Condition of Payment Prior Authorization Program. April 19, 2017

Transcription

1 Condition of Payment Prior Authorization Program April 19, 2017

2 Disclaimer The presentations herein were current at the time they were published or uploaded onto the Web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. The presentations herein were prepared as tools to assist providers and are not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. The Centers for Medicare & Medicaid Services (CMS) employees and agents, including CGS and its staff, make no representation, warranty, or guarantee that this compilation of Medicare information is error free and will bear no responsibility or liability for the results or consequences of the use of this guide. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. Official Medicare Program provisions are contained in relevant laws, regulations, and rulings. Noridian DME Outreach and Education April

3 Webinar Protocol Attendee lines are muted upon entry Questions Written questions in Questions section Verbal questions at the conclusion of the material Certificate of Completion CEUs are NOT offered for this course Certificate of completion/ceu available and presentation PDF available in the Handouts panel Noridian DME Outreach and Education April

4 New Webinar Product Navigation Open/Close the access panel Full screen mode Raise hand for verbal questions Handouts Submit written questions Noridian DME Outreach and Education April

5 Join the Audio Conference Dial the toll free number Enter the access code when prompted Enter your audio PIN when prompted This is required in order to ask verbal questions later in the presentation Noridian DME Outreach and Education April

6 How to Ask a Written Question From the access panel Type your question into the Questions field Be concise Click Send Noridian DME Outreach and Education April

7 Asking a Verbal Question To ask a verbal question: Click on the hand icon (with the green arrow) to the left of the access panel Noridian DME Outreach and Education April

8 Acronyms 7EO: 7 Element Order ABN: Advanced Beneficiary Notice of Noncoverage ADMC: Advanced Determination of Medicare Coverage ADR: Additional Documentation Request CFR: Code of Federal Regulation DPD: Detailed Product Description FTF: Face-to-Face Examination LCD: Local Coverage Determination LCMP: Licensed/Certified Medical Professional MLN: Medicare Learning Network MRADL: Mobility-related Activities of Daily Living PA: Prior Authorization PAR: Prior Authorization Request PMD: Power Mobility Device POD: Proof of Delivery PWC: Power Wheelchair UTN: Unique Tracking Number Noridian DME Outreach and Education April

9 Agenda Overview Prior Authorization Process Submitting a Prior Authorization Request Prior Authorization Request and Scenarios Medicare and Other Insurance Basic Coverage Criteria CERT Resources & Reminders Noridian DME Outreach and Education April

10 Overview

11 Background Information MLN Matters MM9940 Prior authorization of certain durable medical equipment Condition of payment Master List of DMEPOS items 135 items identified as being frequently subject to unnecessary utilization Any of the items from the Master List could potentially be added to the prior authorization requirement by CMS Fee for Service Medicare Noridian DME Outreach and Education April

12 PMDs Included in Condition of Payment Prior Authorization Program HCPCS K0856 DESCRIPTION Power wheelchair, group 3 standard., single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds K0861 Power wheelchair, group 3 standard., multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds Noridian DME Outreach and Education April

13 Where Jurisdiction A, New York Jurisdiction B, Illinois Jurisdiction C, West Virginia Jurisdiction D, Missouri Based on beneficiary s address As reported to Social Security Administration Nationwide effective July 17, 2017 Noridian DME Outreach and Education April

14 Benefit Allows the supplier to know earlier in the process whether Medicare will likely pay for the DMEPOS item(s). Allows the beneficiary to know, prior to receipt of the item(s), whether Medicare will likely pay for the item(s). Allows DME MACs to assess medical information, prior to making a claim determination, to provide provisional feedback on the item(s) to be rendered. Note: A PAR affirmation does not exempt other entities from reviewing the claim decision Noridian DME Outreach and Education April

15 Exclusions Veterans Affairs Rep Payees Once the PA program becomes national, this exclusion will not apply Indian Health Services Medicare Advantage Part A and Part B Demonstrations The ADMC process is available when applicable for excluded beneficiaries Noridian DME Outreach and Education April

16 PAR Effective Dates Submit Prior Authorization Request to DME MAC March 6, 2017 New York (JA), Illinois (JB), West Virginia (JC), and Missouri (JD) Claims submitted for K0856 or K0861 are subject to prior authorization decision for payment All new rental claims with Date of Service on or after March 20, 2017 Prior Authorization Process will be Expanded Nationwide July 17, 2017 Noridian DME Outreach and Education April

17 No Changes NCD and LCD coverage unchanged Documentation requirements unchanged Advanced Beneficiary Notice of Noncoverage (ABN) Claims submitted with an ABN and the GA modifier without a PA decision will be suspended to request documentation and review the ABN Appeal rights unchanged Noridian DME Outreach and Education April

18 Additional Information CMS Website Prior Authorization Process for Certain Durable Medical Equipment, Prosthetic, Orthotics, Supplies (DMEPOS) Items Programs/Medicare-FFS-Compliance-Programs/DMEPOS/Prior-Authorization-Processfor-Certain-Durable-Medical-Equipment-Prosthetic-Orthotics-Supplies-Items.html Noridian DME Websites JA: JD: CGS DME Websites JB: JC: Noridian DME Outreach and Education April

19 Prior Authorization Process

20 Process Noridian DME Outreach and Education April

21 The Face-to-Face Examination (FTF) State that a major reason for the face-to-face was to discuss the need for a PMD. History of present condition and relevant past medical history Physical examination relevant to mobility needs, including: Height and weight, Cardiopulmonary examination; and Arm and leg strength and range of motion. Neurological examination, including: Gait, and Balance and coordination. Noridian DME Outreach and Education April

22 F2F Element Medical History Symptoms that Limit Ambulation Diagnoses that are responsible for symptoms Medications or other treatment for symptoms Progression of ambulation difficulty over time Other Diagnoses that may relate to ambulatory problems Distance beneficiary can walk without stopping Pace of ambulation Ambulatory assistance currently used Change in condition that now requires a PMD Description of home setting Ability to perform ADLs in the home NOTE: Not all elements listed apply to every beneficiary. Professional discretion is necessary to determine which items are required as part of the face-to-face examination. Noridian DME Outreach and Education April

23 The Valid 7-Element Written Order 1. Beneficiary name 2. Description of item ordered Power operated vehicle Power wheelchair Power mobility device Or something more specific 3. Date of face-to-face examination 4. Diagnoses/conditions related to need for PMD 5. Length of need 6. Physician/practitioner signature 7. Date of physician/practitioner signature Must include: Date stamp to document receipt date Noridian DME Outreach and Education April

24 Date of Face to Face Exam FTF date is the date of discharge if exam performed during inpatient stay Physician must review, state concurrence or disagreement, sign and date report Supplier must receive within 45 days of date of exam for 7EO Noridian DME Outreach and Education April

25 Detailed Product Description (DPD) Created by the supplier on or after completion of the 7EO Reviewed & signed by the treating physician/practitioner It must contain: Specific HCPCS code for base and all options and accessories that will be separately billed; Narrative description of the items or manufacturer name and model name/number; Physician signature & date signed; and Date stamp to document receipt date Noridian DME Outreach and Education April

26 Submitting a Prior Authorization Request

27 Documentation Flow Chart Obtain Necessary Documentation Face-to-Face (F2F) Exam 7-Element (7E) Order Detailed Product Description (DPD) Date stamp to show received within 45 days Medical records addressing beneficiary s mobility related abilities and policy criteria Physician must state concurrence, sign and date an LCMP exam in order to incorporate into the F2F exam. ATP Specialty Eval if applicable Completed by same practitioner who performed and completed the F2F exam Date stamp to show received within 45 days and prior to preparation of the DPD Financial attestation between supplier and LCMP Proof supplier employees RESNA certified ATP and their involvement Prepared following completion of the 7E- Order Date stamp to show receive date Submit all documentation along with the PAR Cover Sheet by fax, mail or ESMD to the appropriate jurisdiction Noridian DME Outreach and Education April

28 PAR Content Completed coversheet Face to Face assessment 7 Element Order Detailed Product Description Specialty evaluation Documenting the medical necessity for the wheelchair and it s special features Policy requirement Other relevant medical documentation Noridian DME Outreach and Education April

29 PAR Coversheet CGS Noridian Noridian DME Outreach and Education April

30 Expedited Requests Submit expedited request with supporting medical documentation Practitioner documents that the 10 business day timeframe for an initial decision could jeopardize the beneficiary s life or health Unsupported expedited requests will be downgraded to a standard request Noridian DME Outreach and Education April

31 Submit PAR Noridian Jurisdiction A and Jurisdiction D Fax to: Submit package with coversheet Mail to: Noridian Attn: DME PMD Prior Authorization PO Box 6742 Fargo, ND CGS Jurisdiction B Fax: Mail: CGS JUR B DME Medical Review Condition of Payment Program PO Box Nashville, TN Jurisdiction C Fax: Mail: CGS JUR C DME Medical Review Condition of Payment Program PO Box Nashville, TN Noridian DME Outreach and Education April

32 Prior Authorization Request and Scenarios

33 Scenarios Decision Letter Received Affirmative Decision Nonaffirmative Decision Deliver the PMD and obtain Proof of Delivery Review decision and resubmit PAR Deliver and submit claim for denial Do not deliver or bill Bill with correct UTN Complete home assessment Gather missing and/or clarifying documentation and resubmit Able to submit unlimited resubmissions Execute ABN prior to deliver, if appropriate Appeal Noridian DME Outreach and Education April

34 Prior Authorization Request The DME MAC will review PAR and POSTMARK notification of a written decision within 10 business days to: Supplier Beneficiary (If PA was requested by Beneficiary) Within 10 business days, the DME MAC will either Affirm the prior authorization request Not affirm the prior authorization request Provide a detailed written explanation outlining which specific policy requirement(s) was/were not met. Noridian DME Outreach and Education April

35 PAR Affirmative Decision Affirmative Decision Process Complete a home assessment Deliver the PMD (within 6 months of the PAR decision date) and obtain Proof of Delivery Submit UTN on claim to link to PAR Paper CMS 1500 claim form Item 23 Electronic claim Loop 2300 REF02 (REF01 = G1) or Loop 2400 REF 02 (REF01 = G1) Noridian DME Outreach and Education April

36 Change in Supplier Affirmative decision follows beneficiary New Supplier Process New Detailed Product Description is required PIM Section Comply with documentation and claim submission requirements per the LCD Number of days between the F2F and the delivery date Noridian DME Outreach and Education April

37 PAR Non-Affirmative Decision Non-Affirmative Decision Process Review decision and submit a subsequent PAR Gather missing and/or clarifying documentation and resubmit Able to submit unlimited resubmissions Deliver PMD and submit claim for denial Execute Advance Beneficiary Notice of non-coverage (ABN) prior to delivery, if appropriate File an appeal Do not deliver or bill Noridian DME Outreach and Education April

38 Non-affirmed Decision Prior Authorization Request Submitter may re-submit (unlimited requests allowed) DME MAC will review SUBSEQUENT requests and POSTMARK notification of a written decision within 20 business days. Non-affirmed decision Two options 1. Resubmit PAR or 2. Submit claim with non-affirmed decision Noridian DME Outreach and Education April

39 Non-affirmed and Resubmitting a PAR Submitter should review detailed decision letter Submitter should make needed modifications to PAR package Submitter should follow submission procedures Noridian DME Outreach and Education April

40 Non-affirmed and Submitting a Claim Submit claim with 14 byte UTN located on decision letter Paper CMS 1500 claim form Item 23 Electronic claim Loop 2300 REF02 (REF01 = G1) or Loop 2400 REF02 (REF01 = G1) Claim will deny Appeal rights engaged Claim can be submitted to secondary insurance Noridian DME Outreach and Education April

41 Reasons for PAR Rejection The HCPCS code is not specified The beneficiary is deceased The PAR is a duplicate submission The HCPCS code is not subject to PA The beneficiary has a Representative Payee on file and is not subject to PA Requests involving a Rep Payee can be submitted to ADMC The beneficiary does not reside in a PA state Noridian DME Outreach and Education April

42 Medicare and Other Insurance

43 Medicare Primary and Other Insurance Secondary Claim denial needed for secondary insurance payment: Submit PAR with complete documentation All coverage not met for PMD Non-affirmed PAR decision sent to entity requesting PA (i.e., the supplier or beneficiary) After receiving non-affirmed PAR Supplier submits claim to DME MAC with PAR UTN for denial Submitter or beneficiary forwards denied claim to secondary insurance Noridian DME Outreach and Education April

44 Other Insurance Primary and Medicare Secondary Supplier bills other insurance first and Medicare second Two options 1. Prior Authorization Submit PAR with complete documentation and if all Medicare coverage met: Affirmative decision sent to entity requesting PA (i.e., the supplier or beneficiary) Supplier delivers item and submits claim to primary insurance If other insurance denies claim, supplier submits claim to DME MAC with PAR UTN. Noridian DME Outreach and Education April

45 Other Insurance Primary and Medicare Secondary [2] 2. Skip Prior Authorization Deliver item and submit claim to primary insurance for determination Claims billed with the GA modifier will receive an ADR letter to have the ABN reviewed for validity Noridian DME Outreach and Education April

46 PAR Frequently Asked Questions

47 Frequently Asked Questions Are wheelchair accessories included in the prior authorization process? No. All codes subject to required prior authorization must be identified on the Master List (CMS 6050). For inclusion on the master list, an item must meet specific criteria. Wheelchair accessories do not meet these criteria, and thus, aren t separately eligible for prior authorization under this program. When the specialty evaluation supports the need for specific options/accessories and are needed to address a Medicare patient s particular limitations, these options/accessories will be considered as part of the PAR. Noridian DME Outreach and Education April

48 Frequently Asked Questions Does the Condition of Payment Prior Authorization Program apply to replacement items? Yes. If a K0856 or K0861 is replaced on or after March 20, 2017 for a beneficiary residing in NY, IL, WV, or MO the item must receive a prior authorization to be considered for payment. If a K0856 or K0862 wheelchair was submitted to ADMC and approved prior to March 20 th, but will not be delivered until after March 20 th will the ADMC be accepted in place of PA? Yes. When the claim is submitted the DME MACs will accept the claim. Noridian DME Outreach and Education April

49 Basic Coverage Criteria

50 Power Wheelchair Criteria Covered if all coverage criteria is met: Basic Criteria A-C are met; and Beneficiary doesn t meet criteria D, E or F for POV; and Criterion J or K is met; and Criterion L, M, N and O are met; and Coverage Criteria pertaining to specific wheelchair type are met Noridian DME Outreach and Education April

51 Basic Coverage Criteria A. Mobility limitation Prevents accomplishing MRADL entirely, or Beneficiary at risk secondary to performing MRADL Cannot complete MRADL in reasonable timeframe B. Limitation not resolved with cane or walker C. Insufficient upper extremity function to propel manual wheelchair Noridian DME Outreach and Education April

52 PWC Basic Coverage Criteria Does Not meet the following POV criteria D, E or F: Ability to: D. Safely transfer to/from POV; and E. Operate tiller steering system; and F. Maintain postural stability and position while operating Noridian DME Outreach and Education April

53 PWC Coverage Criteria J-K J. Has mental and physical capabilities to safely operate; or K. Has a caregiver who is unable to propel an optimally configured manual wheelchair, but available, willing and able to operate power wheelchair; and Noridian DME Outreach and Education April

54 PWC Coverage Criteria L-O L. Weight weight capacity & 95% of weight capacity of next lower weight class M. Home provides adequate access N. Use of chair will improve ability to participate in MRADLs O. Beneficiary or caregiver has not expressed an unwillingness to use PWC in the home Noridian DME Outreach and Education April

55 Group 3 SPO or MPO PWC Group 3 NPO PWC AND Meets criteria A and B; Group 2 SPO or MPO respectively Meets criteria A and B Specialty evaluation Documentation of direct in-person involvement by a RESNA-certified ATP Noridian DME Outreach and Education April

56 Group 3 NPO PWC A. Meets coverage criteria A-E for PWC; and B. Mobility limitation due to: Neurological condition Myopathy Congenital skeletal deformity Noridian DME Outreach and Education April

57 Group 3 Single Power Option PWC (K0856) Meets Group 2 Single Power Option 1 OR 2 below: 1. Beneficiary requires a drive control interface other than a hand or chinoperated standard proportional joystick (examples include but are not limited to head control, sip and puff, switch control); 2. Beneficiary meets coverage criteria for a power tilt or a power recline seating system and the system is being used on the wheelchair Noridian DME Outreach and Education April

58 Group 3 Multiple Power Option PWC (K0861) Meets Group 2 Multi Power Option 1 OR 2 below: 1. Beneficiary meets coverage criteria for a power tilt or a power recline seating system and the system is being used on the wheelchair 2. Beneficiary uses a wheelchair mounted ventilator Noridian DME Outreach and Education April

59 Additional Coverage Criteria Specialty Evaluation Performed by LCMP Physical or occupational therapist Physician with specific with specific training and experience in rehabilitation wheelchair evaluation PT, OT or physician have no financial relationship with supplier o o RESNA Certified ATP Specializes in wheelchairs Has direct, in-person involvement in PWC selection **Submit documentation to support certification** Reference: Noridian DME Website > Browse by DMEPOS Category > Power Mobility Devices (PMDs) > Supplier Assistive Technology Professional Involvement Noridian DME Outreach and Education April

60 Documentation Noridian DME Outreach and Education April

61 Home Assessment On-site evaluation of beneficiary s home Prior to or at time of delivery Verify beneficiary can maneuver PMD Physical layout Doorway width Doorway thresholds Surfaces Written report available upon request Noridian DME Outreach and Education April

62 Invalid Home Assessments Noridian DME Outreach and Education April

63 Valid Home Assessment Noridian DME Outreach and Education April

64 Advanced Beneficiary Notice of Noncoverage (ABN) Written notice of non-coverage Informs beneficiary that Medicare may not pay for item Allows beneficiary to make informed decision Protects supplier from liability Can only be used for beneficiaries enrolled in the Medicare Fee-For-Service program ABN Form Information/BNI/ABN.html Noridian DME Outreach and Education April

65 Resources and Reminders

66 JA and JD Modifier Resources Browse by Topic Modifiers JA - JD - One stop includes Modifier definitions Modifier presentations Modifier Q & A DME on Demands for Modifiers (A1-A9, Au, AV, AW, GA, GZ, CX, EY, GY, KX, RT/LT and Upgrades) Policies JA JD - Noridian DME Outreach and Education April

67 JB and JC Modifier Resources Modifier Finder Tool: JB: JC: KE & KY Modifier Tool: ke_ky_modifier_tool.asp KX Table: JB: JC: Repair Modifier Tool: repair_modifier_tool.asp LCDs and Policy Articles JB: JC: Noridian DME Outreach and Education April

68 Contacts Jurisdiction A Contact Center Jurisdiction B Contact Center Jurisdiction C Contact Center Jurisdiction D Contact Center Noridian DME Outreach and Education April

69 Additional Resources Coding - PDAC National Supplier Clearinghouse CEDI NGS.CEDIHelpdesk@wellpoint.com Noridian DME Outreach and Education April

70 Questions?

71 Thank You!