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How to submit an Inpatient Service Authorization Request Presented by KePRO INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT 1.

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Presentation on theme: "How to submit an Inpatient Service Authorization Request Presented by KePRO INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT 1."— Presentation transcript:

1 How to submit an Inpatient Service Authorization Request Presented by KePRO INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT 1

2 INPATIENT SERVICES INPATIENT ACUTE-MEDICAL--SURGICAL SRV AUTH SERVICE TYPE 0400 INPATIENT ACUTE PSYCHIATRIC SRV AUTH TYPE 0401 INPATIENT PSYCHIATRIC –- PRIVATE AND STATE MENTAL HOSPITALS- SRV AUTH TYPE 0093 (EPSDT) INPATIENT REHABILITATION – SRV AUTH TYPE

3 Service Authorization and General Background Information Service authorization (Srv Auth) is the process to approve specific services for an enrolled Medicaid, FAMIS Plus or FAMIS individual by a Medicaid enrolled provider prior to service delivery and reimbursement. The purpose of service authorization is to validate that the service requested is medically necessary and meets DMAS criteria for reimbursement. Service authorization does not guarantee payment for the service; payment is contingent upon passing all edits contained within the claims payment process, the individual’s continued Medicaid eligibility, the provider’s continued Medicaid eligibility, and ongoing medical necessity for the service. KePRO will approve, pend, reject, or deny all completed Srv Auth requests. If Clinical information is missing form the Srv Auth request after the initial evaluation, the clinical reviewer will pend the case for one business day 3 3

4 Service Authorization and General Background Information The clinical reviewer will send a message via Atrezzo as well as faxing a letter to the Provider requesting additional information. The Provider has one business day to provide the requested information. If the additional information requested does not meet the criteria to determine medical necessity then the request is sent to the KePRO Physician to make a medical necessity determination. The KePRO Physician will provide a decision within one business day of receiving the request to review for medical necessity. The provider will be notified of the decision by a message entered into Atrezzo, as well as the Atrezzo case notes. If the MD decision is to approve the case a system generated approval will be received by the provider. If the MD has denied the case a letter will be faxed to the provider with the details of the MD decision. The clinical reviewer will also send an Atrezzo message, and will document the decision in the Atrezzo case notes. 4

5 Service Authorization and General Background Information Requests that are unable to be approved due to not meeting medical criteria are automatically sent to medical staff for review. When a final disposition is reached KePRO notifies the the provider in writing of the status of the request. Srv Auth decisions by KePRO are based upon clinical review and apply only to individuals enrolled in Medicaid fee-for-service on dates of service requested. KePRO’s decision does not guarantee Medicaid eligibility or fee-for-service enrollment. It is the provider's responsibility to verify member eligibility and to check for managed care organization (MCO) enrollment. For MCO enrolled members, the provider must follow the MCO's Srv Auth policy and billing guidelines. 5

6 Member Eligibility Verification is Provider Responsibility VIRGINIA MEDICAID WEB PORTAL It is the Provider’s Responsibility to verify Member eligibility DMAS offers a web-based Internet option to access information regarding Medicaid or FAMIS member eligibility, claims status, check status, service limits, service authorizations, and electronic copies of remittance advices. Providers must register through the Virginia Medicaid Web Portal in order to access this information. – The Virginia Medicaid Web Portal can be accessed by going to: If you have any questions regarding the Virginia Medicaid Web Portal, please contact the Xerox State Healthcare Web Portal Support Helpdesk, toll free, at from 8:00 a.m. to 5:00 p.m. Monday through Friday, except holidays. –The MediCall audio response system provides similar information and can be accessed by calling or Both options are available at no cost to the provider. –Providers may also access service authorization information including status via KePRO’s Provider Portal at 6 6

7 Member Eligibility Verification Vendors ELIGIBILITY VENDORS DMAS has contracts with the following eligibility verification vendors offering internet real-time, batch and/or integrated platforms. Eligibility details such as eligibility status, third party liability, and service limits for many service types and procedures are available. Contact information for each of the vendors is listed below: Passport Health Communications, Inc.www.passporthealth.com Telephone: 1 (888) SIEMENS Medical Solutions – Health Services Foundation Enterprise Systems/HDXwww.hdx.comwww.hdx.com Telephone: 1 (610) Emdeon 1 (877) www.emdeon.com 7

8 Communicating with DMAS and KePRO Provider manuals are located on the Virginia Medicaid Web Portal. The Virginia Medicaid Web Portal can be accessed by going to: The DMAS/KePRO website has information related to the service authorization process for Inpatient Admissions. To Access the DMAS/KePRO website go to: To access fax forms select the Forms tab. DMAS 362 and 362 A are specific to Inpatient Services. A service specific checklist for Inpatient Med/Surg, Inpatient Intensive Rehab, and Inpatient Psych may be found by clicking on “Service Authorization Checklists” on KePRO’s website. For educational material, click on the Training tab and scroll down to click on the Inpatient tab. 8

9 Submitting Requests for Srv Auth KePRO will accept requests through direct data entry (DDE), fax, telephone and US mail. The preferred method is by DDE through KePRO’s provider portal, Atrezzo Connect. To access Atrezzo Connect on KePRO’s website, go to For direct data entry requests, providers must use Atrezzo Connect Provider Portal. Provider Registration is Required to use Atrezzo Connect The registration process for providers happens immediately on-line. From providers not already registered with Atrezzo Connect may click on “First Time Registration” to be prompted through the registration process. Newly registering providers will need their 10-digit National Provider Identification (NPI)number and their most recent remittance advice date for YTD 1099 amount. The Atrezzo Connect User Guide is available at Click on the Training tab, then the General tab. Providers with questions about KePRO’s Atrezzo Connect Provider Portal may contact KePRO by at 9

10 Submitting Requests for Srv Auth For service authorization questions, providers may contact KePRO at KePRO can also be reached by phone at , or via fax at OKBYFAX or All fax forms are available on KePRO’s website at Providers may click on the “Forms” tab to view a listing of all KePRO fax forms, labeled by form number and service type. 10

11 Service Authorization Requests: General Information Inpatient Admissions (0400,0401,0093,0200) On admission to Inpatient Acute Services the member must meet criteria for inpatient hospitalization and have a treatment plan in place that requires and inpatient level of care. All admissions must be authorized within 1 business day of the admission. A business day is defined as 12:00 am – 11:59 pm Monday – Friday with the exception of State recognized holidays. Medicaid defines “observation beds” as outpatient services and does not require service authorization To initiate service authorization of the admission the provider must provide the member’s name; the identification number; the admitting physician’s name; the primary care physician’s name (if applicable); the admission diagnosis and ICD-9-CM diagnosis code(s); the medical indication for hospitalization; and the plan of care KePRO will apply InterQual® ISD criteria. A service authorization number will be assigned for admission for medical/surgical services or for the initial admission and length of stay for psychiatric inpatient and for Intensive Rehab admissions. Medical/surgical services must have their own service authorization number and cannot be combined with a psychiatric service authorization. DMAS will not reimburse claims that have conflicting diagnosis codes on the claim versus the type of service authorization provided 11

12 Service Authorization Requests: General Information Inpatient Admissions (0400,0401,0093,0200)(continued) Retrospective review will be performed when a provider is notified of a patient’s retroactive eligibility for Virginia Medicaid coverage. Prior to billing Medicaid the provider must have a Srv Auth. The health care provider should request a Srv Auth for retrospective review within 30 days of the notice of Medicaid eligibility KePRO will not accept reviews for members who have Medicare Part A. If Medicare denies the requested stay and/or if the Medicare benefits are exhausted, the provider may submit a Srv Auth request for retrospective review within 30 days of the notice of denial or exhaustion by Medicare. 12

13 For Organ Transplants, Gastric Bypass Surgery, Cosmetic Procedures including Breast Reduction, the inpatient hospitalization services must be authorized separately from the physician’s service authorization. Admissions require service authorization by KePRO. KePRO will provide a service authorization number for the admission date. Under the DRG reimbursement methodology, no continued stay reviews will be conducted for members receiving general acute medical/surgical services. For those members who do not meet InterQual criteria on admission but do meet the criteria later in the hospitalization, the Provider must request service authorization within one business day of the patient’s meeting the criteria. Service Authorization is not required for normal maternity/newborn inpatient care. This includes normal vaginal deliveries with a length of stay less than or equal to three days from the date of admission;. · 13 Service Authorization Requests: Specific Information for Inpatient Med/Surgical Admissions (0400)

14 Caesarian section deliveries, with a length of stay less than or equal to five days from the date of admission; and newborns who are in the normal nursery with a length of stay less than or equal to five days from the infant’s date of birth. Service authorization will be required for the entire newborn stay if the infant is in any other nursery setting for any part of the stay. KePRO must service authorize maternity and newborn stays which do not fall within these parameters, and the service authorization must be on file with DMAS prior to billing for the stay. Certain procedures done as outpatient do require service authorization if the patient is subsequently admitted to the hospital due to postoperative complications, the provider must call to authorize admission within 1 business day. 14 Service Authorization Requests: Specific Information for Inpatient Med/Surgical Admissions (0400)

15 Service Authorization Requests: Specific Information for Psychiatric Services (0401, 0093) Inpatient Acute Psychiatric Services in both acute hospitals and freestanding hospitals require Service Authorization. Planned/scheduled admissions must be service authorized within 24 hours of admission, or on the next business day after admission. Obtaining Service Authorization prior to the admission is encouraged. Unplanned/urgent or emergency admissions must be service authorized within 24 hours of admission, or on the next business day after admission. Prior to the expiration of the initial assigned length of stay, if the member requires continued inpatient hospital care, the health care provider must contact KePRO’s review staff to initiate the concurrent review process. Concurrent review will continue in the same manner until the member is discharged For psychiatric inpatient services the Provider should call KePRO if the member is discharged prior to the approved length of stay. The provider must also call KePRO to extend the length of stay if the patient stays beyond the assigned length of stay. The exception to this is for the adult patient who stays beyond 21 days. The hospital is only responsible for obtaining service authorization for the first 21 days of inpatient psychiatric care.. 15

16 Service Authorization Information Specific Information for Intensive Rehab Admissions (0200) All requests for Service Authorization must be received through KePRO within 72 hours of admission. Requests received after 72 hours will be denied up to the date the request is received. If the member continues to meet medical necessity criteria and is still in the facility, the request may be approved starting the day the request is received at KePRO. DMAS will conduct post payment review audits for intensive rehabilitation providers and will strongly enforce the 72-hour notification policy. Within 72 hours of the Intensive Rehab admission, the provider must submit a request for Srv Auth to KePRO. The review analyst will assign an initial length of stay. The provider must contact KePRO prior to the Srv Auth end date if services are to extend beyond the initial authorization period. 16

17 Out of State Service Authorization Requests: Specific Information for Intensive Rehab (0200) Effective March 1, 2013 out of state providers need to determine and document evidence that one of the following items is met at the time the service authorization request is submitted to the service authorization contractor: 1. The medical services must be needed because of a medical emergency. 2. Medical services must be needed and the recipient’s health would be endangered if he were required to travel to his state of residence; 3. The state determines, on the basis of medical advice, that the needed medical services, or necessary supplementary resources, are more readily available in the other state; 4. It is the general practice for recipients in a particular locality to use medical resources in another state. Authorization requests for certain services can also be submitted by out-of-state facilities. Refer to the Out of State Request Policy and Procedure on Pages 8 & 9 for guidelines when processing out of state requests, including 12VAC The provider needs to determine item 1 through 4 at the time of the request to the Contractor. If the provider is unable to establish one of the four KePRO will: Pend the request utilizing established provider pend timeframes Have the provider research and support one of the items above and submit back to the Contractor their findings 17

18 Out of State Service Authorization Requests: Specific Information for Intensive Rehab (0200) Specific Information for Out of State Providers Out of state providers are held to the same service authorization processing rules as in state providers and must be enrolled with Virginia Medicaid prior to submitting a request for out of state services to KePRO. If the provider is not enrolled as a participating provider with Virginia Medicaid, the provider is encouraged to submit the request to KePRO, as timeliness of the request will be considered in the review process. KePRO will pend the request back to the provider for 12 business days to allow the provider to become successfully enrolled. If KePRO receives the information in response to the pend for the provider’s enrollment from the newly enrolled provider within the 12 business days, the request will then continue through the review process and a final determination will be made on the service request. 18

19 Out of State Service Authorization Requests: Specific Information for Intensive Rehab (0200) Specific Information for Out of State Providers If the request was pended for no provider enrollment and KePRO does not receive the information to complete the processing of the request within the 12 business days, KePRO will reject the request back to the provider, as the service authorization can not be entered into MMIS without the providers National Provider Identification (NPI). Once the provider is successfully enrolled, the provider must resubmit the entire request. Out of state providers may enroll with Virginia Medicaid by going to https://www.virginiamedicaid.dmas.virginia.gov/wps/myportal/ProviderEnrollmenthttps://www.virginiamedicaid.dmas.virginia.gov/wps/myportal/ProviderEnrollment. At the toolbar at the top of the page, click on Provider Services and then Provider Enrollment in the drop down box. It may take up to 10 business days to become a Virginia participating provider. 19

20 Resource Information DMAS offers a web-based Internet option to access information regarding Medicaid or FAMIS member eligibility, claims status, check status, service limits, service authorizations, and electronic copies of remittance advices. Providers must register through the Virginia Medicaid Web Portal in order to access this information. The Virginia Medicaid Web Portal can be accessed by going to: If you have any questions regarding the Virginia Medicaid Web Portal, please contact the Xerox State Healthcare Web Portal Support Helpdesk, toll free, at from 8:00 a.m. to 5:00 p.m. Monday through Friday, except holidays. The MediCall audio response system provides similar information and can be accessed by calling or Both options are available at no cost to the provider. Providers may also access service authorization information including status via KePRO’s Provider Portal at Medicaid Memoranda and Manuals DMAS publishes electronic and printable copies of its Provider Manuals and Medicaid Memoranda on the DMAS Web Portal at https://www.virginiamedicaid.dmas.virginia.gov/wps/portal.https://www.virginiamedicaid.dmas.virginia.gov/wps/portal This link opens up a page that contains all of the various communications to providers, including Provider Manuals and Medicaid Memoranda. The Internet is the most efficient means to receive and review current provider information. If you do not have access to the Internet or would like a paper copy of a manual, you can order it by contacting: Commonwealth-Martin at A fee will be charged for the printing and mailing of the manual updates that are requested. 20

21 The End Thank You for your Participation 21


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