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PCS0050 (09/08) Welcome to the Indiana Health Coverage Program Seminar: MDwise Care Select Prior Authorization Presented by MDwise Provider Relations October.

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Presentation on theme: "PCS0050 (09/08) Welcome to the Indiana Health Coverage Program Seminar: MDwise Care Select Prior Authorization Presented by MDwise Provider Relations October."— Presentation transcript:

1 PCS0050 (09/08) Welcome to the Indiana Health Coverage Program Seminar: MDwise Care Select Prior Authorization Presented by MDwise Provider Relations October 6 – 8, 2008

2 Agenda Welcome Eligibility Review – The Key to Success MDwise 101 The Prior Authorization (PA) Process Questions/Answers

3 Care Select Eligibility Always verify the Care Select member’s eligibility Review the entire eligibility record to determine the member’s Care Management Organization (CMO) The member’s CMO affiliation determined on the date of eligibility verification determines everything: 1.Which CMO receives a PA request 2.Member’s Care Manager 3.CMO who processes restricted card information 4.Where members can change primary medical providers (PMP)

4 Care Select Eligibility Reminders: Know the member’s assigned PMP and contact information Providers rendering services that require the PMP’s two character certification code must obtain that certification code prior to rendering the service (see BT200804 for a list of services requiring the certification code) Services where the PMP declines to provide the certification code are non – covered by the Indiana Health Coverage Programs (IHCP) A patient waiver as described in Chapter Four, Section 5 of the IHCP Provider Manual can be used if the member insists on receiving the service not authorized by the assigned PMP

5 MDwise 101

6 MDwise Prior Authorization Process Procedures: Submit the PA request to the CMO the member is affiliated with on the date of request Reminder: ADVANTAGE Health Solutions processes PA requests for Traditional Medicaid members Services which require PA due to State regulations are discussed in the IHCP Provider Manual Chapter 6 (Also refer to handout) Reminder: Care Select PA rules are not the same as Hoosier Healthwise PA requirements – don’t get them confused Services which require PA are processed according to the guidelines specified in the IHCP Provider Manual Chapter 6 Reminder: Do not submit PA requests to a MDwise HHW Delivery System

7 MDwise Prior Authorization Process Procedures: Providers have 30 days to submit additional information for a PA that is suspended Reminder: Submit this documentation to the CMO you originally sent the PA request to Suspended PA requests are denied in 30 days Reminder: Respond to suspended PA requests timely and if that PA request is denied for timeliness, submit a new PA request The preferred method to submit PA requests is via fax or Web interChange Reminder: Submit PA requests in writing or via web and not via phone

8 MDwise Prior Authorization Process Does the service require PA? Services the State requires PA for: 1. Transplants 2. Outpatient surgeries 3. Home Health - No inpatient discharge 4. Durable Medical Equipment and Home Medical Equipment 5. Inpatient psychiatric admissions, inpatient surgeries, rehabilitation, burn and substance abuse 6. Therapies (Physical, Speech, and Occupational) – No inpatient discharge 7. Transportation (>20 one way trips or >50 miles one way) 8. Outpatient Mental Health (>20 visits) 9. PRTF Check the fee schedule at to determine if a code requires

9 MDwise Prior Authorization Process Select a method to submit your PA to MDwise: 1. Fax PA Forms: (877-822-7186 or 317-822-7515) Note: Preferred method to receive PA requests 2. Web interChange ( Note: Select provider specialties only 3. Mail PA requests to: MDwise Care Select Prior Authorization P.O. Box 44214 Indianapolis, Indiana 46244-0214 Note: Providers can follow a PA request’s status using Web interChange regardless of the method of submission

10 MDwise Prior Authorization Process General Institutional PA Guidelines Criteria used to process PA requests for institutional services are located in 405 IAC 5 Inpatient services that require PA are substance abuse, inpatient psychiatric, surgical procedures, rehabilitation, and certain burn cases Days that are not approved by PA are non – covered by the IHCP The PA Request Form is always required when submitting a PA (located at

11 MDwise Prior Authorization Process Supporting Documents Necessary for Institutional PA Requests Note: Free-Standing Inpatient Psychiatric Hospitals or Acute Care Hospital Psychiatric Units Pre-certification must be phoned in for all emergent and non- emergent requests The Division of Family Resources 1261A must be submitted within 10 days of a non-emergent request and 14 days of an emergent request Recertification as specified by the State for continued inpatient psych admissions Reimbursement is not allowed if pre-certification and the Form 1261 A are not completed within the time frames specified

12 MDwise Prior Authorization Process Psychiatric Residential Treatment Facility (PRTF) Supporting Documentation Requirements: Intake Assessment Form 1261A Physician History Physical Current Inpatient Treatment Plan Physician Progress Notes Inpatient Nursing Notes Physician Recommendation Letter

13 MDwise Prior Authorization Process Inpatient emergency admissions requiring PA Reported to MDwise within 48 hours of admission See Chapter 8 of the IHCP Provider Manual for a list of applicable emergency diagnosis codes. Complete the PA Request form if applicable Report emergency services to member’s PMP within 48 hours

14 MDwise Prior Authorization Process Non-Institutional PA Requirements Criteria used to process PA requests for institutional services are located in 405 IAC 5 Practitioners: Doctor of Chiropractic Medicine Medical Doctor Doctor of Osteopathy Doctor of Podiatric Medicine Health Services Provider in Psychology Optometrist

15 MDwise PA Process Physician PA requirements found in 405 IAC 5-25 Bariatric surgery Blepharoplasties Bone marrow or stem cell transplants Brand name medically necessary drugs Genetic testing for detection of cancer Home health services Intersex surgeries Long-term acute care hospitalization Mastectomies for gynecomastia Maxillo-facial surgeries related to diseases of the jaw and contiguous structures Organ transplants

16 MDwise PA Process Physician Services: PA required for Evaluation and Management (E&M) services that exceed 30 visits per member per rolling calendar year: E&M Codes subject to PA after 30 visits: 99201 – 9920599211 - 9921599241 - 99245 99381 - 9938799391 - 9938799401 – 99429 Please note: Physician services rendered during an inpatient stay that do not receive PA are not reimbursable

17 MDwise PA Process PA requirements for podiatry services are found in 405 IAC 5-26 Podiatry services rendered during inpatient or outpatient stays that were not require PA PA requirements for chiropractic services are found in 405 IAC 5-12 Chiropractic services rendered without PA are subject to denial

18 MDwise PA Process – Home Health PA criteria for home health services located at 405 IAC 5-16 Note: PA is required for home health services except for those services ordered in writing by a physician before the patient’s discharge from a inpatient stay that do not exceed 120 hours within 30 days of discharge provided by: Registered nurse Licensed practical nurse Home health aide PA requests submitted must include the following: Appropriate home visit nursing level code – 99600 TD-Unlisted home visit, service, or procedure-registered nurse

19 MDwise PA Process – Home Health Copy of written plan of treatment signed by attending physician, current through date of request that documents effectiveness of treatment Estimate of costs for the required services ordered by the physician and signed by the physician reflected in plan of treatment Number and availability of non-paid caregivers that assist in member care (even if none available) Number of members in household receiving home health services to coordinate care efficiently Number of hours of service per day, number of visits per day, and number of days per week the service is to be provided

20 MDwise PA Process – Home Health Home health visits greater than three per day provided to the same household or member Other non-IHCP home health services provided to the member including Medicare, CHOICE, Waiver, private insurance, private pay, school system, and other paid caregivers (include number of hours per day and number of days per week for each service) Encounter – direct personal contact between patient and authorized person to furnish services to patient Frequency of visits is the number of encounters in a given period between patient and person authorized to furnish services (specific number of range)

21 MDwise PA Process – Home Health Prescribed in writing by physician (medically confined to home) Medically necessary and reasonable Less expensive than alternative modes of care Progress notes detailing patient evaluation and physical involvement by physician to document acute needs

22 MDwise PA Process – Home Health Medical plan of care must be developed with home health agency and in consideration of all pertinent diagnoses, includes the following: Mental status Types of services/equipment Frequency of visits Prognosis Rehabilitation potential Functional limitations Activities permitted

23 MDwise PA Process – Home Health Nutritional requirements Medications and treatments Safety measures to protect against injury Instructions for timely discharge or referral Specific procedures/modalities to be used along with frequency, amount, and duration of each Note: The medical plan of care must be reviewed by the practitioner at least every two months Note: A written summary by the agency must be sent to the practitioner every two months

24 MDwise PA Process – Home Health New authorization requests for home health services must include: The clinical summary of PA form must be updated to reflect any change in patient’s status (as documented in the patient plan of care) Non-covered services under home health benefit: Homemaker Chore services Sitter/companion services

25 MDwise PA Process - Therapy Criteria for therapy services is located in 405-IAC 5-22-6 through 405-IAC-5-22-11 Note: Therapy service PA requests may be submitted by home health agencies or individual therapy providers (See BR200831) for limitations PA is not required for: Initial evaluations Emergency respiratory therapy Therapy services ordered in writing by a physician at inpatient discharge, up to 30 hours, sessions or visits in 30 calendar days

26 MDwise PA Process - Therapy Deductible or co-payment for services covered by Medicare Therapy services provided by a nursing facility of ICF/MR which are included in the facility’s per diem rate PA criteria for occupational, physical, respiratory, or speech therapy Written evidence of physician involvement and patient evaluation needed to document acute needs Current plan of treatment Physician order

27 MDwise PA Process - Therapy Current plan of treatment and progress notes documenting necessity and effectiveness of therapy Qualified therapist or qualified assistant under supervision of therapist must provide therapy Therapy must be of a level of complexity and sophistication and the condition of the member must be such that judgment, knowledge, and skills of a qualified therapist are required Medically necessary Rehabilitative service covered for a member no longer than two years from initiation of therapy unless a significant change in medical condition is noted

28 MDwise PA Process - Therapy Maintenance therapy not covered Progress evaluations not separately reimbursable and are covered as part of the therapy program One hour of therapy must include minimum of 45 minutes of direct patient care with balance spent in patient related services Therapy services not approved for more than one hour per day per type of therapy Duplicate therapy services are not covered

29 MDwise PA Process – Mental Health Mental health PA criteria are listed in 405 IAC 5-20-8 PA required for mental health services provided in an outpatient or office setting that exceed 20 units per member, per provider, per rolling 12- month period Criteria reviewed: PA request form Current treatment plan Progress notes – necessity and effectiveness of therapy

30 MDwise PA Process – Mental Health Note: PA required for neuropsychological and psychological testing and includes 96101 – psychological testing, 96111 – developmental test extended, and 96118 – neuropsychological testing battery PA not required: 2 units of psychiatric diagnostic interview allowed per 12 months per member, per provider if a physician or HSPP and a mid level practitioner separately evaluate the member (90801) Medicaid Rehabilitation Option (MRO) services are not subject to PA as outlined in 405 IAC 5-21

31 MDwise PA Process – Mental Health Assertive Community Treatment (ACT) PA is required for ACT services covered by the IHCP per 440 IAC 5.2-2-3 and PA requirements in 405 IAC 5-21-8(d) Required Documents: Assessment of current medical status Psychiatric history Status at time of review for ACT Treatment goals reviewed by ACT team psychiatrist

32 MDwise PA Process – Mental Health Note: Care Select members can self refer to any IHCP enrolled mental health provider. However, mental health services furnished to members by providers enrolled with specialties other than mental health must contact the member’s assigned MDwise Care Select PMP to obtain that PMP’s two character certification code All services billed to EDS as fee for service

33 MDwise PA Process – DME/HME Medical Supplies and Equipment Criteria for medical supplies, durable medical equipment, and home medical equipment can be found in 405 IAC 5-19 PA is not required for the following items: Cervical collars Back supportive devices Hernia trusses Oxygen, supplies, and equipment for its delivery for nursing facility residents Parenteral infusion pumps used with parenteral hyperalimentation Eyeglasses

34 MDwise PA Process – DME/HME Chapter 6, section 5 details other DME and HME which does not require PA. Also, see the IHCP fee schedule at Oxygen: All oxygen equipment and supplies require PA for members in a home setting Physician order required Note: DME/HME that is purchased and require repair also require PA

35 MDwise PA Process – DME/HME A Medical Clearance Form is required for certain types of DME, HME or medical supplies and must accompany the PA request form Note: The medical clearance form is used to justify the medical necessity of certain DME, HME, or medical supplies: Augmentative communication systems – Augmentative Communication System Selection form Certificate of Medical Necessity (CMN) for home oxygen therapy – Certificate of Medical Necessity: Oxygen form CMN parenteral or enteral nutrition – Certificate of Medical Necessity: Parenteral or Enteral form

36 MDwise PA Process – DME/HME Audiometric tests for hearing aid fitting – Medicaid Medical Clearance and Audiometric Test form Hearing Aids – IHCP Medical Clearance and Audiometric Test form Hospital beds – Medical Clearance Form: Hospital and Specialty beds Motorized wheelchairs or other power-operated vehicles – IHCP Medical Clearance for Motorized Wheelchair Purchase form Negative pressure wound therapy – IHCP Medical Clearance form for Negative Pressure Wound Therapy

37 MDwise PA Process – DME/HME Non-motorized wheelchairs – IHCP Medical Clearance form for Non-motorized Wheelchair Purchase Standing equipment – Medical Clearance Form: Physical Assessment for Standing Equipment Transcutaneous electrical nerve stimulator (TENS) – Medical Clearance form for TENS Unit Note: All forms are available in the IHCP Provider Manual or by contacting EDS Customer Service at 1-800-577-1278 or at

38 MDwise PA Process – DME/HME PA request for DME and HME are reviewed on a case-by case basis based on the following: The item must be medically necessary for the treatment of an illness or injury or to improve the function of a body part The item must be adequate for the medical need; however, items with unnecessary convenience or luxury features are not allowed The anticipated period of need, plus the cost of the item is considered in determining whether the item is rented or purchased

39 MDwise PA Process – DME/HME Note: The IHCP case mix rate for long term care facilities includes costs for the following and cannot be separately authorized or billed to the IHCP: Medical and non-medical supplies Mental health service Nursing care Room and board Therapy services Transportation Habilitation

40 MDwise PA Process - Transportation PA criteria for transportation services are found in 405 IAC 5-30 PA is required for transportation trips exceeding 20 one – way trips per member, per rolling 12-month period (exception: emergency ambulance, transport to or from a hospital admission or discharge, patients on dialysis, and patients in nursing homes) Trips 50 or more miles one way Out – of – state or non – designated trips Airline or air ambulance by a provider located out-of-state or in a non – designated area In state bus or train services Family member transportation (authorized by the county office of the DFR)

41 MDwise PA Process - Transportation Submit the following information: PA form Proper procedure codes Member’s age, diagnosis, and condition Level of service needed Reason for and destination of service Frequency of service Duration of service Total mileage for each trip Total wait time for each trip Note: PA not required for accompanying parent or attendant unless the trip exceeds 50 miles one - way

42 MDwise PA Process – Genetic Tests Genetic testing for breast and ovarian cancer Documentation required: PA request form Appropriate procedure codes Medical necessity documentation

43 MDwise PA Process – Reminders Verify member eligibility Verify member’s CMO affiliation (No Delivery Systems in Care Select) Verify if the service requires PA Complete the PA request form Complete with appropriate CPT/HCPCS codes Fax PA form and supporting documentation to MDwise 877-8227186 or 317-822-7515 Verify PA status using web interChange Finalize all PA requests (including suspended PAs) with CMO receiving original PA request

44 MDwise PA Process Questions? Thanks for attending!

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