Welcome to the Indiana Health Coverage Program Seminar: MDwise Care Select Prior Authorization

1
Welcome to the Indiana Health Coverage Program
SeminarMDwise Care Select Prior Authorization

• Presented byMDwise Provider Relations
• October 6 8, 2008

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Agenda

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

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Care Select Eligibility

• Always verify the Care Select members
  eligibility
• Review the entire eligibility record to determine
  the members Care Management Organization (CMO)
• The members CMO affiliation determined on the
  date of eligibility verification determines
  everything
• Which CMO receives a PA request
• Members Care Manager
• CMO who processes restricted card information
• Where members can change primary medical
  providers (PMP)

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Care Select Eligibility

• Reminders
• Know the members assigned PMP and contact
  information
• Providers rendering services that require the
  PMPs 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

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MDwise 101
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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 dont 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

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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

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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 (gt20 one way trips or gt50
  miles one way)
• 8. Outpatient Mental Health (gt20 visits)
• 9. PRTF
• Check the fee schedule at www.indianamedicaid.com
  to determine if a code requires PA

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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 (www.indianamedicaid.com)
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 requests status using Web interChange
regardless of the method of submission
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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 www.indianamedicaid.co
  m)

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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

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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

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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 members PMP within
  48 hours

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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

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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

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MDwise PA Process
Physician Services PA required for Evaluation
and Management (EM) services that exceed 30
visits per member per rolling calendar year EM
Codes subject to PA after 30 visits 99201
99205 99211 - 99215 99241 - 99245 99381 -
99387 99391 - 99387 99401 99429 Please note
Physician services rendered during an inpatient
stay that do not receive PA are not reimbursable
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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

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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 patients 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

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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

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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)

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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

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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

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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

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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 patients status (as
  documented in the patient plan of care)
• Non-covered services under home health benefit
• Homemaker
• Chore services
• Sitter/companion services

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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

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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 facilitys
  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

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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

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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

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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

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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

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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

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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 members assigned
MDwise Care Select PMP to obtain that PMPs two
character certification code All services billed
to EDS as fee for service
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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

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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 www.indianamedicaid.com
• 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

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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

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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

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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
  www.indianamedicaid.com

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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

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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

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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)

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MDwise PA Process - Transportation

• Submit the following information
• PA form
• Proper procedure codes
• Members 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

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MDwise PA Process Genetic Tests

• Genetic testing for breast and ovarian cancer
• Documentation required
• PA request form
• Appropriate procedure codes
• Medical necessity documentation

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MDwise PA Process Reminders

• Verify member eligibility
• Verify members 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

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MDwise PA Process
Questions?Thanks for attending!