by ADVANTAGE Care Select and MDwise Care Select Provider Relations

by ADVANTAGE Care Select and MDwise Care Select Provider Relations
Presented by ADVANTAGE Care Select and MDwise Care Select Provider Relations PCS0080 (09/09)

Agenda Welcome Session Objectives
Eligibility Review – The Key to Success The Prior Authorization (PA) Process Questions/Answers PCS0080 (09/09)

Session Objectives Following this session, providers will be able to:
Identify the two care management organizations (CMOs) Understand eligibility and its relationship to PA Understand the suspended PA procedures when a member switches health plans Understand which contractor processes pharmacy PA requests Common PA submission procedures by specialty Common PA processing procedures by specialty Understand the PA appeal process PA contact information PCS0080 (09/09)

Care Select Eligibility Review
Verify eligibility using Web interChange, OMNI or Automated Voice Response (AVR) 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: Which CMO receives the member’s PA request Member’s Care Manager Member’s Primary Medical Provider (PMP) CMO who processes restricted card information Where members can change PMP PCS0080 (09/09)

Care Select Eligibility Review
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 BT 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 requested from the member if he/she insists on receiving the service not authorized by the assigned PMP PCS0080 (09/09)

Prior Authorization Two health plans were selected to function as CMOs for the Care Select program ADVANTAGE Health Solutions, Inc.sm – Care Select PA – Traditional PA MDwise, Inc. – Care Select PA ADVANTAGE was selected to function as the Traditional Medicaid fee – for – service Note: All PA for prescription drugs are processed and adjudicated by ACS and not the CMOs PCS0080 (09/09)

Prior Authorization General Information
The STATE plan requirements for Prior Authorization are the same for both Indiana Care Select and Traditional Medicaid (FFS) The CMO’s PA departments use OMPP approved criteria in addition to the Indiana Administrative Code (IAC), PA guidelines, and Indiana Health Coverage Programs (IHCP) bulletins, banner pages, and newsletters when considering PA requests The CMO’s PA Departments review all medical, facility, or dental PA requests Decisions to authorize, modify, or deny a PA is based on medical reasonableness, necessity, and other criteria outlined in 405 IAC 5-3 and reflects the current standards of practice in the provider community For a full detailed explanation of PA processes and procedures, please refer to Chapter 6 of the 2008 IHCP Provider Manual Out of state providers must obtain PA prior to performing services (except emergencies) PCS0080 (09/09)

Prior Authorization Methods of Submission – All PAs are submitted to the plan the member is assigned to By Fax – Providers may fax the Indiana Prior Review and Authorization Request form along with supporting documents Note: CMO preferred method By Web interChange - application on the IHCP website allows providers to submit non-pharmacy PA requests and to inquire on request via web interChange. Note: Providers must have administrator capability setup on Web interChange in order to submit PA or to perform PA Inquiry on Web Interchange By Mail – Written requests for PA are submitted using an Indiana Prior Review and Authorization Request form along with supporting documents PCS0080 (09/09)

Prior Authorization Web interchange
The following provider types can submit PA requests via Web interChange: Chiropractor Dentist Doctor of Medicine Doctor of Osteopathy Home Health Agency (authorized agent) Hospice Hospitals Optometrist Podiatrist Psychologist endorsed as a Health Service Practitioner in Psychology (HSPP) Transportation providers PCS0080 (09/09)

CMO Prior Authorization Process
Procedures Use the fee schedule at to locate services which require PA due to State regulations for Care Select and Traditional Medicaid Reminder: Care Select service 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, Indiana Administrative Code, and bulletins, banner pages, and newsletters Reminder: Do not submit PA requests to a MDwise HHW Delivery System New services require a new Prior Authorization request form Reminder: Providers may not add new services to an existing PA request as this constitutes a new PA request Indiana Prior Review and Authorization Request Form, System Update Form and Dental Prior Review and Authorization Request Form These forms are available on the Forms page of the IHCP Website at PCS0080 (09/09)

Prior Authorization Process
Request Sent to Wrong CMO Paper and faxed requests are rejected Requesting provider will receive a decision letter advising of rejected status PA requests sent electronically via the 278 transaction are rejected with reason code 78 – Subscriber/Insured not in Group/Plan identified Requesting provider will not receive a decision letter PA requests sent via web interChange are systematically routed to the correct CMO Providers will need to resubmit the PA request to the appropriate CMO PCS0080 (09/09)

Prior Authorization Outstanding Prior Authorizations
Members can change between Traditional Medicaid fee-for-service, Hoosier Healthwise, and Care Select The receiving organization must honor PAs approved by the member’s previous organization for the first 30 days following the re-assignment, or for the remainder of the PA dates of service, whichever comes first Example: Member transitions from Hoosier Healthwise MCO to a Care Select CMO on November 14, The MCO approved PA for dates of service 10/22/07 through 12/13/07 The CMO must honor the approved PA for 30 days from November 14, 2007 PCS0080 (09/09)

Suspended Prior Authorization
PA requests are suspended when additional information is needed by the provider to determine medical necessity Requested documentation must be received within 30 calendar days Member switches CMO’s Important: When a member is re-assigned to a different CMO after a PA request is suspended: Providers must send the added documentation to the CMO which received the original PA request from the provider Providers should verify member eligibility for the original PA request date via web interChange prior to sending additional documentation PCS0080 (09/09)

Prior Authorization Does the service require PA under the State Plan?
Examples of general 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. Psychiatric Residential Treatment Facility (PRTF) PA determines the medical necessity of a service or item PCS0080 (09/09)

Prior Authorization 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 Note: The CMOs request that hospitals notify us via web interChange, fax, or phone when one of our Care Select members becomes an inpatient so we can assist in planning patient discharge PCS0080 (09/09)

Supporting Documents Necessary for Institutional PA Requests
Prior Authorization 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 PCS0080 (09/09)

Prior Authorization Psychiatric Residential Treatment Facility PA requests must include the PA request form and the following: 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 PCS0080 (09/09)

Prior Authorization Inpatient emergency services requiring PA
Reported to CMO 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 Report emergency services to member’s PMP within 48 hours PCS0080 (09/09)

Prior Authorization Non-Institutional PA Requirements (Physician)
Criteria used to process PA requests for non-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 PCS0080 (09/09)

Prior Authorization Process - Physician
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 PCS0080 (09/09)

Prior Authorization Process - Physician
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 – Please note: Physician services rendered during an inpatient stay that do not receive PA are not reimbursable PCS0080 (09/09)

Prior Authorization Process – Physician
PA requirements for podiatry services are found in 405 IAC 5-26 Corrective features built into shoes for members younger than age 20 Orthopedic shoes for members with severe diabetic foot disease Palliative or hygienic care Routine foot care in excess of six services per year for patients with diabetes mellitus, peripheral vascular disease or preripheral deuropathy Podiatry services furnished during an inpatient stay requires PA If using this layout, photos can be used in a circular format. Additional text can be used below the photo as shown. Bullets should move to the the right side of the slide. PCS0080 (09/09)

Prior Authorization Process – Physician
PA requirements for chiropractic services are found in 405 IAC 5-12 Reimbursement limited to 50 office visits or treatments per member per year (includes five office visits per year) New patient office visits are reimbursable once per provider per lifetime of the member Chiropractic services rendered without PA are subject to denial If using this layout, photos can be used in a circular format. Additional text can be used below the photo as shown. Bullets should move to the the right side of the slide. PCS0080 (09/09)

Prior Authorization 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 – TD-Unlisted home visit, service, or procedure-registered nurse If using this layout, photos can be used in a circular format. Additional text can be used below the photo as shown. Bullets should move to the the right side of the slide. PCS0080 (09/09)

Documentation Reviewed by the PA Department: 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 If using this layout, photos can be used in a circular format. Additional text can be used below the photo as shown. Bullets should move to the the right side of the slide. PCS0080 (09/09)

Documentation Reviewed by the PA Department continued: 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) PCS0080 (09/09)

Documentation Reviewed by the PA Department continued: 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 PCS0080 (09/09)

Documentation Reviewed by the PA Department continued: 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 PCS0080 (09/09)

Documentation Reviewed by the PA Department Continued: 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 PCS0080 (09/09)

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 PCS0080 (09/09)

Prior Authorization Process - Therapy
General Information Criteria for therapy services is located in 405-IAC through 405-IAC 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 PCS0080 (09/09)

Prior Authorization - Therapy
PA not Required Continued: 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 PCS0080 (09/09)

Prior Authorization - Therapy
PA Criteria Continued: 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 PCS0080 (09/09)

Prior Authorization Process - Therapy
Additional Information: 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 PCS0080 (09/09)

Prior Authorization Process – Mental Health
Mental health PA criteria are listed in 405 IAC 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 PCS0080 (09/09)

Note: PA required for neuropsychological and psychological testing and includes – psychological testing, – developmental test extended, and – 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 PCS0080 (09/09)

Assertive Community Treatment (ACT) PA is required for ACT services covered by the IHCP per 440 IAC and PA requirements in 405 IAC (d) Required Documents: Assessment of current medical status Psychiatric history Status at time of review for ACT Treatment goals reviewed by ACT team psychiatrist PCS0080 (09/09)

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 The CMO’s do not retain a mental health benefits administrator for their respective Care Select products PCS0080 (09/09)

Prior Authorization 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 PCS0080 (09/09)

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 PCS0080 (09/09)

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 PCS0080 (09/09)

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 PCS0080 (09/09)

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 or at PCS0080 (09/09)

Prior Authorization – 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 PCS0080 (09/09)

Prior Authorization – DME/ HME
Traditional Medicaid members – Nursing home benefits and 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 PCS0080 (09/09)

Prior Authorization - 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) PCS0080 (09/09)

Prior Authorization Contact Information Advantage Health Plan (Traditional Medicaid) P.O. Box 40789 Indianapolis, IN 46240 MDwise – CMO P.O. Box 44214 Indianapolis, IN Advantage Health Plan – CMO P.O. Box 80068 Indianapolis,IN 46280 ACS (Fax) PCS0080 (09/09)

Prior Authorization 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 PCS0080 (09/09)

Prior Authorization Process – Genetic Tests
Genetic testing for breast and ovarian cancer Documentation required: PA request form Appropriate procedure codes Medical necessity documentation PCS0080 (09/09)

Prior Authorization Process – Hearings/Appeals
Hearing, Appeal and Administrative Review Procedures for hearings, appeals, and administrative review remain unchanged Providers may exercise PA appeal rights to the CMO that denied the PA request If the member is re-assigned to another program after the PA request is denied, the provider may send a PA request to the new organization, or appeal to the organization that denied the request Appeals sent to the wrong CMO are returned to the provider unprocessed Refer to Chapter 6 of the IHCP Provider Manual as well as each CMO’s Provider Manual regarding the hearing, appeal, and administrative review procedures PCS0080 (09/09)

Prior Authorization – Summary
Verify member eligibility Verify member’s CMO affiliation on date of PA request Verify if the service requires PA Complete the PA request form for all PA requests Complete with appropriate CPT/HCPCS codes All out – of – state services providers must receive PA before providing services (except designated IFSSA areas) Fax PA form and supporting documentation to appropriate CMO MDwise: or ADVANTAGE Care Select: ADVANTAGE Traditional Medicaid: Verify PA status using web interChange PA inquiry Finalize all PA requests (including suspended PAs) with CMO receiving original PA request PCS0080 (09/09)

Questions Use this layout to divide sections within the presentation. PCS0080 (09/09)

Kelvin Orr – Provider Network Director, ADVANTAGE Care Select
Presentation by ADVANTAGE Health Solutions, Inc. and MDwise, Inc. Provider Relations Team in cooperation with each organization’s PA Department Kelvin Orr – Provider Network Director, ADVANTAGE Care Select Mark Willeman – PA Director, ADVANTAGE Care Select & FFS Chris Kern – Provider Relations Manager – Care Select Marcia Franklin – Senior Manager – Care Select Prior Authorization ADVANTAGE Traditional Medicaid PA P.O. Box 40789 Indianapolis, IN 46240 ADVANTAGE Care Select PA P.O. Box 80068 Indianapolis, IN 46280 MDwise Care Select PA P.O. Box 44214 Indianapolis, IN 46244 PCS0080 (09/09)

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