Authorization Review Process. Ultrasound and Biophysical Profiling. April 2014

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1 Authorization Review Process Ultrasound and Biophysical Profiling April

2 Introduction to eqhealth 2

3 Partnership: Agency for Health Care Administration and eqhealth eqhealth is the Agency for Health Care Administration s contracted quality improvement organization (QIO), responsible for the Comprehensive Medicaid Utilization Management Program for the state of Florida Local office/operations in Tampa Bay area 5802 Benjamin Center Drive, Suite 105 Tampa, FL

4 Scope of Services 4

5 Service Requirements Recipients must be: Enrolled in a Medicaid benefit program that covers the service requested: Fee for service MediPass Medically Needy Presumptive Eligible Pregnant Women (PEPW) Eligible at the time services are rendered 5

6 Not Subject to Prior Authorization by eqhealth Recipients who are: Members of a Medicaid HMO Members of a Medicaid Provider Service Network (PSN) Members of Children s Medical Services (CMS) Dually eligible (Medicare/Medicaid, Commercial Insurance/Medicaid.) 6

7 Medical Necessity Medicaid reimburses services that do not duplicate another provider s service and are medically necessary for the treatment of a specific documented medical disorder, disease or impairment. The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, goods or services medically necessary or a medical necessity or a covered service. 7

8 Multi-Specialty Services Effective 5/1/14: Authorization, by eqhealth Solutions, is required for: Ultrasounds that are over the Medicaid limit of 3 per pregnancy, and Biophysical Profiles that are over the Medicaid limit of 2 per pregnancy. 8

9 Authorizations Prior Authorization numbers are valid for 120 days if an extension is needed, contact eqhealth Customer Service. 9

10 OB Ultrasound Codes Requiring Authorization (for dates of service on or after 5/1/14) CODE DESCRIPTION MODIFIERS Ultrasound of pregnant uterus, one or more fetuses, during the first trimester OR Ultrasound re-evaluation of a pregnant uterus, per fetus, during the second and third trimester 22 if more than 3 Ultrasounds TH for Multiple gestations 22 if more than 3 Ultrasounds TH for Multiple gestations Vaginal ultrasound of pregnant uterus 22 if more than 3 ultrasounds 10

11 Biophysical Profile Codes Requiring Authorization (for dates of service on or after 5/1/14) CODE DESCRIPTION MODIFIERS BPP with non-stress testing 22 if more than 2 BPPs TH for Multiple gestations (less than or equal to 4 fetuses) TH and 22 more than 4 fetuses BPP without stress testing 22 if more than 2 BPPs TH for Multiple gestations (less than or equal to 4 fetuses) TH and 22 more than 4 fetuses 11

12 Review Requests 12

13 Submission of Review Requests Please submit all review requests to: Mail: eqhealth Solutions Attn: Inpatient 5802 Benjamin Center Drive, Suite 105 Tampa, FL Toll-free fax:

14 Review Requests Prior to submitting a review, verify that the: Recipient is Medicaid eligible Requested service is: A covered Medicaid benefit Required to be prior authorized by eqhealth Required supporting documentation is: Complete Legible Prior Authorization request form is complete and appropriately signed and dated 14

15 Review Requests Types of Review Requests: Prior Authorization Retrospective Reconsideration review response to an adverse determination 15

16 Request Submission & Response REQUEST TYPE SUBMISSION REVIEW COMPLETION Prior Authorization Request At least 10 days prior to initiation of services 1 st Level 3 business days 2 nd Level 2 additional business days Retrospective Request Within 12 months of the date of service 20 business days Reconsideration Request Within 30 calendar days of the adverse determination notification date. 3 business days receipt of request 16

17 First Level Review Screening Verification that there are no review exclusions: Recipient is not eligible for the service Duplicative request Requested service is not covered by Medicaid 17

18 Review Determination Process 1 st Level Clinician Review: Administrative Screening Clinical Screening 2 nd Level Peer Review 18

19 Review Determination Process First Level Clinical Reviewers base the determination on InterQual criteria and may: Approve the request Issue a technical denial of the request, if appropriate, for example Duplicative service Noncompliant with Medicaid policy Pend the request back to the provider for: Additional or clarifying information Supporting documentation Refer the request to a second level Peer Reviewer 19

20 Review Determination Process Pended Requests (Administrative/Clinical) An advisory letter is mailed to the requesting provider. The information should be submitted within five (5) business days of the request. 20

21 Second Level Review Peer Reviewers base their determination on generally accepted professional standards of care, their clinical experience and judgment, Medicaid s medical necessity criteria, and peer-to-peer consultation with the requesting provider when necessary. Peer Reviewers may render an approval or an adverse determination. An adverse determination may be a full denial of the requested services or a partial denial of the requested services. 21

22 Review Determination Notification Determination notifications are issued to providers, and recipients within one (1) business day of the determination. The requesting provider will receive a written notification of the determination via mail. The recipient, or legal guardian, also receives written, mailed notification of the determination via mail. 22

23 Review Determination Notification Notifications include: Services approved or denied Reason for an adverse determination Rights to a reconsideration and how to request one Recipient s right to a fair hearing and how the recipient may request one 23

24 Reconsiderations A peer reviewer, not involved in the original adverse determination, will: Uphold the original adverse determination; Modify the original determination, approving some of the services requested; or Reverse the original determination, approving all the services requested. Reconsideration reviews are completed within three (3) business days of receipt of a complete and valid request. Please Note: When requesting a reconsideration, new and/or additional clinical information must be submitted.

25 Reconsiderations Any party involved in the case may request a reconsideration of an adverse determination: Requesting Provider Recipient or Legal Guardian Methods to request a reconsideration: Mail Fax 25

26 Fair Hearings Recipients or their legal representatives may appeal an adverse determination by requesting a fair hearing. The request must be submitted within 90 days from the date of the adverse notification letter by calling or writing: The local Medicaid area office; or Department of Children Families Office of Appeals and Hearings 26

27 Required Supporting Documentation Supporting documentation is determined by AHCA policy and is required to substantiate the necessity of items or services. All supporting documentation must be submitted with the request for authorization. ALL authorizations must be requested using Prior Authorization Request form. 27

28 Supporting Documentation Requirements SERVICE TYPE DOCUMENTATION Ultrasound Biophysical Profile The diagnosis for which the study is requested Clinical information to support the diagnosis.. 28

29 Supporting Documentation Additional Information eqhealth s peer reviewers reserve the right to request additional information or clarifying information to substantiate the medical necessity of the service(s) requested. 29

30 Submitting Supporting Documentation Submit all supporting documentation with the Prior Authorization Request form via mail or fax. Additional supporting information requested after the initial request may be submitted via mail or by fax to

31 Transition Timeline 4/30/14: Last date to submit claims/authorization requests to AHCA 5/1/14 : First date to submit retrospective authorization requests to eqhealth using the fax request form (do not submit claims.) 4/21/14: First date to submit prior authorization requests to eqhealth for dates of service on or after 5/1/14. 31

32 Dedicated Florida Website Website demonstration 32

33 Provider Communications and Resources Customer Service: Monday-Friday, from 8 a.m. 5 p.m. Eastern Time Dedicated Florida Provider Website Blast s Nancy Calvert, Director, Provider Education & Outreach ncalvert@eqhs.org 33

34 Questions and Answers Thank-you for attending. Your opinion is important to us. Please complete the survey which will appear on your computer when the webinar ends. 34