Qualis Health Care Management Services for South Carolina Medicaid

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Qualis HealthCare Management Servicesfor South
Carolina Medicaid

• Barbara Excell, RN, MSHA, CPHQ, CPUR, PMC
• Director Medicaid Services Central/East

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Goals Objectives

• Provide a brief overview/background of Qualis
  Health including the mission/vision and values
• New additions to the Prior Authorization list and
  timeframe changes for submission of retro charts
  as required by SC DHHS.
• What these changes mean for providers
• Prior authorization review form
• Care Management Services and timeframes
• Contact Information

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Qualis Health Background

• Qualis Health, headquartered in Seattle, WA is a
  private, non-profit health care quality
  improvement organization (QIO).
• Qualis Health has offices in Cayce, SC
  Anchorage, AK Boise, ID Tustin, CA and Lincoln
  NE.
• Qualis Health has 30 years of experience
  providing health care utilization/case management
  and quality assessment/improvement services to
  public and private sector customers.

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Care Management Is Our Core Business
Vision To be recognized for leadership,
innovation and excellence in improving the
health of individuals and populations
Mission To generate, apply, and disseminate
knowledge to improve the quality of healthcare
delivery and health outcomes
Values Integrity, professionalism,
collaboration, and stewardship
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Qualis Health South Carolina Staff includes

• Director Medicaid Services
• Registered Nurses
• RHIA
• Professional Intake and Administrative Staff
• Medical Director
• Associate Medical Director
• Physician Specialty Consultants

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Qualis Health SC Medicaid Services

• Care Management
• Utilization Review and Quality of Care Reviews
• Retrospective reviews
• DRG Analysis
• Pre-authorization reviews
• Support Documentation reviews
• Sterilization reviews
• Quality of care reviews utilizing CMS guidelines
• HINN reviews
• Therapeutic Foster Care onsite reviews
• PRTF precert reviews
• PRTF postcert reviews
• PRTF annual reviews
• ICF/MR reviews
• IMD/RTF QOC reviews

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Qualis Health Supports the additional codes SC
DHHS is implementing for Prior Authorization
Effective Beginning February 1, 2009
The changes include additions to the Prior
Authorization (PA) list and include mastectomy
codes, back and spine codes. These codes are in
addition to all other codes requiring prior
authorization. The following slides will
assist providers in determining the best method
for updating daily operations/processes to
comply with these new changes. Please refer to
the SC DHHS provider manual to reference all
changes at http//www.dhhs.state.sc.u
s/dhhsnew/index.asp
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Effective February 1, 2009 Additional Codes
requiring Prior Authorization
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Prior Authorization Update Medicaid Bulletin
The policy for Mastectomy and Reconstructive
Breast Surgery has not changed. Reimbursement is
allowed for reconstructive breast surgery
following a mastectomy when performed for the
removal of cancer or for prompt repair of an
accidental injury. Breast reconstruction done for
cosmetic reasons is non-covered. Breast
Augmentation is non-covered under all
circumstances. Program information can be found
in the provider and hospital manuals located at
www.scdhhs.gov.
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Effective February 1, 2009 Record receipt
timeframe change per the SC DHHS bulletin South
Carolina Department of Health and Human Services
will no longer grant the additional 60 days in
which providers may submit medical records to
Qualis Health for retrospective reviews. Once
Qualis Health has issued a technical denial for
records that have not been received within 30
days of the request, that decision stands as
final. To be sure Qualis has the correct
information you may contact Qualis Health at
1-877-717-8592 to confirm the correct mailing
address and correct hospital contact in order to
ensure notifications are received and records are
submitted within the thirty-day time
period. Qualis will accept and encourages all
providers to submit medical records on CDs.
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Qualis Health SC Medicaid ServicesTimeframes

• Retrospective-Qualiss goal is to provide a
  decision to the provider within 30 days from
  receipt of all requested information. Effective
  February 1, 2009, providers will have 30 days to
  provide the retrospective records to Qualis.
• Pre-authorization-Qualiss goal is to provide a
  decision to the provider within 15 days from
  receipt of all requested information.

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SC Medicaid PreauthorizationReview Process

• Review Request Received
• Facsimile
• Mail
• Telephone
• iEXCHANGE

Review completed by qualified reviewers
To physician reviewer with option of peer-to-peer
discussion offered when not approved
Notification to all parties Approval given to
providers telephonically
Meets Criteria?
Yes
No
Notification to facility, provider and SC
Medicaid via letter with reconsideration rights
included
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Qualis Health Supports the SC Medicaid Review
Process

• Through formal training sessions
• Working consistently with SC DHHS
• During the utilization review process
• With outreach to local provider associations
• Through the local Qualis Health office. You may
  call us anytime.

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• As we continue to provide these QIO services, it
  is important for us to hear from you regarding
• How the review process works for you
• Any issues or concerns that may arise
• Additional ways Qualis Health can assist you with
  education on UM
• Process improvement opportunities
• Educational opportunities

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Contact Information
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Contact Information
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Questions?