Molina/BMS 2012 Provider Workshops IRG d/b/a APS Healthcare, Inc. Updates. Presented by: Helen C. Snyder, Associate Director

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1 Molina/BMS 2012 Provider Workshops IRG d/b/a APS Healthcare, Inc. Updates Presented by: Helen C. Snyder, Associate Director

2 Updates Provider Registration with APS v. Molina Medicaid enrollment Eligibility/Provider Verification for PA requests Out-of-Network Requests Denials and Reconsiderations Tips and tricks for Using APS Medical CareConnection (C3) FAQ s

3 Provider Registration with APS v. Molina WV Medicaid Enrollment Providers must register specifically with APS Healthcare in order to access the Medical CareConnection Providers must be WV Medicaid enrolled in order to register with APS- providers enroll in WV Medicaid through Molina Providers who try to register with APS and ARE NOT WV Medicaid enrolled will be unable to submit prior authorization requests

4 APS Registration Process There is a self-registration portal available at on the log-in page select self-enrollment Brief instructions on registration are in your packet- for more detailed instructions go to (medical providers online prior auth link) or contact us at: wvmedicalservices@apshealthcare.com

5 When Should We Register? Acute Inpatient, Inpatient Rehabilitation <21; PT/OT; Speech & Audiology providers should already be registered as these review areas are live in Medical CareConnection (C3). Remaining review areas are tentatively scheduled to be released in the following order: Cardiac and Pulmonary Rehabilitation and Chiropractic Services; Podiatry, Laboratory, Imaging and Radiology; Outpatient Surgery and Practitioner Services; Dental & Orthodontics and Vision Services; Home Health, Private Duty Nursing and Hospice Services; DME and Orthotics and Prosthetics Services.

6 Member Eligibility Verification for Prior Authorization Requests It is the responsibility of provider to verify Medicaid eligibility and other types of coverage. APS will check member eligibility before a provider can create a request based on member enrollment information from Molina (daily file update). All coverage types listed in Molina will be presented to the provider. If a member is not found the system will indicate the Member cannot be located. The provider should check the name and Medicaid number to verify the information has been keyed correctly. If the member is still not found, a Courtesy Review can be requested and the confirmed Medicaid information should be attached (e.g. copy of Medicaid card) when the request is submitted. The system confirms eligibility for the service start date requested upon submission. Dates not contained in the active Medicaid span will cause the submitted request to be stopped for eligibility verification before it goes to the clinical queue to be reviewed.

7 Provider Eligibility Verification for Prior Authorization Requests APS will check provider eligibility based on provider enrollment information from Molina (daily file update). The provider enrollment governs the provider s ability to create requests (access); ability to request certain service types (limited to certain provider types); ability for the prior authorization to be linked to the appropriate Medicaid Provider ID or NPI in the Molina system. The organizations created upon registration with APS are linked to provider enrollment in Molina (one organization can be created in the APS system to link to many Medicaid ID or NPI numbers OR many organizations can be created in the APS system to link to a single Medicaid ID or NPI number). The REFERRING PROVIDER MUST be a WV Medicaid enrolled provider.

8 Courtesy Review This option should only be utilized when the member has verified Medicaid coverage but is not found in the APS system at the time the request is created (e.g. because they are newly enrolled and not yet in the Molina system). The request is submitted AND reviewed for medical necessity and a determination of medical necessity is made but no PA number is assigned. Once Medicaid number is found in Molina system, APS staff links the record to the Medicaid ID and a prior authorization number is sent to Molina and is available for billing. Providers may also wait to submit a request until the number is located in Molina as timelines and medical urgency of the request permit.

9 Definition of Medically Urgent Case Review a) a delay could seriously jeopardize the life or health of the consumer or, b) the ability of the consumer to regain maximum function or, c) in the opinion of a physician with knowledge of the consumer s medical condition, would subject the consumer to severe pain that cannot be adequately managed without the care or treatment that is the subject of the case. NOTE: Some review areas do not recognize medically urgent requests. In these instances it is not a choice in the admission type dropdown. For those review areas that recognize medically urgent (e.g. inpatient) each admission type has a medically urgent choice (e.g. direct admission OR direct admission-medically urgent). Requests not meeting the medically urgent definition WILL NOT be clinically reviewed as medically urgent.

10 Retrospective Review Policy Retrospective review is available in the following instances: Weekends or holidays, or at times when APS/WVMI is closed. Retrospective reviews must be initiated within 72 business hours following the service; Member eligibility has been back-dated and must be initiated within 12 months of the date of service; A procedure/service denied by the member s primary payer provided all requirements for the primary payer have been followed including the appeals process (must submit EOB, copy of denied payment). Turn around time for processing of retrospective requests is 72 hours (3 business days); reviews that require physician review may require an additional 24 hours, depending upon the nature of complexity of the case. If the retrospective request DOES NOT meet the criteria for processing, it will not be reviewed for medical necessity (policy denial). If the retrospective request meets the criteria for processing, the normal review process will ensue.

11 Out-of-Network Requests Only an enrolled WV Medicaid provider may request an out-of-network service for a WV Medicaid member (this is why the referring provider must always be an enrolled WV Medicaid provider). For servicing provider select Out-of-network OR select the specific Out-of-network provider if they appear in the service provider table (e.g. Out-of-Network- Geary Hospital). An out-of-network provider found in the provider list merely indicates they have enrolled in WV Medicaid as out-of-network and have not termed. This does not guarantee that the authorization request will be processed if the requested service is available in-network. If the review determines that the service is medically necessary AND not available in-network, the out-of-network provider will be notified that they must enroll with Molina and a notice that medical necessity is met awaiting provider enrollment will be assigned. If the provider has previously enrolled to provide out-of-network services AND enrollment has not termed the prior authorization number is assigned. If medical necessity is not met (denial) there is no need for the provider to enroll and the member and referring provider are notified of the denial. If the provider is not enrolled as out-of-network, call tracking is opened with Molina and kept open until APS is notified the provider has enrolled. The authorization number is posted at the time of enrollment and sent to Molina. The out-of-network provider may then view the authorization request and bill Molina using the assigned prior authorization number.

12 Denials and Reconsiderations Status can be seen at the authorization record level OR in reports. Denial letters are always found on the Summary & Submit page of C3. If you entered the prior authorization request in C3, you will be messaged to your C3 inbox. Reconsiderations are requested from the action menu for requests that have been denied for medical necessity. Providers have 60 days to request reconsideration, so make sure all appropriate information is provided at the time of the reconsideration request. If you mail your reconsideration chart, wait until it is mailed prior to requesting in system and indicate in the note that the record has been mailed (or faxed if you do not attach at the time of reconsideration request).

13 Timeframes for Reconsideration Provider must request and submit reconsideration with all pertinent documentation within 60 calendar days from member/provider notification of the service denial. APS/WVMI have 14 calendar days to complete the review and notify the provider and member of results.

14 C3 Tips Current Authorization Start Date; Admission Date; Service Start Date-all 3 must match for inpatient. No admission date for other review types. Authorization Start Date must be the earliest Service Start Date if multiple services are requested. You must be registered as the provider type indicated for the review area. If you provide many types of services you must expand your registration as each review area is added to be sure requests can be made. Remember to save your work- some areas (e.g. notes) require a save within the page. If you hit Save and not Save and Continue the record will be saved in your work queue. Please be patient. We know the system is slow sometimes, but IT believes the cause of cases not going to the WVMI work queue is submit button being pushed prior to all information being loaded to the Summary & Submit page-there are multiple additional validations at the time of submission so this takes time!

15 Review Statuses Saved: in provider s work queue/not submitted Pending: in WVMI s work queue, awaiting review In Process: with nurse/physician reviewer Closed: either duplicate, inappropriate recon request, or TPL case Complete: Case has been reviewed. The denial reason and letter can be found at the record level and the PA number is at the record level OR in the daily report. Submitted: User who worked case has only AUM Provider role/not AUM Manager role so the case has not been submitted to APS.

16 FAQs Who do I contact with questions and concerns? A: Clinical inquiries will continue to be handled by WVMI, technical inquiries (log-on, passwords, registration, C3 assistance, etc.), training requests and questions about CareConnection will be handled by APS. Complaints should be directed to APS and will be routed to the appropriate parties for follow-up. APS- Medical Services: ; wvmedicalservices@apshealthcare.com WVMI-Acute Review: , Option 1, Fax #: Who do I contact if I have a question about a prior authorization? A: If you are trying to determine if the case has been denied or approved, first look in the C3 system. If you do not know how to do this, please call APS and we will teach you how. If you have faxed a request to WVMI, are registered with APS and do not see it in the C3 system, call WVMI. If you are not registered with APS, call APS to get registered. What do we do if we realize the date of service is wrong? A: Contact APS either by phone or explaining what the correct date of service should be, the authorization request ID, and any other pertinent information related to the case. APS will issue an IT ticket and within 72 hours, you will be able to re-submit your bill. Where do I find what covered services are available to members? A: BMS Manual Chapters are available on the BMS website at

17 APS Contact Information Main Telephone: Medical Services ONLY: Local: Voic ONLY: ext Fax: Web Address: General Medical Services Helen Snyder, Associate Director ~ hcsnyder@apshealthcare.com ext Heather Thompson, UM Nurse Reviewer ~ hthompson@apshealthcare.com ext Sherri Jackson, Office Manager ~ shjackson@apshealthcare.com ext Denise Burton, Utilization Review Coordinator ~ eburton@apshealthcare.com ext Alicia Perry, Eligibility Specialist ~ aperry@apshealthcare.com ext Jackie Harris, Eligibility Specialist ~ jharris@apshealthcare.com ext LeAnn Phillips, Eligibility Specialist ~ lphillips@apshealthcare.com ext. 6906