Please pay special attention to the following information when submitting medical requests:

Transcription

1 October 2014

2 ALL Review areas for Medicaid services requiring prior authorization are currently in the APS Medical CareConnection - if you are a Medicaid provider who makes prior authorization requests for Traditional or Medicaid Expansion (ABP) members you should already be registered with APS. If you are NOT registered there is a selfregistration portal available at on the log-in page select self-enrollment OR you may contact APS at and ask for assistance registering with APS as a medical provider.

3 Please pay special attention to the following information when submitting medical requests: Be sure you have selected the CORRECT NPI for the servicing provider- if they have multiple NPI listed for multiple sites please confirm the appropriate number/site with the servicing facility. Proper definitions of Referring and Servicing Provider Servicing provider: If you are unsure as to whether or not you are the servicing provider, if you do not plan to bill for the service in question, your physician is NOT the servicing provider. For Lab, Imaging, Radiology, Servicing Provider should be the facility where the service is going to be performed. If the service is not to be performed in your office, you are not the servicing provider for a lab/ imaging/radiology service. For Outpatient Surgery, request should be made for BOTH the Surgeon AND the facility. If you are requesting the PA from the surgeon s office, you need to submit a line request for the facility, as well as your provider. If you are submitting the request from the facility, you need to also submit a line request for the surgeon.

4 Copy for Correction/Update: Is to be used when a request/service has been denied or closed due to insufficient or incorrect information. This action results in a DIFFERENT PA number for the new submission so should NOT be used when a SINGLE PA is needed for a group of services (e.g.pt/ot services when a service was not included in the group) OR when a second service of a particular type (e.g. 2 nd imaging service) was denied but will be provided on the SAME date of service as the approved service. A copy for correction has no impact on services ALREADY authorized- any changes to a service already modified must be completed as a post- modification adjustment. Copy Authorization Request: Is to be used to copy forward information from a previous request so a NEW submission with a different prior authorization number/different services can be made. In instances where a group of services has been authorized but a service/services was omitted in the authorized request the ORIGINAL group of services authorized PLUS the omitted services must be included in the new request. The units and service end date of the existing authorization will be modified based on the new request. Request Reconsideration: This is to be used to request Level I Peer-to-Peer or Level II Reconsideration of a denied request. This action will be deactivated when timelines for requesting reconsideration have passed OR AFTER the Level II Reconsideration is requested. Modify Authorization Request:: this is the post modify function BUT is only available to internal (APS/WVMI) users. A modification request form must be submitted indicating the requested changes to the authorization. Supporting documentation may be required in order to complete the requested action (e.g. physician order required to change service start date of an inpatient authorization).

5 Modification Requests: Modification request forms are only to be used for request situations that do NOT need additional clinical review and are limited to the following: Date Changes: For example, in the event that unforeseen circumstances prevent the patient from having the service provided within the set timeframe on the authorization, it can be modified to reflect a later set of dates. Please make a reasonable attempt in these cases to make sure the patient is seen within the second time-frame, as a 90-day request can only be adjusted for ONE MORE 90-day period before the provider will be required to obtain a new PA. A request to backdate an inpatient request will require an order from the physician. Servicing Provider: For example, a patient is scheduled at one facility, but gets worked into the schedule at a facility closer to home, that facility can be modified to reflect the new site. Combining of two separate PA numbers: For example, if a patient had a CT Chest and a CT Abdomen performed on the same date at the same facility and the procedures were given two separate PA numbers, those can be modified into a new single PA number. The following issues CANNOT be modified, as they need to be clinically reviewed and will need to be copied and resubmitted. Additional CPT Codes for a request previously approved Changing the Service Code for a previously approved request. Changing status from Outpatient to Inpatient. When copying a request, please do not use the Modification form. To copy a request to make updates, please use the attached instructions. Please send all Modification Requests to the fax number listed on the form. This allows APS to keep them all in one place and can track progress in a more timely and efficient manner. You will no longer be receiving a fax to inform you that your request has been performed. Feel free to use the attached instructions in order to determine on the APS Provider Portal if a requested change has been made. In cases where a new authorization number has to be issued such as combination requests, you will need to look in the note on the Summary and Submit screen to obtain your new authorization number.

6 Update sent to providers (available upon request) Form has been updated based on feedback from providers REMINDERS: ALL Out-of-Network services requested for WV Medicaid members require prior authorization by the Utilization Management Contractor (UMC) or the Bureau for Medical Services (BMS) before services are provided. Out-of-Network services must be requested by an enrolled West Virginia Medicaid provider with required documentation of medical necessity (completed request form for the relevant service type and completed OON request form) AND justification of why requested service(s) cannot be obtained from an in-network provider (complete relevant sections on the OON request form). Out-of-Network services, with the exception of confirmed emergent situations, shall not be authorized or reimbursed when the requested service is available in West Virginia. The treating Out-of-Network physician and facility must enroll as a West Virginia provider to be eligible for reimbursement, accept West Virginia Medicaid s reimbursement as payment in full, and attach a copy of the approval form to the BMS Fiscal Agent billing form for payment consideration OR bill under the authorization number granted by the UMC if the request is entered into their systems.

7 Refresher Training on NH PAS submission and Level I/Level II Review process is scheduled for November 4 & 6, Contact APS Healthcare, Inc to register Hospice Services for members in Nursing Homes- a pilot is underway for pricing the authorizations for Revenue Code 0658 (NH Reimbursement). Beginning January 1, 2015 all claims for Revenue code will require prior authorization and pricing by APS for claims to be reimbursed by Molina. Training will be provided to all Hospice providers in December, 2014 following the pilot. The Hospice Rule went into effect October 1, 2014.

8 Ensure that NEW requests for prior authorization of Hospice services list ALL diagnoses for the member. Requests that do not meet the new guidelines related to diagnosis will be ADMINISTRATIVELY CLOSED and a letter will be sent indicating that the submission is not compliant with Hospice Policy related to diagnosis; ALL CLAIMS submitted to Molina after October 1, 2014 for existing members should list the primary diagnosis that qualifies for eligibility under the new rule- not the Alzheimer s, Dementia or adult failure to thrive diagnosis. Any prior authorization ALREADY granted under one of these diagnoses DOES NOT need to be modified BUT the claim must contain a valid diagnosis that meets under the new rule. For the next election period for the member list ALL diagnoses on the APS prior authorization request when you enter it in the C3 Medical AUM system. Requests that do not meet the new guidelines related to diagnosis will be ADMINISTRATIVELY CLOSED by APS and a letter will be sent indicating that the submission is not compliant with Hospice Policy related to diagnosis. These requests will not be clinically reviewed for authorization but may be resubmitted with appropriate diagnoses. An existing authorization for a member whose SOLE diagnosis is now excluded (no other diagnosis on record) will only pay for Hospice claims through September 30, 2014 AND a new authorization will not be granted for subsequent elections in these instances. When the member s diagnosis does not meet the new guidelines the request will be ADMINISTRATIVELY CLOSED by APS and a letter will be sent indicating that the submission is not compliant with WV Medicaid Hospice Policy related to diagnosis. NOTE: This is ONLY APPLICABLE TO HOSPICE MEMBER S WHOSE SOLE diagnoses are Alzheimer s, Dementia (not related to a coexisting terminal medical condition), and/or adult failure to thrive with no medical etiology AND there is NO OTHER medical diagnosis of a terminal condition on record. For questions regarding specific cases please contact APS Healthcare at or wvmedicalservices@apshealthcare.com.

9 Traditional AND ABP Members REQUIRE prior authorization from the first visit for Home Health. The initial authorization for 60 visits IS NOT a clinical review BUT there must be a diagnosis and justification for the service on the request. Once a MEMBER has an initial request submitted by ANY provider in a calendar year =- all other requests are considered established, require prior authorization AND are clinically reviewed for medical necessity. Detailed information on Home Health prior authorization requests was recently sent to providers. Copies are available at the APS table if you did not receive a copy.

10 ABP Members REQUIRE prior authorization from the first visit for PT/OT. The initial authorization for 6 sessions IS NOT a clinical review BUT there must be a diagnosis and justification for the service on the request. Traditional members still may receive 20 visits without authorization BUT APS is recommending obtaining a PA for the initial 20 visits-this request IS NOT a clinical review BUT there must be a diagnosis and justification for the service on the request. This will ensure if the member changes to the ABP plan OR another provider has been involved a prior authorization is in place. Detailed information on PT/OT prior authorization requests was recently sent to providers. Copies are available at the APS table if you did not receive a copy. BMS plans to align the Traditional and ABP benefit in the near future. The ABP benefit mirrored the proposed PT/OT manual which has not yet been implemented.

11 Urgent Requests can still be requested by phone. Be sure you have the correct NPI of the facility that will be performing the imaging service- this is the SERVICING PROVIDER in the APS C3 Medical AUM System. For MRI and CT requests related to the musculoskeletal system be sure you: Include NSAIDS interventions- what has been tried, length of time, outcome and compliance. If NSAIDS are contraindicated explain why in the notes section; Activity modification and PT/OT interventions- amount, outcomes and compliance; if no activity modification has been tried and/or activity modification is contraindicated explain why in the notes section.

12 FOR customer service contact APS: ext Medical Services Helen Snyder Associate Director ext Valerie Chapman UM Nurse Coordinator ext Teresa Hardesty Office Manager ext Cindy Bunch UM Coordinator ext Alicia Perry Eligibility Specialist ext Jackie Harris Eligibility Specialist ext Harmon Harris Eligibility Specialist ext GENERAL APS INFORMATION: Fax: (For Registration and/or Technical Support Only) ORG MANAGERS: AUTHORIZATIONS: FOR CLINICAL SUPPORT CONTACT WVMI: