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INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT QIO Request Submission Requirements Surgical Justification Organ Transplant New 6/14/2012.

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Presentation on theme: "INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT QIO Request Submission Requirements Surgical Justification Organ Transplant New 6/14/2012."— Presentation transcript:

1 INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT QIO Request Submission Requirements Surgical Justification Organ Transplant New 6/14/2012

2 Topics Service Type(s) KePRO SCDHHS Website Service Type Requirements Contact Information

3 Prior Authorization Service Types ORGAN TRANSPLANT

4 Organ Transplant Eligibility: - Medicare Primary, Medicaid MCO, Private Insurance: KePRO will review and authorize for the transplant event only - Transplant evaluation / workup is done outpatient, KePRO does not review for evaluation; follow Primary Insurance carrier policy for prior authorization Out-of-State Transplant: - Transplant services must not be available in SC - Evaluation is outpatient. KePRO does not review / authorize

5 REQUIRED DOCUMENTATION Required Documentation : –Transplant Prior Authorization request Form (must be completely filled out). –Letter of Medical Necessity, signed by physician –**Without submission of the above 2 forms, case will receive an administrative denial. ** – Fax Submissions require KePRO Prior Authorization Fax Form – Transplant and Surgical justification

6 Transplant Prior Authorization Request Form


8 Organ Transplant Organ transplant must be performed at CMS Approved transplant Center: Servicing Provider: Referring Physician NPI number Timely submission: at least 10 days advance notice, excluding emergent cases Transplant authorization: - Transplant authorization approved for 365 days from date of PA request - Authorization covers 75 hours prior to transplant event and up to 90 days after transplant event.

9 Organ Transplant Transplant MUST have a current PA before the event occurs Types of transplants requiring a PA: –Heart transplant –Liver transplant –Lung transplant –Mismatched Bone Marrow –Multi-organ transplant Liver/Small Bowel Liver/Pancreas, Liver/Kidney, Kidney/Pancreas Heart/Lung Multivisceral –Small bowel –Pancreatic transplant

10 Organ Transplant No prior authorization is required for –Corneal transplant –Kidney transplant –Matched bone marrow (autologous inpatient and outpatient, allogeneic related and unrelated, and cord). Includes stem cell transplant Pre-transplant admission for chemotherapy and/or cell harvest may require inpatient prior authorization (follow policy of primary insurance carrier for inpatient admission).

11 Prior Authorization Service Types SURGICAL JUSTIFICATION

12 Codes Requiring Authorization  Not all CPT codes require authorization. For current list, go to: SC DHHS Manuals Physician’s Provider Manual Section 4 – Procedure Codes CPT Codes Requiring Prior Authorization Review

13 FORMS If submitting via fax, form is required. Form may be found at under the FORMS TAB. Donwload: Prior Authorization Fax Form – Transplant and Surgical Justification If submitting via portal, form is not required; however, clinical information must be submitted. NPI of servicing provider is required.

14 TIMELINESS Request must be made prior to surgery. Request may be made up to 30 days prior to requested surgical date. – Note that requests for bariatric surgeries or hysterectomies may be made prior to the 30 days, due to the clinical preparation/documentation required.

15 Information Needed for Surgical Justification Exact name of surgery to be performed. Clinical history. – Date of original diagnosis – Pathology reports – Scans/x-rays

16 SPECIFIC PROCEDURES These procedures often require submission back to the provider for more information: Mastectomy Laminectomy Hysterectomy Gastric Bypass

17 MASTECTOMY Be sure to submit: Pathology report If distant metastases are present

18 LAMINECTOMY Are symptoms unilateral or bilateral? Has the patient tried NSAIDs? Home PT or exercise program? Activity modification? How long have these been tried? For lumbar surgery, is pain made worse by walking? Relieved by forward flexion? Include imaging studies.

19 HYSTERECTOMY ALL requests must include the “Surgical Justification for Hysterectomy” form – found under the FORMS TAB at Without submission of this form, case will receive an administrative denial.

20 HYSTERECTOMY All hysterectomy requests must include the “Consent for Sterilization” form UNLESS the woman is already sterile due to a tubal ligation OR being postmenopausal. Documentation of either is required. The Consent (if required) must be signed at least 30 days prior to the procedure unless it is being done on an urgent/emergent basis – this requires submission of a physician statement as to the reason. The form is available under the FORMS TAB and is labeled “Required Document – Sterilization Consent.”

21 Surgical Justification-Hysterectomy

22 Consent for Sterilization Form

23 HYSTERECTOMY Clinical information should include: History of hormone use Any procedures (endometrial ablation or biopsy) Pap smear report Ultrasound report (if performed) Length of time symptoms have been present

24 GASTRIC BYPASS -Two questions that must be answered in clinical documentation 1)Is it medically necessary for the individual to have such surgery. 2) Is the surgery to correct an illness that caused the obesity or was aggravated by obesity. If No, to the above questions please submit additional information regarding why procedure is needed.

25 RETROACTIVE ELIGIBILITY Retro Eligibility -If a patient has received retroactive Medicaid eligibility, the provider needs to notate that either on the 1 st page of the KePRO fax form or by selecting “Retro” as the request type via the Atrezzo Provider Portal when creating the case. -NOTE: Retro eligibility refers to when a member is not eligible for Medicaid at the time the services are provided, but then becomes Medicaid eligible at a later date that is extended retroactively to cover the date of service

26 Medical Necessity Denials I f you disagree with denial decision, please follow instructions as outlined in your denial letter. -Reconsideration request- within 60 days from receipt of denial letter. Submission methods include fax, mail, or portal submission -Appeals request- within 30 days of receipt of denial letter. Appeals should be submitted after a reconsideration review has been completed.

27 Administrative Denials I f you disagree with an administrative denial decision, please follow instructions as outlined in your denial letter. -Appeals request- within 30 days of receipt of denial letter. -There is no reconsideration for an administrative denial

28 Response Time For Providers Providers have two business days to respond to additional information pend notices. –If no response received to pend, the request will be forwarded for Higher level review or administratively denied Providers have two business days to respond to Insufficient information requests –If no response received to pend, the request will be closed requiring re-submission for prior authorization

29 Response Time for Decisions from the QIO For Surgical Justification cases and Organ Transplant cases, KEPRO must render a decision within 24 hours. Note***this is excluding time for pending for additional information, physician review

30 South Carolina Web Site

31 Forms Navigate to Form Tab to obtain Documents such as: Fax and Justification forms

32 Registration for Atrezzo Connect Provider Portal INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT

33 How To Register For Atrezzo Connect Website Address: Select “ Registration For Atrezzo Connect” (Slide 3) Enter your 10 digit National Provider Identifier (NPI) number and Legacy South Carolina Medicaid provider ID Select a unique user name and password & complete required user information


35 Atrezzo Connect Atrezzo Connect allows for: – Secure access to Atrezzo Connect (Provider Portal) – Provider will be able to access letters by Case/Request, Respond/Send messages To/From KePRO

36 Required Information for Security Verification The provider must enter information to verify authenticity for security reasons Registration Code: – SCDHHS Legacy ID

37 Simple -5 Step Registration Process Start by clicking the Atrezzo Login button on the SCDHHS-KePRO website

38 Login Page You will be brought to this login page

39 Step 2 – Enter NPI and Legacy ID Enter your organization’s NPI number and Legacy Provider ID = Provider Registration Code Click NEXT

40 Step 3 – Terms of Agreement Review Terms of Agreement. Upon acceptance, you will be taken to setup for User information.

41 Step 4 – Verify Address Click on the correct address(s) for the new account (this associates your user information with these locations) If all apply, check all of them Click SELECT

42 Step 5 – Enter Account Information Enter user account information User Name, Password, First/Last Name, E-mail and Fax Number are required fields! Click NEXT-This will take you to the Password setup and security question Slide) Passwords do not expire. Minimum 8 characters required.

43 Successful Completion Successful Completion of setup, takes you to the Home Page

44 View all request and Create new request Click Member to search using Member id or Last name/DOB Click Request/Case to search using Case id, Member info or Request info

45 Create Preferences, Manage User accounts and New Provider Registration Use this tab to change your password or update your contact information View Atrezzo User Guide and View FAQs

46 Account Administrator All information submitted for registration under Provider/Facility Information will represent as the Provider Portal Administrator (Group Admin). The Group Admin is responsible for managing and creating all Submitting User accounts for your NPI # – Create other Group Admins’ & Admin Users – Set Preferences, i.e. Diagnosis and Procedure codes, etc

47 KePRO Contacts

48 48 Thank You!

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