MEDICAL POLICY. Click to edit Master title style Indiana Health Coverage Programs. Presentation by: Health Care Excel Medical Policy Staff

Transcription

1 MEDICAL POLICY Click to edit Master title style Indiana Health Coverage Programs Presentation by: Health Care Excel Medical Policy Staff 1

2 Today s Agenda Medical Analysis & Review Department Overview Medical Policy Objectives Medical Policy Inquiries and Projects Code Reviews Approved Provider Code Sets Provider Notifications Reviewed/Revised Medical Policies 2

3 Medical Policy Overview Health Care Excel Independent Contractor with State of Indiana for Medical Policy Business Functions. Department referred to as Medical Analysis & Research or MAR. Goals Improve alignment with current Medical Policies Assist in communication and education Provide oversight Develop cost containment strategies Bridge operations and policies Create alignment across all IHCP programs 3

4 Medical Policy Objectives Primary emphasis is researching and developing Medical Policy. Coordination with other contractors such as EDS, Myers & Stauffer, and Milliman. The MAR Department focuses on customer satisfaction. Measurements response, publications, provider surveys, etc. 4

5 Inquiries Medical Policy Inquiries How do we receive them? Fax Mail Telephone Internal at HCE from PA & SUR departments Examples of Inquiries Clarification of Medical policy Requests for coverage of new products/services Requests for revision of Medical Policy HCPCS, CPT, ICD-9-CM, and Revenue Codes 5

6 Non Medical Policy Inquires These types of inquires should be directed to EDS Customer Service Department or your EDS Provider Representative Requests for IndianaAIM system changes Review of claim denials Billing questions Claim submission questions Provider and Member services 6

7 Inquiry Review Process/Response 10 business days to research and respond to a inquiry Some inquires may require extensive research (>10 days) Some inquires may require referral to appropriate agency or contractor Many provider inquiries can be answered by Referring to existing publications (banners/bulletins, Provider Manuals, IHCP website, etc.) Viewing the IHCP fee schedule Contacting EDS Customer Assistance 7

8 Medical Policy Projects What generates a Project? OMPP initiative Inquiry regarding coverage, billing, etc. Legislative origin, directive, etc. New Technology (both service and products) Issues with a potential fiscal impact to the State (both positive and or negative) Issues with a potential benefit or scope impact to the State; program(s), access to care, providers, etc. 8

9 Examples* of Medical Policy Projects Bariatric Surgery Coverage Determinations Telemedicine Implementation Dental (Prior Authorization requirements, denture coverage, etc.) Power Mobility Devices * List is not all inclusive and does not necessarily reflect coverage determination at this time. 9

10 Project Review Process Usually a 3-6 month process allows for complete research with analysis Fiscal and Business impact analysis completed depending upon Project scope Projects require OMPP participation and oversight Projects may require CMS Approval of Medicaid State Plan amendments Legal Involvement (New Law, Rule Promulgation, etc) may extend the process for an additional months Recommendations are sent to OMPP for final determination 10

11 Qualifications for New Medical Policy The product or service requested must be medically necessary and reasonable The medical policy must be consistent with federal and state law, and meet IHCP s objectives The medical policy must define the scope of coverage, exclusions, and limitations 11

12 New policy research should answer the following questions; 1. Is the product/service medically necessary? 2. Under what authority is the product/service covered or non-covered? Federal Regulation (CFR) Indiana Administrative Code (IAC) Indiana Code (IC) 3. Is the product/service covered by Medicare, other state Medicaid programs, or private insurers? 4. Is or should PA be required? 5. How will the product/service be billed? 6. How will the product/service be coded? 7. What is the fiscal impact? 8. What is the potential for fraud and abuse? 9. Is rule promulgation required? Is a State Plan Amendment required? 10. Does current policy reflect coverage? 12

13 Code Reviews Annual and quarterly HCPCs updates Bi-annual ICD-9-CM updates Provider Code Sets Coding inquiries specific to Medical Policy 13

14 Approved Provider Code Sets Providers whose enrolled specialties correspond with an active code set are only reimbursed for services within that specific code set(s) Claims billed with HCPCS/CPT codes not included in a provider s code set will be denied for edit 1012 Rendering Provider Specialty Not Eligible to Render Procedure Code For providers with multiple specialties, claims processing will review the provider file for all specialties when claims are submitted 14

15 Examples* of Provider Specific Code Sets That Have Been Implemented Chiropractic Durable Medial Equipment (DME) Home Medical Equipment (HME) HIV Care Coordinators Hearing Services (Audiology & Hearing Aid Dealers) Optometrists Opticians Transportation *List may not be all inclusive 15

16 Code Set Updates Providers may request code set updates in writing to the HCE Medical Analysis & Research Department. HCE Medical Analysis & Research P.O. Box Indianapolis, IN

17 Medical Policy Communications Banner pages, which clarify policies, provide notice of system changes, and provide notice of minor policy changes Bulletins, which provide notice of major policy changes or new policy Newsletters, which provide information that could be published in banner pages or bulletins, and can include rule changes 17

18 Policies* Currently Under Review Pacemakers and Cardiodeverters Power Mobility Devices Home Health and Hospice Dental Policy Psychological and Neuropsychological Testing Tobacco Cessation Counseling and Prescription Treatment *List may not be all inclusive 18

19 Web Site References Indiana Health Coverage Programs Indiana Family and Social Services Administration Indiana Administrative Code The Centers for Medicare and Medicaid Services Health Care Excel 19

20 ? Questions 20