean Health Plan Utilization Management no later than 1 business day from admission if over the weekend/holiday. Medical Policy The applicable Dean Health Plan Medical Policy for the service being requested should be reviewed prior to submission of an authorization. The Medical Policies can be found by going to www.deancare.com or direct link https://www.deancare.com/providers/forms-and-documents-searchresults/?termid=fbe80271-bd07-e011-88a4-e0cb4ef9b7ad. 6
Medical Codes HCPCS/CPT Codes Submit the necessary HCPCS/CPT codes specific to the procedure being requested. Do not submit CPT codes for Evaluation and Management Services. Unlisted Codes If there is a true code, then you are required to use it. If there is not a true code, then you are required to use an unlisted code. Non Covered Items Authorizations for non-covered items will be cancelled. Some medical intervention may be subject to the limitations and exclusions outlined in the member's benefit certificate. Also, some procedures and services may not be covered by Dean Health Plan because they failed to meet our definition of medical necessity; are considered investigational and/or experimental; or are considered cosmetic. Follow-Up Services When submitting an authorization request for follow up services with a Non Contracted provider, attach the clinical notes from previous visits with the Non Contracted provider to support continued ongoing services. **For EPIC users a note should be added to the authorization request detailing where this information is located within the EPIC record. Resubmitting Authorization Request If resubmitting a request following a denial, updated supporting documentation must be included with the request for it to be reviewed Peer to Peer Review There is a 10 day peer to peer review window applicable to all denials. If you should miss this timeframe, a new request with new supporting clinical information can be submitted for review. Skilled Nursing Facility (SNF) SNF requests need to be completed fully. SNFs will need to have to identify what type of stay that is being requested whether it be Medicare Prime or 30 Day Mandate. If a 30 Day Mandate is being requested then the provider needs to submit the DHFS rate. Provider should indicate how many Medicare Days have been used at time of submission. 7
Member Not Yet Enrolled If there is no enrollment in our system, the authorization request can be submitted via paper indicating Member Not Yet Enrolled. Selective Nerve Root Injections (SNRI)/Epidural Steroid Injection (ESI)/Facet Joint Injections The correct pathway for submission of authorizations for an SNRI is as follows. Auth Class: Pain Management Auth Sub Class: Pain Management Injections Although the member is not receiving pain management the procedure is being done to determine the nerve pathway associated with pain. ESI requests must include a completed ESI checklist. Here is a direct link to the ESI checklist: http://www.deancare.com/app/files/public/3696/pdf-providers- Epidural_Steroid_Injection.pdf. Non-Contracted Providers When referring to a Non-Contracted provider use the Authorization Classification (Auth Class) of Specialist Adult Medicine or Specialist Pediatric Medicine Sleep Studies When referring for an outpatient sleep study, use the Authorization Classification (Auth Class) of Outpatient Surgery. Please note: We are working to get our system updated to reflect the Auth Class of Outpatient Surgery/Procedure. Newborns A completed Newborn Assessment Form is required. This information is required when a newborn goes to the Neonatal Intensive Care Unit (NICU), used for reporting purposes and to faciliatate claim payment. 8
Elective Inpatient Hospital Admissions It is the responsibility of the servicing hospital to submit an authorization for an elective inpatient hospital admission. Please note: A clinic/physician should not be submitting an authorization for an elective inpatient hospital admission. Documentation Appropriate file types include:.bmp.jpg.pdf.gif.pnl.docx.xlsx.msg The maximum attachement size is 40 mg. 9
How do I save documents to PDF format? Word document 1. Point to Save As, and then click PDF or XPS. 2. In the File Name list, type or select a name for the workbook. 3. In the Save as type list, click PDF. 4. If you want to open the file immediately after saving it, select the Open file after publishing check box. This check box is available only if you have a PDF reader installed on your computer. Excel document 1. Point to Save As, and then click PDF or XPS. 2. In the File Name list, type or select a name for the workbook. 3. In the Save as type list, click PDF. 4. If you want to open the file immediately after saving it, select the Open file after publishing check box. This check box is available only if you have a PDF reader installed on your computer. 5. Next to Optimize for, do one of the following, depending on whether file size or print quality is more important to you: a. If the workbook requires high print quality, click Standard (publishing online and printing). b. If the print quality is less important than file size, click Minimum size (publishing online). 10
Internet Help Popups Note: Please check with your security advisor before completing the following steps. To allow popups on your internet explorer browser, there are a few steps that you need to take. This will allow the claim appeals module to work as expected within the provider portal. Setting 1: You will need to add the provider portal to your allowed sites. To see how to do this follow the below: 1. Navigate to internet options. 2. Select the Privacy tab. 3. Select Settings 4. Type the following address into the address of website to allow: window. mail-qa.emdeon.com 5. Select Add 6. You should see the site in the Allowed Sites window. 11
Setting 2: You need to ensure that the Scripting of java applets is enabled. 1. Again, navigate to internet options. 2. Select the Security tab 3. Select the Custom level option. 4. Scroll down until you see the Scripting of Java applets 5. Click the radio button next to Enable 6. Select ok. 12
Pop-up-FAQ 1. What is a pop-up? a. A pop-up is a small web browser window that appears on top of the website you're viewing. Pop-up windows often open as soon as you visit a website and are usually created by advertisers. 2. What is Pop-up Blocker? a. Pop-up Blocker is a feature in Internet Explorer that lets you limit or block most pop-ups. You can choose the level of blocking you prefer, from blocking all pop-up windows to allowing the pop-ups that you want to see. When Pop-up Blocker is turned on, the Information bar displays a message saying "Pop-up blocked. To see this pop-up or additional options click here." 3. How do I make pop-ups display in a tab? a. By default, pop-ups display in separate windows. 4. Who should I contact if I am having issues with the pop-up blocker? a. Please reach out to your Provider Portal Super User (Site Administrator) if you are having trouble with the above steps, or those steps are not resolving your issues. 13