Provider Manual Change Control Record

Transcription

1 Revised: Select Health additionally queries the following sources to review state sanctions, Medicare/Medicaid sanction activity, restrictions on licensure or limitations on scope of practice for all health care professionals/providers: Required Credentialing Documentation 5 National Practitioner Data Bank (NPDB)/Health Integrity Protection Data Bank (HIPDB data was merged and is currently included within the NPDB database). Office of the Inspector General (OIG) List of Excluded Individuals and Entities (LEIE) database. General Services Administration (GSA) System for Award Management (SAM) South Carolina Department of Health and Human Services (SCDHHS) SC Excluded Providers List. SCDHHS Provider Termination list. SC DHHS Provider Suspension list. If a health care professional/provider is found to be excluded or terminated from any government program, the credentialing process will cease and the health care professional/provider s file will be discontinued. Provider Network Credentialing Appeals Process 12 Revised: The QAPI Professional Review Committee, a subcommittee of the Credentialing Committee throughout this section. Bariatric Surgery Centers Revised: Programs that are accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), as listed on the American College of Surgeons website: American College of Surgeons MBSAQIP Accredited Bariatric Surgery Centers SC, are considered to have preferred status with Select Health. All bariatric surgical procedures require prior authorization. Providers are to submit requests to Select Health Medical Management via telephone at or by completing the prior authorization request form located on the Select Health website at: >prior-auth-general and faxing it to Participating facilities with a bariatric program should submit a prior authorization request to the Select Health Medical Management department. Prior authorization requests submitted by bariatric centers not accredited by the MBSAQIP may be denied as not meeting preferred status based on the standards set forth by the American College of Surgeons MBSAQIP. Medical Management will review requests and authorize those that meet medical necessity requirements. SH Page 1 of 5

2 Services That Require Prior Authorization 22 Revised: Therapy services speech, occupational and physical therapy: Private/professional speech and occupational therapy require prior authorization after initial assessment or re-assessment. This applies to private and outpatient facility based services. Outpatient facility-based speech and occupational therapy require prior authorization after initial assessment and first 12 visits Private/professional and outpatient facility based physical therapy require prior authorization after initial assessment and first 12 visits Psychotherapy Supervision Guidelines Added: Reimbursement will be made for covered psychiatric and psychotherapy services provided by a physician or nurse practitioner (NP) or by Licensed Master Social Workers (LMSWs) under the direct supervision of the physician or NP. The LMSW cannot be reimbursed directly under the Medicaid Physician Services program but will be reimbursed under the physician or NP. The physician/np must: See each member initially unless the member was accepted as a referral from another physician. Authorize the treatment services to be provided by the LMSW. Participate in patient staffing with the LMSW to document progress summaries. If the member is referred by a non-physician (e.g., Department of Social Services, school counselor, etc.), the referral source must be documented in the chart. Services rendered by Licensed Independent Counselor Interns (LPC/I), Licensed Marriage and Family Therapist Interns (LMFT/I) and applicants for LISW licensure. under the supervision of Licensed Psychologists (PhD), Licensed Professional Counselor Supervisors (LPC/S), Marriage and Family Therapist Supervisors(LMFT/S), Licensed Independent Social Work-clinical practice Supervisors (LISW-CP-S) and Licensed Psycho-Education Specialists (LPES) supervisor are subject to the following limits In addition to the above requirements, the South Carolina Board of Examiners for Licensure of Professional Counselors, Marriage and Family Therapists and Psycho-Educational Specialists maintains policies and guidelines for intern supervision. SH Page 2 of 5

3 Added: Standard Prior Authorizations: Utilization Management (UM) may extend the determination time frame up to fourteen (14) additional calendar days, if The member or provider requests an extension. UM justifies a need for additional information and how the extension is in the member s interest. Extension of Authorization Time frames Urgent Prior Authorizations: UM may extend the determination time frame up to fourteen (14) calendar days, if The member or provider requests an extension. UM justifies a need for additional information and how the extension is in the member s interest. UM will document the justification to provide to South Carolina Department of Health and Human Services (SCDHHS) if requested. Medical Director Availability (Peer-to-Peer) 34 Revised: The requesting/ordering provider may request a peer-to-peer review with one of the Select Health medical directors within 3 calendar business days from verbal notification of the determination that the authorization request does not meet medical necessity criteria. The peer-to-peer option is no longer available to the health care professional/ provider after 3 calendar business days from the verbal notification of the determination. Added: (7) the denial of a member s request to dispute a financial liability, including cost sharing, co-payments, premiums, deductibles, coinsurance, and other member financial liabilities." Appeal of Utilization Management Decisions 35 Revised: Appeals must be filed within 60 calendar days from the date of receipt of on the denial or action adverse benefit determination notification. If the written confirmation is received after thirty calendar days from the date of filing an oral appeal request but is within the ninety sixty calendar day filing period, the thirty calendar day resolution time frame will begin at the time of receipt of written confirmation. Adult Vaccines 50 Revised: Effective for dates of service on or after July 1, 2017, the following vaccinations are covered were added to the coverage for Select Health members 19 years of age and older Adult Vaccine Claims SH Page 3 of 5

4 For administration of the vaccine, providers should bill for the vaccine and the administration codes, The following is the complete listing of vaccines are also covered for adult members 19 years of age and older: 13-valent pneumococcal conjugate (PCV13). 23-valent pneumococcal conjugate (PPSV23). Haemophilus influenza type b conjugate vaccine (Hib). Hepatitis A (HepA). Hepatitis B (HepB). Hepatitis A and B. Influenza. Measles, mumps and rubella (MMR). Measles, mumps and rubella and varicella (MMRV). Meningococcal Serogroups A, C, W, and Y meningococcal conjugate or polysaccharide vaccine (MenACWY or MPSV4). Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B (MenB), 2 & 3 dose schedule, for intramuscular use. Rabies. Tetanus and diphtheria toxoids (Td). Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap). Varicella (VAR). When billing for vaccines for adult vaccines, providers should bill for both the vaccine and the immunization administration code, Definitions) 74 Revised: Action Adverse benefit determination: (1) the denial or limited authorization of a requested service, including the type or level of service; (2) the reduction, suspension, or termination of a previously authorized service; (3) the denial, in whole or in part, of payment for a service; (4) the failure to provide services in a timely manner, as defined by SCDHHS; (5) the failure of the managed care organization (MCO) to act within the time frames provided in 42 C.F.R (b) as further provided by SCDHHS in Select Health s contract with SCDHHS; or (6) for a resident of a rural area with only one MCO, the denial of a Healthy Connections MCO member s request to exercise his or her right, under 42 C.F.R (b)(2)(ii), to obtain services outside the MCO s network. (7) the denial of a member s request to dispute a financial liability, including cost sharing, co-payments, premiums, deductibles, coinsurance, and other member financial liabilities. SH Page 4 of 5

5 Added: 2018 Prior Authorization Information Exhibits 80 Revised Therapy: Speech, occupational and physical therapy require prior authorization after initial assessment or re-assessment. This applies to private and outpatient facility based services. SH Page 5 of 5