MEDICAID PRIOR AUTHORIZATION TRANSITION

Transcription

1 MEDICAID PRIOR AUTHORIZATION TRANSITION Prepared for: Mississippi Medicaid Hearing Providers November 2013

2 December 1, 2013 The Road Ahead 12/8/2013 HEARING PROVIDER PRESENTATION 2

3 Today s Goals and Objectives What stays the same and what changes? When does the new process begin? What do I need to know? 12/8/2013 HEARING PROVIDER PRESENTATION 3

4 What stays the same Admin Code and DOM regulations are the same, but 12/8/2013 HEARING PROVIDER PRESENTATION 4

5 A BIG change 12/1/13 Revised DOM Fee Schedule allows higher reimbursement and covers digital hearing aids 12/8/2013 HEARING PROVIDER PRESENTATION 5

6 What also changes? The Prior Authorization Process changes effective December 1, 2013 Where and when you send the authorization request Envision is only used for checking eligibility and claims No DOM forms Who reviews the request Timeframes for submitting your request Increased speed of approvals and communication Do not send ear molds unless eqhealth requests 12/8/2013 HEARING PROVIDER PRESENTATION 6

7 When does the new process begin? Effective December 1, 2013 eqhealth will perform prior authorization reviews for Hearing Services 12/8/2013 HEARING PROVIDER PRESENTATION 7

8 What happens to requests for services prior to December 1, 2013? Services requested prior to December 1, 2013 Continue to submit requests via Envision through November 30, 2013 DOM will continue to process these requests Any service approved by DOM will remain in effect Requests previously submitted to DOM should not be resubmitted to eqhealth 12/8/2013 HEARING PROVIDER PRESENTATION 8

9 eqhealth has a 16 year Utilization Management partnership with DOM Our multidisciplinary Hearing review team includes: Mississippi licensed Audiologists, and other specialists trained in Hearing services The review team is overseen by our Medical Director, Dr. Thomas Joiner 12/8/2013 HEARING PROVIDER PRESENTATION 9

10 What do we need to know? Admin Code and DOM Regulation eqhealth Systems & Review Process 12/8/2013 HEARING PROVIDER PRESENTATION 10

11 Getting to Know Mississippi Division of Medicaid (DOM) Hearing Coverage For comprehensive information about Hearing services covered, limitations and exclusions; the following are important resources to be familiar with: Mississippi Administrative Code Title 23 Medicaid, Part 217, Hearing Services Mississippi Medicaid Provider Reference Guide (PRG 217) Medicaid Hearing Fee Schedule 12/8/2013 HEARING PROVIDER PRESENTATION 11

12 Will all Hearing service codes require prior authorization (PA) on December 1, 2013? Good question, let s take a closer look 12/8/2013 HEARING PROVIDER PRESENTATION 12

13 Hearing Codes Requiring PA Code & Description All Current Procedural Terminology (CPT) Codes and Descriptors are copyrighted 2013 by the American Medical Association V HEARING AID, BILATERAL BODY WORN V DISPENSING FEE, BILATERAL V REPAIR/MODIFICATION OF A HEARING AID V BINAURAL, BODY V BINAURAL, IN THE EAR V BINAURAL, BEHIND THE EAR 12/8/2013 HEARING PROVIDER PRESENTATION 13

14 New Codes Opening, Hooray! 12/8/2013 HEARING PROVIDER PRESENTATION 14

15 Hearing Codes Requiring PA Code & Description All Current Procedural Terminology (CPT) Codes and Descriptors are copyrighted 2013 by the American Medical Association V DISPENSING FEE, BINAURAL V HEARING AID, DIGITAL, MONAURAL, CIC V HEARING AID, DIGITAL, MONAURAL, ITC V HEARING AID, DIGITAL, MONAURAL, ITE V HEARING AID, DIGITAL, MONAURAL, BTE V HEARING AID, DIGITAL, BINAURAL, CIC 12/8/2013 HEARING PROVIDER PRESENTATION 15

16 Hearing Codes Requiring PA Code & Description All Current Procedural Terminology (CPT) Codes and Descriptors are copyrighted 2013 by the American Medical Association V HEARING AID, DIGITAL, BINAURAL, CIC V HEARING AID, DIGITAL, BINAURAL, ITC V HEARING AID, DIGITAL, BINAURAL, ITE V HEARING AID, DIGITAL, BINAURAL, BTE V HEARING AID, NOT OTHERWISE CLASSIFIED 12/8/2013 HEARING PROVIDER PRESENTATION 16

17 Hearing Codes Fee Schedule Revision Code & Description All Current Procedural Terminology (CPT) Codes and Descriptors are copyrighted 2013 by the American Medical Association V5090 Dispensing Fee, Unspecified Hearing Aid 12/8/2013 HEARING PROVIDER PRESENTATION 17

18 Reminder: National Correct Coding Initiative (NCCI) and Hearing Services The National Correct Coding Initiative (NCCI) was developed by the Centers for Medicare and Medicaid Services (CMS) for use in all Medicare Part B and, more recently, Medicaid claims The goal of NCCI is to eliminate "mutually exclusive" code pairings and codes considered to be components of more comprehensive services or otherwise inappropriate to be delivered to the same patient on the same day The NCCI also includes a set of edits called Medically Unlikely Edits (MUEs), also for Medicare Part B and Medicaid claims. An MUE for a CPT or HCPCS Level II code is the maximum number of times that the code can be reported for the same patient on the same day. Not all codes have an MUE and/or NCCI edit 12/8/2013 HEARING PROVIDER PRESENTATION 18

19 Reminder: National Correct Coding Initiative (NCCI) and Hearing Services To avoid MUE coding edits when billing Medicaid for hearing aids each code must be billed separately using appropriate modifiers When you submit a Prior Authorization requests to eqhealth you must request each hearing aid as a line item. This will be explained in greater detail later in the presentation. 12/8/2013 HEARING PROVIDER PRESENTATION 19

20 Reminder: National Correct Coding Initiative (NCCI) and Hearing Services MUE Statement: Medically Unlikely Edits (MUE s) are units of service edits that were established by CMS to prevent payment for an inappropriate number/quantity of the same service. Each line of a claim is adjudicated separately against the MUE value for the HCPCS/CPT code reported on that line. The provider can find the CMS National Correct Coding Initiative Medicaid webpage at Program-Information/By-Topics/Data-and-Systems/National- Correct-Coding-Initiative.html. All policies regarding the billing of units and use of modifiers associated with NCCI edits are located in the Medicaid NCCI Policy Manual Chapter 1 General Coding Principles. 12/8/2013 HEARING PROVIDER PRESENTATION 20

21 Reminder: National Correct Coding Initiative (NCCI) and Hearing Services Modifier Statement: NCCI associated modifiers may be appended if appropriate, based on clinical circumstances, and in accordance with the Medicaid NCCI program and HCPCS/CPT Manual instructions/definitions for the modifier/procedure code combination. The provider can find the CMS National Correct Coding Initiative Medicaid webpage at Program-Information/By-Topics/Data-and-Systems/National- Correct-Coding-Initiative.html. All policies regarding the use of modifiers for bypassing NCCI edits are located in the Medicaid NCCI Policy Manual Chapter 1 General Coding Principles. 12/8/2013 HEARING PROVIDER PRESENTATION 21

22 Before getting started on your Prior Authorization journey, lets look at the information needed along the way 12/8/2013 HEARING PROVIDER PRESENTATION 22

23 Before You Get Started: Checkpoint #1 Did you check beneficiary eligibility? You are responsible for verifying a Medicaid beneficiary s eligibility each time the beneficiary appears for service. You are also responsible for confirming the person presenting the card is the person to whom the card is issued Verify eligibility by access any of the following services: Website verification: Envision Automated Voice Response System (AVRS) at Provider/Beneficiary Services Call Center at Using personal computer (PC) software or point of service (POS) swipe card verification device 12/8/2013 HEARING PROVIDER PRESENTATION 23

24 Before You Get Started: Checkpoint #1 The following beneficiaries under age 21 who require prior authorization by eqhealth: The following beneficiaries do not require prior authorization by eqhealth: Fee-for-service Dual Coverage (Private Insurance and Medicaid) Beneficiaries over age 21 Beneficiaries enrolled in Mississippi Coordinated Access Network (MSCAN) or CHIP Beneficiaries in COE 29, Family Planning Waiver (No Hearing Benefit) Beneficiaries with no Medicaid coverage for the date of service Note: The Federal Government is requiring Medicaid programs to change their categories of eligibility by January 1, Making sure you check eligibility becomes a business necessity 12/8/2013 HEARING PROVIDER PRESENTATION 24

25 Before You Get Started: Checkpoint #2 Select your eqsuite Web Administrator 12/8/2013 HEARING PROVIDER PRESENTATION 25

26 Selecting Your Key Players Who is the best person to be the eqsuite Web Administrator? When is this information due to eqhealth? What type of skills should this person have? 12/8/2013 HEARING PROVIDER PRESENTATION 26

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28 Get Your Provider Contact Form Visit our Web site at ms.eqhs.org 12/8/2013 HEARING PROVIDER PRESENTATION 28

29 Before You Get Started: Checkpoint #3 Effective December 1, 2013, discontinue using all Hearing DOM prior authorization forms DOM forms will be replaced by eqhealth s automated Web based review submission process When a beneficiary requires hearing aides, or other hearing services requiring PA, the following information must be obtained in order to submit your request to eqhealth Review Questions The following information below details the questions you will need to answer in our web based review system eqsuite Note: A printable version of this form can be found at 12/8/2013 HEARING PROVIDER PRESENTATION 29

30 Before You Get Started: Checkpoint #3 To assist with helpful reminders please welcome your Prior Authorization buddy. Pete the PA Parrot 12/8/2013 HEARING PROVIDER PRESENTATION 30

31 Before You Get Started: Checkpoint #3 Please ensure your documentation supports your responses to the following questions 12/8/2013 HEARING PROVIDER PRESENTATION 31

32 Before You Get Started: Checkpoint #3 Is the beneficiary (only applies to ages 0 to 3) participating in the Early Intervention (EI) program? Yes No Please provide the date of the most recent assessment/evaluation, who administered the test, and their qualifications: MM/DD/YY Textbox 12/8/2013 HEARING PROVIDER PRESENTATION 32

33 Before You Get Started: Checkpoint #3 If known, enter the date of the beneficiary's most recent physical exam: MM/DD/YY Will the beneficiary have any other kind of assistive device to help with his/her hearing? If yes, specify the type of device(s): Yes No Textbox 12/8/2013 HEARING PROVIDER PRESENTATION 33

34 Before You Get Started: Checkpoint #3 RIGHT EAR: At a frequency of at least 500 hz in the ear, does the beneficiary have hearing loss? If yes, select the appropriate type of loss Yes No Check all that apply Conductive - refers to hearing loss to the outer ear, eardrum, or middle ear Sensorineural - refers to hearing loss to the inner ear Mixed Other: please specify 12/8/2013 HEARING PROVIDER PRESENTATION 34

35 Before You Get Started: Checkpoint #3 RIGHT EAR: Select the measured hearing loss in db ranges. Check all That Apply (Slight) (Mild) (Moderate) (Moderate to Severe) (Severe) 12/8/2013 HEARING PROVIDER PRESENTATION 35

36 Before You Get Started: Checkpoint #3 LEFT EAR: At a frequency of at least 500 hz in the ear, does the beneficiary have hearing loss? If yes, select the appropriate type of loss Yes No Check all that apply Conductive - refers to hearing loss to the outer ear, eardrum, or middle ear Sensorineural - refers to hearing loss to the inner ear Mixed Other: please specify 12/8/2013 HEARING PROVIDER PRESENTATION 36

37 Before You Get Started: Checkpoint #3 LEFT EAR: Select the measured hearing loss in db ranges. Check all That Apply (Slight) (Mild) (Moderate) (Moderate to Severe) (Severe) 12/8/2013 HEARING PROVIDER PRESENTATION 37

38 Before You Get Started: Checkpoint #3 IMPORTANT REMINDER: the physician's order must be kept in the beneficiary medical record and be readily available if requested 12/8/2013 HEARING PROVIDER PRESENTATION 38

39 Before You Get Started: Checkpoint #3 When should I send my request to eqhealth? New Request/Admission Submit the PA request a minimum of three (3) business days prior to the planned service date (ordering or dispensing of assistive devices) Urgent or Emergent conditions (i.e. replace broken or damaged devices and the condition severely limits the beneficiary's ability to safely perform activities of daily living) 12/8/2013 HEARING PROVIDER PRESENTATION 39

40 Before You Get Started: Checkpoint #3 When should I send my request to eqhealth? Retrospective For beneficiaries who are retroactively eligible, and have been discharged from care Submit the review request as soon as eligibility is confirmed and within one (1) year of the retroactive eligibility determination date If services are in progress when the retroactive eligibility is determined, submit an admission review request 12/8/2013 HEARING PROVIDER PRESENTATION 40

41 A Quick Checklist Review Before You Get Started: Know the codes that require PA, covered items, and the rules in Administrative Code and DOM Regulations Check beneficiary eligibility Collect answers to review questions and include timeframes for submitting PA requests in your planning of care for the beneficiary Congratulations now you are ready to send the information to eqhealth 12/8/2013 HEARING PROVIDER PRESENTATION 41

42 The next step of the transition journey Checkpoint #4: Learning how to use our Web tool equniversity Review Process and eqsuite Web Administrator Registration Support and Training 12/8/2013 HEARING PROVIDER PRESENTATION 42

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49 To be NCCI compliant and avoid MEU edits, each hearing aide must be requested and billed as a separate line with a quantity of one (1) unit. Single line item requests or claims for two (2) units will cause claims problems. The PA does not require the modifier, but your claim will 12/8/2013 HEARING PROVIDER PRESENTATION 49

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60 Beginning 12/1/13: What will eqhealth do with your request? 12/8/2013 HEARING PROVIDER PRESENTATION 60

61 eqhealth Solutions First Level Reviewers audiologists, speech and language pathologists, and registered nurses Apply Admin Code and DOM regulations Apply DOM approved medical necessity guidelines May request additional information Pending a review Approve services based on DOM regulations and guidelines Refer requests they can not approve to a second level reviewer (physician) 12/8/2013 HEARING PROVIDER PRESENTATION 61

62 eqhealth Solutions Second Level Reviewers physicians with expertise and experience with hearing disorders May contact the ordering physician/audiologist to obtain additional information Pending a review Approve services Deny services 12/8/2013 HEARING PROVIDER PRESENTATION 62

63 National Guidelines for Hearing related disorders and services eqhealth Solutions uses DOM approved National Clinical Guidelines (referred to as Clinical Guidelines) as tools when making clinical determinations concerning the medical necessity of care. These guidelines are available at 12/8/2013 HEARING PROVIDER PRESENTATION 63

64 What is a Pend? Pends are questions submitted to providers from either a first level reviewer or a second level reviewer that generally involve a need for clarification or additional information before a review can be completed Pends may occur anytime there are: Questions about the information that has been submitted Missing required information 12/8/2013 HEARING PROVIDER PRESENTATION 64

65 How Do I Know I ve Been Pended? eqsuite will provide information about your request/case at all times eqsuite is accessible 24 hours a day, 7 days a week to check the status of your request/case, including pend messages The image on the left highlights where to respond to a pend question. The upper box will contain the question. The lower box is where you may respond eqhealth will contact the review submitter or physician s office by phone to inform you of the information needed to complete your request. If you are not available we will leave a message to check eqsuite 12/8/2013 HEARING PROVIDER PRESENTATION 65

66 How Do I Respond To a Pend? Responding to pends as soon as possible keeps the review process progressing You can respond to pends online via the eqsuite 12/8/2013 HEARING PROVIDER PRESENTATION 66

67 Should I Like Being Pended? How do I prevent being pended? 12/8/2013 HEARING PROVIDER PRESENTATION 67

68 Is getting Pended good? The up side about a pended review is that it opens a line of communication between eqhealth and the provider The down side, the review process stops until you respond Applying a few easy tips can keep your review moving along 12/8/2013 HEARING PROVIDER PRESENTATION 68

69 Pend Prevention Tips To prevent pends or apendaphobia: Don t copy and paste clinical information into reviews Attend equniversity trainings Answer the pend question completely and accurately If you feel you are receiving numerous pends, immediately consult an equniversity Team Member at for assistance 12/8/2013 HEARING PROVIDER PRESENTATION 69

70 How Many Business Days Does eqhealth Have To Process Your Review? eqhealth completes requests for services as quickly as possible, but within specific timeframes. The timeframe depends on when the service is anticipated to occur (new request/admission review) or if the service has already occurred. The review completion timeframe is measured from the date eqhealth receives your request. New Requests/Admission review requests: 2 business days Retrospective review requests: 20 business days (Retrospective eligibility only) 12/8/2013 HEARING PROVIDER PRESENTATION 70

71 Denials 12/8/2013 HEARING PROVIDER PRESENTATION 71

72 What Is a Denial? A denial occurs when any portion of requested services are not approved Clinical Denial Any portion of requested services are not approved by a second level reviewer for a clinical reason 12/8/2013 HEARING PROVIDER PRESENTATION 72

73 Reconsiderations 12/8/2013 HEARING PROVIDER PRESENTATION 73

74 Reconsiderations - Another Look Must be requested within 30 calendar days of the denial notification Beneficiary or provider may request a reconsideration 12/8/2013 HEARING PROVIDER PRESENTATION 74

75 Reconsiderations - Another Look A reconsideration is another look at your request/case by a different second level reviewer (a different physician who was not involved in the original denial decision) Available when eqhealth issues a clinical denial The denial notification will have specific instructions for requesting a reconsideration HELPLINE assistance is available by calling /8/2013 HEARING PROVIDER PRESENTATION 75

76 Reconsiderations - Another Look Outcomes: Upheld denial remains in place Modified part of the request is approved and the remainder is denied Overturned denial is removed and request is certified, and Treatment Authorization Number (TAN) Approval information sent daily to fiscal intermediary 12/8/2013 HEARING PROVIDER PRESENTATION 76

77 Appeals 12/8/2013 HEARING PROVIDER PRESENTATION 77

78 DOM Administrative Appeal Right If a reconsideration is Upheld or Modified(partially approved) ONLY the beneficiary, parent, legal guardian/caregiver may request an administrative appeal of the eqhealth determination Administrative Appeals must be requested in writing within 30 calendar days of the reconsideration notification date DOM performs the Administrative Appeal/Hearing 12/8/2013 HEARING PROVIDER PRESENTATION 78

79 A Helpful Transition Aide for December 1, 2013 Do not use existing DOM forms eqsuite replaces DOM forms. Our web site ms.eqhs.org has a sample copy of questions to assist in planning ahead Know the Rules - Admin Code and DOM regulations Check Eligibility prior to every visit Eligibility changes will be occurring on 1/1/2014 Answer the questions thoroughly in eqsuite Plan ahead to allow time for eqhealth to process the request By12/1/13: Send your completed Provider Contact Form to eqhealth via at Education@eqhs.org OR call Completing this form allows your eqsuite Administrator to setup access for submitting PA requests. If you do not have a form, download one at ms.eqhs.org 12/8/2013 HEARING PROVIDER PRESENTATION 79

80 November 2013 and going forward equniversity will continue to provide education support to you: Monthly and Quarterly webinars Education materials posted on website ms.eqhs.org HELPLINE Tailored educational offerings to meet your needs 12/8/2013 HEARING PROVIDER PRESENTATION 80

81 November 2013 and going forward Training is free No limit on the number of times you can attend Idea: Incorporate equniversity into your new employee orientation 12/8/2013 HEARING PROVIDER PRESENTATION 81

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84 For additional training and links to resources: Visit our Web site at ms.eqhs.org 12/8/2013 HEARING PROVIDER PRESENTATION 84

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86 Thank you for attending.. 12/8/2013 HEARING PROVIDER PRESENTATION 86