Prior Authorizations. I H C P A n n u a l S e m i n a r

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1 Prior Authorizations I H C P A n n u a l S e m i n a r

2 How to Submit Prior Authorization Requests Phone Fax Mail Fax the prior authorization form to The prior authorization request form can be found on CareSource.com. CareSource Attn: Medical Management P.O. Box 743 Dayton, OH

3 Prior Authorization Form For prior authorization requests, please use the IHCP Prior Authorization Request Form. It is located on the Forms page on CareSource.com: Click on: Providers Indiana Medicaid Plan Resources Forms 3

4 Prior Authorization Checklist When you request prior authorization (PA), be sure to include the following: Member/patient name and Medicaid RID number Referring and Servicing Provider name and NPI Anticipated date of service Diagnosis code and narrative Procedure, treatment or service requested Number of visits requested, if applicable Reason for referring to an out-of-network provider if applicable Clinical information to support the medical necessity of the service Inpatient services need to include whether the service is elective, urgent, or emergency, admitting diagnosis, symptoms & plan of treatment Where do I find more information? Find more information in our Health Partner Manual on CareSource.com. We may not require a referral to see a specialist. However, prior authorization may still be required for services provided by specialists. 4

5 Prior Authorization Timeframes Authorization Type Decision Extension Standard Pre-service Seven calendar days 14 calendar days Expedited Pre-service 72 hours 48 hours Urgent Concurrent 24 hours 48 hours Post Service (Retrospective Review) 30 calendar days 14 calendar days 5

6 Dental Authorizations CareSource partners with Scion Dental to administer dental benefits. Dental authorization requests may be submitted via paper or online at ONLINE: Participating Providers contact the web portal team at to get registered for the Scion Provider Web Portal and request a demonstration. Some of the time-saving features of the dental Provider Web Portal include: View member service history, covered benefits and fee schedules. Create a member eligibility calendar and view real-time eligibility for multiple members. View authorization guidelines and required documentation prior to submitting authorizations. Submit authorizations with attachments for faster determinations. PAPER: Paper dental authorization requests may be sent to: CareSource IN: Authorizations P.O. Box 745 Milwaukee, WI,

7 Services Requiring Prior Authorization All services provided out-of-network, unless operating as an open network Inpatient services Partial hospitalization programs All surgical services Advanced diagnostic imaging through NIA Magellan (i.e. PET, MRI, MRA, CT etc.,) Certain outpatient procedures and tests as specified by PA list on the Provider Portal Purchase or rental of specified medical supplies, durable medical equipment (DME) supplies or appliance, as well as items exceeding $750. Skilled nursing facilities Home infusion therapy Accidental dental (reconstruction due to accident) Pain management services Behavioral health facility: Inpatient and outpatient including alcohol and substance abuse 7

8 Services Requiring Prior Authorization Refer to the Health Partner Manual to view a more comprehensive list of covered services and limitations. Prior authorization of a service does not guarantee payment. The service must be a covered benefit in the member s plan and the member must be eligible on the date of service. 8

9 Self-Referral Services CareSource includes self-referral health partners in our network. For both HHW and HIP, members may self-refer to IHCP-enrolled providers for the services eligible for self-referral. HHW Members May receive self-referral services from IHCP-enrolled self-referral health partners who are not in the CareSource network CareSource reimburses self-referral services up to the applicable benefit limits and at Indiana Health Coverage Programs (IHCP) Fee For Service (FFS) rates HIP Members Must go to an in-network health partner; OR Receive PA from CareSource to go to an out-of-network health partner Exceptions: Family planning & emergency services CareSource reimburses self-referral services up to the applicable benefit limits and at a rate not less than the Medicare rate, or at 130 % of Medicaid if no Medicare rate 9

10 Self-Referral Services The following services are eligible for self-referral: Psychiatric services Family planning services The following services are eligible for self-referral, but may only be provided to members receiving services through Hoosier Healthwise, HIP State Plan, or while receiving the additional HIP pregnancy-only benefits. Chiropractic services Eye care services, except surgical services Routine dental services Podiatry services The Indiana Administrative Code 405 IAC 5 (Hoosier Healthwise) and 405 IAC 9-7 (Healthy Indiana Plan) provide further detail. 10

11 NIA Magellan Imaging CareSource partners with NIA Magellan to implement a radiology benefit management program for outpatient advanced imaging services. Procedures requiring prior authorization through NIA Magellan: Services NOT requiring prior authorization through NIA Magellan: NIA Magellan authorization phone number: CT/CTA MRI/MRA PET Scans 11 Inpatient advanced imaging services Observation setting advanced imaging services Emergency room imaging services Expedited authorizations are accepted. Register at RadMD.com. Authorization requests are approved at intake in most cases. If an approval cannot be issued during the initial intake, more information may be required. Note: Imaging procedures performed during an inpatient admission, hospital observation stay or emergency room visit are not included in this program.

12 DENISE EDICK ENGAGEMENT SPECIALIST MELISSA KAMEN TONYA THOMPSON SUSAN SCHURMAN TROY MCKINLEY PAULA DRYE Manager, Health Partnerships ASSIGNED COUNTIES / HEALTH SYSTEMS IU Health and Suburban Health Organization Engagement Specialist Assignments Counties: Benton, Cass, Fulton, Jasper, Lake, LaPorte, Marshall, Newton, Porter, Pulaski, Starke, White Health Systems: Franciscan & Beacon Health Systems Counties: Adams, Allen, DeKalb, Elkhart, Huntington, Kosciusko, LaGrange, Miami, Noble, St. Joseph, Steuben, Wabash, Wells, Whitley Health Systems: Parkview, Lutheran & SJRMC Counties: Bartholomew, Blackford, Decatur, Delaware, Fayette, Franklin, Grant, Henry, Jay, Madison, Randolph, Rush, Union, Wayne Health Systems: Community Health Network Counties: Boone, Hamilton, Hendricks, Johnson, Marion, Hancock, Morgan and Shelby AMY WILLIAMS amy.williams@caresource.com BONNIE WAELDE bonnie.waelde@caresource.com VACANT ANGELINA WARREN angelina.warren@caresource.com 12 Counties: Brown, Carroll, Clay, Clinton, Fountain, Howard, Monroe, Montgomery, Owen, Parke, Putnam, Tippecanoe, Tipton, Vermillion, Vigo, Warren Health System: American Health Network & Eskanazi Health Counties: Daviess, Dubois, Gibson, Greene, Knox, Lawrence, Martin, Perry, Pike, Posey, Spencer, Sullivan, Vanderburgh, Warrick Health System: Deaconess & St. Vincent Health Counties: Clark, Crawford, Dearborn, Floyd, Harrison, Jackson, Jefferson, Jennings, Ohio, Orange, Ripley, Scott, Switzerland, Washington Health System: KentuckyOne & Norton Health Statewide Behavioral Health CONTRACTING MANAGERS HOSPITALS / LARGE HEALTH SYSTEMS MANDY BRATTON mandy.bratton@caresource.com TENISE HILL tenise.hill@caresource.com

13 Thank You! 13 IN-P-0282; Date Issued: 10/17/17 Date Approved: 9/20/17