Overview of the Prior Authorization Customized Wheelchairs E1220 Unbundling Process. June 20, 2016

Transcription

1 Overview of the Prior Authorizatio Customized Wheelchairs E1220 Ubudlig Process Jue 20, 2016

2 Objectives Improve uderstadig of the customized wheelchairs E1220 ubudlig process for HUSKY Health prior authorizatio (PA) Access ad use the Departmet of Social Services (DSS) Fee Schedule Miimize admiistrative burde associated with the E1220 ubudlig process for PA Improve provider satisfactio with the PA process 1

3 Perso-Ceteredess Providig the member with eeded iformatio, educatio ad support required to make fully iformed decisios about his or her care optios ad to actively participate i his or her self-care ad care plaig Supportig the member, ad their desigated represetative(s) i workig together with his or her o-medical, behavioral health ad medical providers ad Care Maager(s) to obtai ecessary supports ad services Reflectig care coordiatio uder the directio of ad i partership with the member ad his/her represetative(s) that is cosistet with his or her persoal prefereces, choices ad stregths ad that is implemeted i the most itegrated settig 2

4 Defiitio of Medical Necessity Sectio 17b-259b(a) Medical Necessity (or Medically Necessary ) meas those health services required to prevet, idetify, diagose, treat, rehabilitate or ameliorate a idividual s medical coditio; icludig metal illess, or its effects, i order to attai or maitai the idividual s achievable health ad idepedet fuctioig provided such services are: (1) Cosistet with geerally-accepted stadards of medical practice that are defied as stadards based o: (A) Credible scietific evidece published i peer-reviewed medical literature that is geerally recogized by the relevat medical commuity (B) Recommedatios of a physicia-specialty society (C) The views of physicias practicig i relevat cliical areas (D) Ay other relevat factors 3

5 Defiitio of Medical Necessity (cot.) (2) Cliically appropriate i terms of type, frequecy, timig, site, extet ad duratio, ad cosidered effective for the idividual s illess, ijury or disease (3) Not primarily for the coveiece of the idividual, the idividual s healthcare provider, or other healthcare providers (4) Not more costly tha a alterative service or sequece of services at least as likely to produce equivalet therapeutic or diagostic results as to the diagosis or treatmet of the idividual s illess, ijury, or disease (5) Based o a assessmet of the idividual ad his/her medical coditio All fial determiatios of medical ecessity must be based upo this statutory defiitio 4

6 Customized Wheelchair Prior Authorizatio Process 5

7 Submit a Prior Authorizatio Request Providers may submit PA requests for customized wheelchairs via: Olie - Clear Coverage Portal Fax: Cotiue to use the budled E1220 code 6

8 E1220 Ubudlig Process Commuity Health Network of Coecticut, Ic. (CHNCT) processes request as a E1220 code ad staff will: Maually ubudle E1220 code requests Review provider pricig quotatios Cross-check all codes with the DSS Fee Schedule Determie which codes require PA ad how the PA will be give 7

9 E1220 Ubudlig Process (cot.) Codes ot requirig PA will ot be etered ito the authorizatio request Codes o the DSS Fee Schedule with a max fee will be etered i the authorizatio request ad approved with uits Codes o the DSS Fee Schedule with ZERO or List-15 will be etered i the authorizatio request ad approved per a egotiated rate as outlied i the DSS MEDS Pricig Policy The ubudlig process was developed to help reduce the admiistrative burde for DME Providers 8

10 E1220 Ubudlig Process PA Requests Clear Coverage: CHNCT will replace E1220 code with codes requirig PA as separate lie items Customized Wheelchair PA requests will have otes etered ito Clear Coverage idicatig elimiated codes ad codes requirig PA Fax: CHNCT will replace E1220 code with idividual codes requirig PA 9

11 E1220 Ubudlig Process Special Notes Idividual authorizatios are limited to 10 HCPCS codes or less Authorizatios requirig more tha 10 HCPCS codes for PA (accordig to the DSS Fee Schedule), will be split ito 2 separate authorizatios Clear Coverage E1220 requests with more tha 10 HCPCS codes may have: Origial authorizatio that ca be viewed i the portal 2d authorizatio that was maually etered by CHNCT that caot be viewed i the portal 10

12 Wheeled Mobility Device Policy Guidelies Go to click For Providers, Wheeled Mobility Devices, the Wheeled Mobility Device Policy Guidelies Review the policy frequetly for ay chages 11

13 Natioal Correct Codig Iitiative Medically Ulikely Edits A Medically Ulikely Edit (MUE) is a uit of service edit for a HCPCS/CPT (Curret Procedural Termiology) code that applies to services performed by the: Same provider For the same beeficiary O the same date of service Ceters for Medicare ad Medicaid Services (CMS) MUE tables: Quarterly additios, deletios ad revisios are posted 12

14 Natioal Correct Codig Iitiative Medically Ulikely Edits (cot.) Effective April 1, 2015, claims exceedig MUE will: Auto-dey istead of cutback Post Explaatio of Beefits (EOB) code 0770 MUE UNITS EXCEEDED Providers are resposible for idetifyig codes with a MUE prior to submittig a PA If a code has a MUE, claims will dey regardless of authorizatio 13

15 NCCI Procedure to Procedure Edits Provider Bulleti otified MEDS providers that DSS has implemeted Medicaid-Oly Procedure to Procedure (PTP) edits related to wheelchairs: Made cosistet with NCCI updates received from CMS Promote correct codig ad cotrol improper codig that could lead to iappropriate paymets Fid NCCI edits o the CMS website: Systems/Natioal-Correct-Codig-Iitiative.html Review edits frequetly for quarterly updates 14

16 NCCI Procedure to Procedure Edits (cot.) Group 1 Group 2 Group 3 Group 4 Group 5 Wheelchair Edits Groups Wheelchair bases with other wheelchair bases Wheelchair bases with other wheelchair optios ad accessories Wheelchair bases with wheelchair seatig Wheelchair optios ad accessories with other wheelchair optios ad accessories Wheelchair seatig with other wheelchair seatig 15

17 NCCI Procedure to Procedure Edits (cot.) Each of the wheelchair base codes will be paired with each of the other codes, resultig i thousads of uique code pairs/ptp edits The methodology assigs codes based o the techical complexity of the item Example: Power wheelchairs were raked higher tha power operated vehicles (POVs/scooters) which were raked higher tha maual wheelchairs The same cocept will be applied to wheelchair bases, wheelchair optios ad accessories, ad wheelchair seatig i groups 2 through 5 This will prevet a particular accessory to be used with a specific type of wheelchair (e.g., a battery is ot used with a maual wheelchair) A accessory repair part could ot be billed at the time of iitial issue of the wheelchair (e.g., a replacemet motor is ot payable with a power wheelchair base code) 16

18 NCCI Procedure to Procedure Edits Claim Deials Icorrect code combiatios submitted o claims will dey Oe of the followig edits will appear o the EOB: 5924 Claim deied, Correct Codig Iitiative (CCI) greater ad lesser procedures are ot covered o same date of service 5925 CCI colum 1 code or mutually exclusive code was billed o same date as previous colum 2 code 5926 CCI colum 2 code was billed o the same date as previous colum 1 or mutually exclusive code Authorizatio of customized wheelchair compoets is ot a guaratee of paymet Providers are resposible for idetifyig procedure code combiatios that may ot be billed o the same date of service Code combiatios ot allowed based o NCCI edits will dey regardless of authorizatio 17

19 DSS Fee Schedule & Ubudlig 18

20 DSS Fee Schedule Go to Click o Provider Click o the I Accept butto at the bottom of the Licese Agreemet Choose the desired Provider Fee Schedule: MEDS DME is where E ad K codes are foud 19

21 Navigatig the DSS Fee Schedule The colums o the Fee Schedule are as follows: Procedure Code Proc Descriptio Mod1 Mod1 Desc Rate Type Max Fee Effective Date Ed Date PA Qty If there is a Y i the PA colum, the Prior Authorizatio is required for that item 20

22 DSS Fee Schedule/Ubudlig No PA Needed Code Example: No PA required TiSport X2FTR7 1 Piece Over Ceter Foldig Footrest K0037 NU EA 1 K0037 High mout flip-up footrest each DEF /1/ /31/2299 PA Colum is blak 21

23 DSS Fee Schedule/Ubudlig PA Needed for Uits Code Example: Requires PA ad has a max fee 1 Each EZ14 EZ RIDER E1236 NU E1236 Wheelchair pediatric size foldig adjust DEF /1/ /31/2299 Y Max Fee Allowed PA is required 22

24 DSS Fee Schedule/Ubudlig PA Needed for Negotiated Fee Code Example: Requires PA ad maual pricig Permobil, Ic. l11110 Power Adjustable Seat Height 12 E2300 NU Travel E2300 Wheelchair accessory power seat elevate DEF Zero 7/1/ /31/2299 Y Requires maual pricig Approved with egotiated fee PA is required 23

25 DSS Fee Schedule/Ubudlig PA Needed for Miscellaeous Code Code Example: Miscellaeous code requirig PA ad maual pricig 1 Each 2pc Wide Corpus VS Footplates 9 D x 7.5 W - K0108 LEGREST OPTIONS NU K0108 Wheelchair compoet or accessory ot DEF Zero 5/1/ /31/2299 Y Requires maual pricig Approved with egotiated fee PA is required 24

26 DSS Fee Schedule/Ubudlig Example 1 Provider Quotatio Authorizatio Quatum Rehab 1 Each J6 2SP-SS BASE MODEL K Each Swig-away, Ilie, Right JOYSTICK MOUNTING BRACKETS SAMTIR7 1 Each TRU-Balace 2 Power Tilt TRU-Balace 2 SEATING SYSTEM 1 Each Adjustable Ceter Mout Foot Platform, 10-8 Footplate ADJUSTABLE CENTER MOUNT FOOT PLATFORM 1 Pair Calf Pads, Large ADJUSTABLE CENTER MOUNT FOOT PLATFORM E1028 E1002 K0108 K Each U-1 32 amp Batteries - BATTERIES E2365 Motio Cocepts No PA eeded: E1028, E2365 PA with uits: K0835, E1002, E2624 PA with egotiated fee: K Each 16 w d MaTRx LIBRA CUSHION, STARTEX LC1616 E

27 DSS Fee Schedule/Ubudlig Example 2 Provider Quotatio Authorizatio Descriptio F3 Base Corpus F3 MPO Ati-Tippers for F3 / F5 Corpus Seat w/50 Tilt & 175 Power Reclie Fuctioal Reach Package - 20 Aterior Tilt Batteries, Grp 24 (72Ah) Sealed Gel Power Adjustable Seat Height 12 Travel Haress for Expadable Cotroller R-et Remote Color Joystick Programmable Retractable Joystick Mout Right-R-Net VR2 BodyPoit J/S Hadle 4 UShaped w/flexshaft Expadable Cotroller-R-Net Multiple Seat Fuctio Cotrol Kit For R-Net Corpus Ergo Back 18W x 23-28T Corpus 3G Ergo Seat Cushio Adj Removable Kee Support Hardware 2pc Wide Corpus VS Footplates 9 D x 7.5 W Code K0861 K0108 E1007 K0108 E2363 E2300 E2313 K0108 E1028 E2323 E2377 E2311 E2620 E2605 E1028 K0108 No PA eeded: E2363, E2313, E2323, E1028 PA with uits: K0861, E1007, E2377, E2311, E2620, E2605 PA with egotiated fee: K0108, E2300 l Corpus VS Power Elevatig Legrest 180 K

28 DSS Fee Schedule/Ubudlig Miscellaeous Code K0108 K0108 codes etered with the umber of uits requested with the egotiated price: The egotiated pricig will be the sum of each K0108 code Claims must be submitted exactly as the authorizatio appears 27

29 DSS Fee Schedule/Ubudlig Quatity Limits If a code does ot require PA for a quatity of 1 ad you are requestig a higher quatity, PA will be eeded O a case by case basis, the requested code may be authorized with a egotiated fee if it is over the DSS Fee Schedule quatity limit You will eed to verify with CMS if the requested code has a MUE PA will ot override a MUE established by CMS 28

30 DSS Fee Schedule/Ubudlig Quatity Limits & Modifiers Bilateral postural compoets: Example: Code E0956 has a quatity limit of 2 ad does ot require PA If a member requires bilateral lateral thoracic supports ad hip guides, you will eed to specify modifier RT ad LT to allow claims to pay for a quatity of 4 PA is ot required 29

31 E1220 Ubudled Approvals Approval letters detail each lie item approved that requires PA Claims must be submitted exactly as the authorizatio appears, if ot, the claim will ot pay 30

32 E1220 Ubudled Partial Deials The otificatio process for Partial Deials is chagig o 7/1/16: Partial Deials defied as approved for part of a code ad deied for part of the same code Example: 4 K0108 HCPCS codes were requested; 1 K0108 HCPCS was approved ad 3 were deied Authorizatios will show each lie item approval 31

33 E1220 Ubudled Partial Deials (cot.) Partial Deial otificatios detail each lie item that requires PA 32

34 E1220 Ubudled Deials Deials are defied as either a lie item that is fully deied or a etire wheelchair that is fully deied If the etire wheelchair is deied, the deial letters will remai uchaged For requests where lie items are fully approved ad lie items are fully deied: The approval lie items will be separated from the deied lie items Provider will receive 2 separate otificatios: Approval letter detailig approved lie items Deial letter detailig deied compoets with deial ratioale Please ote: PA requests submitted through Clear Coverage will be cacelled ad re-etered to reflect a approval ad deial 33

35 Cotact Iformatio For questios about billig or help accessig the fee schedule, cotact: HP Provider Assistace Ceter Phoe: Hours: Moday through Friday, 8:00 a.m. to 5:00 p.m. For questios about Prior Authorizatio, cotact: CHNCT Phoe: Hours: Moday through Friday, 8:30 a.m. to 6:00 p.m. 34

36 Questios? 35