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Presentation for WV HFMA Revenue Cycle Workshop October 23, 2013.

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Presentation on theme: "Presentation for WV HFMA Revenue Cycle Workshop October 23, 2013."— Presentation transcript:

1 Presentation for WV HFMA Revenue Cycle Workshop October 23, 2013

2 PROVIDER REGISTRATION WITH APS VS. MOLINA WV MEDICAID ENROLLMENT ALL MEDICAL review areas for WV Medicaid services requiring prior authorization are currently in the APS Medical CareConnection® C3 Provider Portal YOUR FACILITY MUST BE REGISTERED with APS and be actively enrolled as a WV Medicaid Provider with Molina to have prior authorization requests processed and claims approved.

3 Each organization and/or department must register specifically with APS Healthcare in order to access the Medical CareConnection® C3 Provider Portal System— regardless of how you submit (electronically, fax, or mail) The system allows you to configure your registration to meet the needs of the facility—whether one registration that houses ALL users and ALL prior authorization requests, or various departments within the organization register independently and only manage their staff and their requests—this is plausible even when all departments are linked to the same NPI.

4 SUBMITTING ELECTRONICALLY ON C3  Gives you the ability to quickly check WV Medicaid Member Eligibility.  Create prior authorization requests that bypass the clerical team and go straight into queue to be reviewed for medical necessity.  Permits you to track your request every step of the way  Allows for a faster turnaround time on determinations

5 ATTACHMENTS  How To: Click on the ‘Browse’ button in the Annotations: Notes section on the screen you want the information to be placed. Find the document you want to attach and double click on it. Click on the blue ‘Save’ button within the notes section.  Where: Either on the applicable screen (ex. MAR on the Medications screen) or on the Summary and Submit screen  Files Accepted:. txt, \.vsd, \.png, \.gif, \.bmp, \.jpg, \.jpeg, \.doc, \.xls, \.pdf, \.TIF, \.TIFF  Size Accepted: up to 4.8 MB only. Larger files need to be compressed or separated.  Please do not attach the same document more than once on the request. This only causes the reviewer to spend extra time looking at documents already viewed. Attaching supporting clinical documentation for C3 Prior Authorization Requests can save you bundles of time by not having to manually enter each data set (i.e. H&P, Diagnostic Results, MAR)—you simply make a statement to see attached clinicals and then include all relevant information up to 50 pages and/or 4.8MB per attachment.

6 NO SCANNER? NO E-RECORDS? NO PROBLEM! FAX YOUR ADDITIONAL INFORMATION  A FAX COVER (preferred) has been devised to assist you, as well as the WVMI review team, when your supporting clinical documentation cannot be attached directly to the C3 record created electronically. For a copy of this form, please contact APS.  Timelines for sending in additional clinical information, whether it be directly attached, faxed, or mailed to WVMI, is 2-business days from the date the request was successfully submitted on C3.  If the information is not received within the allotted timeframe, your request will be closed administratively. You would be required to recreate a new request with clinicals after an administrative closure. When resubmitting a closed case, please submit within the 72-hour timely submission criteria.

7 10-day Retrospective Review Submission Policy WV Medicaid Prior Authorization Retrospective Review Policy previously required a timely 24-hour submission timeframe for all admissions which included weekend and/or holiday admissions. This policy meant all requests must be submitted by the first business day following the admission. Due to the repeated expression of difficulty with meeting this requirement, APS provided the Bureau for Medical Services (BMS) your comments and concerns and after careful consideration, BMS agreed to eliminate the 24-hour timeline, and instead, adopt a 10 day prior authorization timeline in its place. NOTE: After the allowable period has elapsed from the selected service start date prior authorization is NOT available as a selection and retrospective review must be selected. The Retrospective Review Policy is not applicable to all review types you must refer to the POLICY MANUAL for specific requirements (e.g. DME requires PA before placement of equipment except apnea monitors).

8 Definition of “Medically Urgent” STAT Case Review  a) a delay could seriously jeopardize the life or health of the consumer or,  b) the ability of the consumer to regain maximum function or,  c) in the opinion of a physician with knowledge of the consumer’s medical condition, would subject the consumer to severe pain that cannot be adequately managed without the care or treatment that is the subject of the case.  NOTE: Some review areas do not recognize medically urgent requests. In these instances it is not a choice in the admission type dropdown. For those review areas that recognize medically urgent (e.g. inpatient) each admission type has a medically urgent choice (e.g. direct admission OR direct admission-medically urgent). Requests not meeting the medically urgent definition WILL NOT be clinically reviewed as medically urgent.

9 ONLINE COURTESY REVIEW  Courtesy Reviews allow providers to enter prior authorization requests for members they believe to have active Medicaid, although the Medicaid ID number is not yet active in Molina.  The request will be reviewed for medical necessity and if approved, when the Medicaid ID is available in Molina, it will be attached and a Prior Authorization number will be assigned.  Retrospective Courtesy Reviews are not allowed. If the member cannot be found in our system, their Medicaid ID is not active during that time span. The provider will need to wait until the retroactive Medicaid eligibility is present in our system and then submit their request.  Keep in mind that if a Molina linkage is not made within 30 business days of the actual Courtesy Review, the request will be closed and the provider will be notified that WV Medicaid coverage could not be located for the indicated member.

10 WHO IS WVU Hospitals? WVU is your SERVICING PROVIDER on C3 for Inpatient Admissions, Outpatient Surgeries and Diagnostic Tests (e.g. imaging). When completing a faxable form or creating a request online YOU MUST earmark the NPI for WVU Hospitals (ACUTE) when the service is rendered at this location. It is fiscally vital that the location and corresponding facility NPI be selected as servicing. If the prior authorization is linked to an incorrect NPI (e.g. the physician group) WVU cannot be paid. NPI: 1841271459

11 OP SURGERY AUTHORIZATION NUMBERS ARE NOW INDIVIDUALIZED OP SURGERY AUTHORIZATION NUMBERS ARE NOW INDIVIDUALIZED THE FACILITY RECEIVES A PA# UNDER THEIR NPI THE SURGEON RECEIVES A PA# UNDER THEIR NPI For either party to receive payment from Molina the C3 authorization number assigned to the approved member services must match the NPI provided on the request. ONE C3 REQUEST TWO AUTH NUMBERS Please follow WVU policy for communicating facility authorization numbers.


13 C3 DENIALS & RECONS  Status can be seen at the authorization record level OR in reports. Denial letters are always found on the Summary & Submit page of the C3 request.  If you entered the prior authorization request in C3, you will also be messaged a coy of the denial to your C3 inbox.  If you are the referring or servicing and did NOT enter the request a copy of the letter may be mailed to you (if no other means is available).  A reconsiderations of the initial denial are requested from the “action” menu for each not meeting medical necessity. Untimely submissions do not have a reconsideration option.  Providers have 60 days to request reconsideration, so make sure all appropriate information is provided at the time of the reconsideration request.  If you mail your reconsideration chart, wait until it is mailed prior to requesting in system and indicate in the note that the record has been mailed (or faxed if you do not attach at the time of reconsideration request).

14 Currently C3 is built to generate separate Prior Authorization Numbers for each procedure/service code for OP Surgeries and Diagnostic Tests for each corresponding NPI listed. In the event that your Servicing Provider requires one synchronized PA# for all testing performed same day, upon C3 review completion, you will need to contact APS to have a single number manually generated and sent to Molina. You must submit the request on C3 to be reviewed for medical necessity, receive a Review Complete status prior to contacting APS. Please follow these instructions until further notice.

15  Only an enrolled WV Medicaid provider may request an out-of-network service for a WV Medicaid member. The enrolled provider makes a hard-copy request with APS unless it is an emergency situation that would result in a hospital admission at an out-of-network facility.  If the OON case review determines that the service is medically necessary AND not available in-network, the out-of-network provider will be notified that they must enroll with Molina and a notice that medical necessity is met awaiting provider enrollment.  If the provider has previously enrolled to provide OON services AND enrollment has not termed the prior authorization number is assigned immediately. If medical necessity is not met (denial) there is no need for the provider to enroll and the member and referring provider are notified of the denial.  If the provider is not enrolled as out-of- network, call tracking is opened with Molina and kept open until APS is notified the provider has enrolled. The authorization number is posted at the time of enrollment and sent to Molina. The out-of-network provider may then bill Molina using the assigned prior authorization number.  TO OBTAIN AN OON REFERRAL PACKET PLEASE EMAIL: WVMEDICALSERVICES@APSHEALTHCARE.COM

16  When creating a service specific request on C3, you will receive a “Service Preview” that allows for a quick visual of codes currently requiring prior authorization (PA).  The Master Code List (MCL), an MS Excel spreadsheet is an effort to inform providers of codes requiring PA either from first service (listed as required) or after a specified service limit has been reached (beyond service limits) that are currently residing on C3.  In the event, you think a code requires a PA but cannot find it on either list you can contact APS, Molina, or WVMI for verification.  Also, the BMS Manual Chapters indicate covered services that require prior authorization: uals.aspx uals.aspx  If you should receive a denial for a service NOT on the list OR find a service listed in the manual as requiring PA but not on the list please contact APS as soon as possible so we can determine if the PA requirement is in force. If it is we will add the code to the listing. What do I do when I do not see the service code listed on C3 or the MCL? What do I do when the authorized service code on C3 changes?  Once a service code has been authorized on C3 but another code that requires an authorization occurs— the submitting C3 Organization must contact APS within 3-business days from the service start date.  APS will validate the necessary action on a case-by- case basis.  If the procedure code is outside of the C3 “bucket” the submitting C3 Organization may need to resubmit the case in full (referring to the previous case & authorization), listing all procedure codes with supporting clinicals and list reasoning as to why there is now a new submission for medical necessity review. This must transpire successfully within 3- business days from the service start date.  If the procedure codes are within of the C3 “bucket” the C3 Organization and Servicing Provider will not be required to resubmit. EXAMPLE: 162 Surgeon 271 Facility  If the additional procedure codes do not require an authorization, you will not need to make any changes to the existing C3 request.

17 REVIEW AREA UPDATES  Laboratory Services: there are a number of genetic testing service codes added (effective January 1, 2013) that now require PA. Please check the published MCL for a list of these services and requirements. S3854 is now covered (Oncotype) and may be requested retrospectively (back to a service start January 1, 2013) until December 31, 2013.  Nerve Conduction Studies: CPT Codes 95907-95913 are new codes added January 1, 2013 and REQUIRE PA. If you have received denials for these services you need to contact APS to get prior authorizations processed. The EMG codes 95885 and 95886 are add-on codes that do not require PA.  Physical/Occupational Therapy: The new PT/OT manual is not yet effective. Until the effective date of this manual providers may continue to use the WVMI system OR may use CareConnection® to request prior authorization per requirements of the existing manual. When using CareConnection select ESTABLISHED for patients since they have already received the allowable services without prior authorization (per current manual).  DME: While the system allows a period from service start date (SSD) to initiate prior authorization before being considered a retrospective request the POLICY MANUAL (Chapter 506) indicates prior authorization must be obtained BEFORE service provision/equipment placement. This administrative feature DOES NOT override policy. The exceptions are apnea monitors, O2 systems and nebulizers as outlined in policy.  Acute Inpatient: Admissions for labor and delivery DO NOT require prior authorization under the WV001 Inpatient DRG. A list of DRG’s related to labor and delivery have been added to the MCL for provider reference. Admissions for a medical condition (other than those exempted) require prior authorization within 72 hours of admission even if the member is pregnant.  Acute Inpatient: When requesting prior authorization for Medicaid members involved in a motor vehicle accident an accident/police report IS NOT required. In these cases the request must indicate in the notes section that the admission is attendant to a MVA.

18  All AUM Managers have access to the C3 Reports feature—this can assist in tracking WV Medicaid members who have received determinations on completed C3 requests when the binding “Servicing Provider” NPI is linked to your C3 account and is listed as the “Servicing Provider” on a request by any C3 submitter.  C3 Reports are exported into a MS Excel spreadsheet that can be engineered to suit the needs of the AUM Manager’s scope of work (i.e. Service Start Date, Service Type, Provider)  The Reports are only a summary of the request on file and the Servicing Provider Report does not give full access to the actual request built in C3. If you are NOT the submitting C3 provider (the party that entered the request) you MUST utilize REPORTS to obtain the PA number for the member.  When the wrong NPI is selected or inadvertently left off the AUM Manager at the “Servicing Provider” cannot access any information on that member—dependent upon the policy of your “Servicing Provider” a delay in services could occur.  You will need to follow the policy of each “Servicing Provider” when communicating the determinations.

19 Mock Report Service Start Date Service End Date Review Date Service Code Units Approved Prior StatusPrior ReasonCurrent StatusCurrent Reason Authorization Number Servicing Provider Name Servicing Provider Medicaid ID 2012-02-202012-03-202/17/201233730Approved Meets Medical Necessity Approved Meets Medical Necessity 2048246064ABC HOSPITAL12345678910 2011-11-262011-11-29 WV0014Approved Meets Medical Necessity Approved Meets Medical Necessity 2047245970ABC HOSPITAL12345678910 2012-02-242012-03-242/21/201216130Pended Approved Reapproved with Changes 2052245051ABC HOSPITAL12345678910 2012-02-152012-03-152/17/2012WV00130Pended Approved Meets Medical Necessity 2048246039ABC HOSPITAL12345678910 2012-02-162012-03-162/17/201253330Pended Approved Meets Medical Necessity 2048246080ABC HOSPITAL12345678910 2012-02-162012-03-162/22/201220630Pended Approved Reapproved with Changes 2053245061ABC HOSPITAL12345678910 2012-02-272012-03-272/24/201233630Pended Approved Reapproved with Changes 2055245006ABC HOSPITAL12345678910

20 WHEN IN DOUBT… When things aren’t working correctly in C3, there are a few things you can do to make sure it’s not on your end:  1.) Are you registered with APS for C3?  2.) Has your Provider NPI been attached?  3.) Do you have the appropriate user role?  4.) Are you on the correct site? For Requests as AUM Manager: For Enrollment Maintenance as ORG Manager:  5.) Are you using Internet Explorer V.8?  6.) Have you cleared your cache/cookies?  7.) Have you checked your queue to see if it is still in Saved mode? If you have checked these items and are still having difficulties contact APS for technical assistance!

21 FOR CUSTOMER SERVICE CONTACT APS: 1-800-346-8272 ext. 6954 Medical Services email: Helen Snyder Associate Director ext. Heather Huffman UM Coordinator ext. Sherri Jackson Office Manager ext. Denise Burton UM Coordinator ext. Alicia Perry Eligibility Specialist ext. Jackie Harris Eligibility Specialist jharris@apshealthcare.comext. GENERAL APS INFORMATION: WWW.APSHEALTHCARE.COM/WVWWW.APSHEALTHCARE.COM/WV Fax: 1-866-209-9632 (For Registration and/or Technical Support Only) ORG MANAGERS: HTTPS://C3WV.APSHEALTHCARE.COMHTTPS://C3WV.APSHEALTHCARE.COM AUTHORIZATIONS: HTTPS://PROVIDERPORTAL.APSHEALTHCARE.COMHTTPS://PROVIDERPORTAL.APSHEALTHCARE.COM FOR CLINICAL SUPPORT CONTACT WVMI: 1.800.642.8686 WWW.WVMI.ORG

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