MEDICAID PRIOR AUTHORIZATION TRANSITION
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1 MEDICAID PRIOR AUTHORIZATION TRANSITION Prepared for: Mississippi Medicaid General Dentists, Oral and Maxillofacial Surgeons, and Orthodontists November 2013
2 December 1, 2013 The Road Ahead 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? 3
4 What stays the same? Admin Code and DOM regulations are the same for all Dental Services. No change. 4
5 What is changing? 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 5
6 When does the new process begin? Effective December 1, 2013 eqhealth will perform prior authorization reviews of general dental, oral and maxillofacial surgical, and orthodontia services 6
7 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 7
8 eqhealth has a 16 year Utilization Management partnership with DOM Our multidisciplinary review team includes: Mississippi licensed registered nurses, dental hygienists, dental assistants, dentists, orthodontists, and oral maxillofacial surgeons The review team is overseen by our Dental Director, Dr. James Ron Philley 8
9 What do we need to know? Admin Code and DOM Regulations eqhealth Systems & Review Process 9
10 Getting to Know Mississippi Division of Medicaid (DOM) Dental Coverage For comprehensive information about Dental services covered, limitations and exclusions; the following are important resources to be familiar with: Mississippi Administrative Code Title 23 Medicaid, Part 204, Dental Services Mississippi Medicaid Provider Reference Guide (PRG 204) Medicaid Dental Fee Schedule Medicaid Dental Fee Schedule Outpatient Hospital Remember there is no change to DOM regulations regarding what codes need prior authorization or when codes need prior authorization. The only change is where and how you submit your prior authorization requests 10
11 Will all Dental service codes require prior authorization (PA) on December 1, 2013? Good question, the answer is No but let s take a closer look 11
12 Orthodontia: Codes Always Require PA All Current Dental Terminology (CDT) Codes and Descriptors are copyrighted 2013 by the American Dental Association. Orthodontia CDT Codes always require PA D PERIODIC ORTHDONTIC TREATMENT VISIT (AS PART OF CONTRACT) D COMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADOLOSCENT DENTITION D8999 UNSPEC ORTHODONTIC PROCEDURE, BY REPORT 12
13 General Dental Codes: Always Require PA (No change from existing requirements) All Current Dental Terminology (CDT) Codes and Descriptors are copyrighted 2013 by the American Dental Association. Dental CDT Codes that always require PA D0321 -OTHER TEMPOROMANDIDULAR JOINT RADIOGRAPHIC IMAGES BY REPORT D UNSPEC DIAGOSTIC PROCEDURE BY REPORT D CROWN-PORCELAIN FUSED TO HIGH NOBILE METAL D CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL 13
14 General Dental Codes: Always Require PA (No change from existing requirements) All Current Dental Terminology (CDT) Codes and Descriptors are copyrighted 2013 by the American Dental Association. Dental CDT Codes that always require PA D CROWN-PORCELAIN FUSED TO NOBILE METAL D PROTECTIVE RESTORATION POST REMOVAL D POST AND CORE IN ADDITION TO CROWN, INDIRECTLY FABRICATED D UNSPEC RESTORATIVE PROCEDURE BY REPORT D RETREATMENT-INTERIOR BY REPORT 14
15 General Dental Codes: Always Require PA (No change from existing requirements) All Current Dental Terminology (CDT) Codes and Descriptors are copyrighted 2013 by the American Dental Association. Dental CDT Codes that always require PA D RETREATMENT-BICUSPID BY REPORT D RETREATMENT-MOLAR BY REPORT D UNSPEC ENDODONTIC PROCEDURE,BY REPORT D COMPLETE UPPER D COMPLETE LOWER D UPPER PARTIAL-RESIN BASED (INC ANY CONVENTIONAL CLASPS, RESTS) 15
16 General Dental Codes: Always Require PA (No change from existing requirements) All Current Dental Terminology (CDT) Codes and Descriptors are copyrighted 2013 by the American Dental Association. Dental CDT Codes that always require PA D LOWER PARTIAL-RESIN BASED (INC ANY CONVENTIONAL CLASPS, RESTS D PALATAL LIFT PROSTHESIS DEFINITIVE D UNSPEC FIXED PROSTHODONTIC PROCEDURE, BY REPORT D CORONECTOMY-INTENTIONAL PART TOOTH REMOVAL D TOOTH TRANSPLANTATION D SURGICAL ACCESS OF UNERUPTED TOOTH 16
17 General Dental Codes: Always Require PA (No change from existing requirements) All Current Dental Terminology (CDT) Codes and Descriptors are copyrighted 2013 by the American Dental Association. Dental CDT Codes that always require PA D BRUSH BIOPSY-TRANSEPITHELIAL SAMPLE COLLECTION D RADICAL RESECTION OF MAXILLA OR MANDIBLE D ARTHROTOMY D OSTEOPLASTY-FOR ORTHOGNATHIC DEFORMITIES D OSTEOTEMY - MANDIBULAR RAMI WITH BONE GRAFT, INC OBTAINING GRAFT D LEFORT I BASED (MAXILLA TOTAL) 17
18 General Dental Codes: Always Require PA (No change from existing requirements) All Current Dental Terminology (CDT) Codes and Descriptors are copyrighted 2013 by the American Dental Association. Dental CDT Codes that always require PA D LEFORT I BASED (MAXILLA SEGMENTED) D LEFORT II OR III (OSTEOPLASTY OF FACIAL BONES - MID FACE) D LEFORT II OR III - WITH BONE GRAFT D OSSEOUS,OSTEOPERIOSTEAL, OR CARTILLAGE GRAFT OF MANDIBLE OR MAXILLA AUTOGENOUS OR NONAUTOGENOUS, BY REPORT D REPAIR OF MAXILLAFACIAL SOFT AND/OR HARD TISSUE DEFECT D EXCISION OF SALIVARY GLAND BY REPORT 18
19 General Dental Codes: Always Require PA (No change from existing requirements) All Current Dental Terminology (CDT) Codes and Descriptors are copyrighted 2013 by the American Dental Association. Dental CDT Codes that always require PA D CLOSURE OF SALIVARY FISTULA D CORONOIDICTOMY D UNSPEC ORAL SURGERY PROCEDURE, BY REPORT D PALLIATIVE (EMERGENCY) TREATMENT OF DENTAL PAIN- MINOR PROCEDURES D OCCLUSAL GUARDS, BY REPORT D UNSPEC ADJUNCTIVE PROCEDURE, BY REPORT 19
20 Additional Dental Codes: Only requires PA when dollar benefit limit reached for all beneficiaries (No change from existing requirements) Refer to DOM Dental Fee Schedule Professional Services and DOM Dental Fee Schedule Outpatient Hospital for a current listing of CDT codes requiring PA after exceeding expenditure specified in Administrative Code and Fee Schedule, (greater than $2500 per state fiscal year July 1 June 30) 20
21 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 21
22 Before You Get Started: Checkpoint #1 The following beneficiaries require prior authorization by eqhealth: Fee-for-service EPSDT eligible beneficiaries Fee-for-service non EPSDT eligible beneficiaries once the service limit has been exceeded Dual Coverage (Private Insurance and Medicaid) The following beneficiaries do not require prior authorization by eqhealth: Beneficiaries enrolled in Mississippi Coordinated Access Network (MSCAN), or CHIP Beneficiaries in COE 29, Family Planning Waiver 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 22
23 Before You Get Started: Checkpoint #2 Select your eqsuite Web Administrator 23
24 Selecting Your Key Players Who is the best person to be the eq Suite Web Administrator? When is this information due to eqhealth? What type of skills should this person have? 24
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26 Get Your Provider Contact Form Visit our Web site at ms.eqhs.org 26
27 Before You Get Started: Checkpoint #3 Effective December 1, 2013, discontinue using all DOM prior authorization forms DOM forms will be replaced by eqhealth s automated Web based review submission process 27
28 To assist with helpful reminders please welcome your Prior Authorization buddy. Pete the PA Parrot 28
29 Before You Get Started: Checkpoint #3 General Dental & Oral Maxillofacial (Non-Orthodontia) Please ensure your documentation supports your responses to the following questions 29
30 Before You Get Started: Checkpoint #3 General Dental & Oral Maxillofacial (Non-Orthodontia) Review Questions The following pages detail the questions you will need to answer for general dentistry and oral maxillofacial codes in our Web based review system Note: A printable version of this form can be found at and used as a reference tool 30
31 Before You Get Started: Checkpoint #3 General Dental & Oral Maxillofacial (Non-Orthodontia) Question 1: What is the reason for the treatment authorization request? Textbox Question 2: Please address why this is the most cost effective and clinically appropriate treatment option to address the patient's dental needs Textbox Question 3: What is the five year prognosis of the requested treatment procedure? Textbox 31
32 Before You Get Started: Checkpoint #3 General Dental & Oral Maxillofacial (Non-Orthodontia) Question 4: Is this treatment for initial placement of a prosthesis? If yes, please describe if this is maxillary or mandibular. Yes No Textbox Question 5: If treatment is for repair or replacement of a prosthesis, please provide the following: Is this maxillary or mandibular, full or partial, and the date it was inserted Whether the original can be worn or is in use now. Whether the original can be repaired MM/DD/YYYY 32
33 Before You Get Started: Checkpoint #3 General Dental & Oral Maxillofacial A copy of the patient's radiograph is required. To submit you can upload the file directly or create a barcode fax coversheet. These options are available by clicking the [Link Attachments to this Review] button after submitting the review. You may also mail a copy of the radiograph to: eqhealth Solutions Attn: Dental 460 Briarwood Drive, Suite 300 Jackson, MS Note: eqhealth Solutions Review Team can not start the review process until we receive the radiograph. Uploading or faxing is the most efficient and quickest method. Radiographs mailed without the unique patient bar code will delay the review and will be returned to your office for identification eqhealth is required by DOM to return all radiographs to you following the completion of our review 33
34 Before You Get Started: Checkpoint #3 Orthodontia Please ensure your documentation supports your responses to the following questions 34
35 Before You Get Started: Checkpoint #3 Orthodontia Review Questions The following pages provide a reference outlining the questions you will be required to complete when submitting a request for Orthodontia services. All questions are online in eq Suite, eqhealth Solutions Web based review module Note: A printable version of this form can be found at and used as a reference tool 35
36 Before You Get Started: Checkpoint #3 Orthodontia Question 1: Is this a request to transfer services to another dentist/dental practice? If yes, please list the month and year treatment was started with the other Dental practice and reason for transfer Yes No Textbox 36
37 Before You Get Started: Checkpoint #3 Orthodontia Question 2: Please select the reasons for the orthodontic request: Select all that apply. Cleft lip, cleft palate and other craniofacial anomalies Overjet of 9 millimeters or more Reverse overjet of 2 millimeters or more Extensive hypodontia with restorative implications (more than one tooth per quadrant) requiring pre-prosthetic orthodontics Anterior open bites greater than 4 millimeters Upper anterior contact point displacements greater than 4 millimeters Individual anterior tooth crossbites with greater than a 2 millimeter discrepancy between retruded contact position and intercuspal position Impinging overbite with evidence of gingival or paletal trauma Impeded eruption of teeth (except third molars) due to crowding, displacement, presence of supernumerary teeth, retained primary teeth, and any pathologic cause; unless extraction of the displaced teeth or adjacent teeth, requiring no orthodontic treatment would be more expedient. Other: Please explain 37
38 Before You Get Started: Checkpoint #3 Orthodontia Question 3: Medicaid Orthodontic Initial Assessment Form (OIAF) total score: Textbox Note: It is only necessary to provide us with the total score as long as all of the questions are answered; however, the complete form/worksheet and instructions are available at: 38
39 Before You Get Started: Checkpoint #3 Orthodontia Required: A copy of the patient's radiograph and photographs are required. 1. Upload or fax a copy of the OrthoCAD file or other electronic image. These options are available by clicking the [Link Attachments to this Review] button after submitting the review. The system generates a patient specific tracking number that safely and securely attaches all information to the orthodontia request. OR; 2. Submit the patient's tooth mold to us by mailing along with our system generated patient specific bar-coded coversheet to: eqhealth Solutions Attn: Orthodontics 460 Briarwood Drive, Suite 300 Jackson, MS Note: eqhealth Solutions Review Team can not start the review process until we receive the radiographs, photographs and mold. Uploading is the most efficient and quickest method. Molds mailed without the unique patient bar code will delay the review and will be returned to your office for identification eqhealth is required by DOM to return all molds to you following the completion of our review 39
40 Before You Get Started: Checkpoint #3 When should I send my request to eqhealth? New Service/Admission Routine/elective/planned office procedures or outpatient hospital procedures (less than 24 hours) - submit the PA request a minimum of seven (7) business days prior to the planned service date Urgent or Emergent conditions submit as soon as possible, but no later than seven (7) business days after the dental service is performed. Remember to write in the note section the reason for delay in submitting was due to an urgent/emergent condition. Reminder: Inpatient hospitalizations (24 hours or more) for dental treatment refer to Inpatient Acute Care Provider Manual PA requests are submitted online by the hospital or pre-cert line 40
41 Before You Get Started: Checkpoint #3 When should I send my request to eqhealth? Retrospective: Applies to beneficiaries with retroactive eligibility; and the beneficiary has already received the service/procedure Submitting the review request to eqhealth as soon as eligibility is confirmed is preferred. However, the maximum amount of time to submit a claim is within one (1) year of the retroactive eligibility determination date If services are in progress when the retroactive eligibility is determined, submit a new service/admission review request 41
42 A Quick Checklist Review Before You Get Started: Know the codes requiring PA, and rules in Administrative Code and DOM Regulation Check beneficiary eligibility Collect answers to review questions and plan ahead for timeframes for submitting PA requests and processing of your request Congratulations now you are ready to send the information to eqhealth 42
43 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 43
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49 GENERAL DENTISTRY AND SURGICAL 49
50 ORTHODONTICS 50
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52 GENERAL DENTISTRY AND SURGICAL 52
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61 Beginning 12/1/13: What will eqhealth do with your request? 61
62 eqhealth Solutions First Level Reviewers dental hygienist, nurses trained in dental services and/or dentists 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 62
63 eqhealth Solutions Second Level Reviewers dentists, oral & maxillofacial surgeons, and orthodontists May contact the ordering physician/dentist to obtain additional information Pending a review Approve services Partially approve services Deny services 63
64 National Guidelines for Dental and Orthodontia 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 64
65 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 65
66 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 66
67 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 67
68 Should I Like Being Pended? How do I prevent being pended? 68
69 Is getting Pended good? The up side about a pended review is that it opens a line of communication between eqhealth and the dental practice The down side, the review process stops until you respond Applying a few easy tips can keep your review moving along 69
70 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 70
71 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 has occurred. The review completion timeframe is measured from the date eqhealth receives your request. New Service/Admission review requests: 7 business days Retrospective review requests: 20 business days (Retrospective eligibility only) 71
72 Denials 72
73 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 73
74 Reconsiderations 74
75 Reconsiderations - Another Look Must be requested within 30 calendar days of the denial notification Beneficiary or provider may request a reconsideration 75
76 Reconsiderations - Another Look A reconsideration is another look at your request/case by a different eqhealth Solutions second level reviewer (a different dentist/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
77 Reconsiderations - Another Look Outcomes: Upheld no change in original decision to deny. Denial remains in place. Administrative Appeal rights explained in the reconsideration denial outcome notice Modified part of the request is approved and the remainder is denied Overturned original decision to deny the request/service is reversed and approved. A Treatment Authorization Number (TAN) is generated; And, Approval information is sent daily to the fiscal intermediary 77
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79 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 to DOM within 30 calendar days of the reconsideration notification date DOM performs the Administrative Appeal/Hearing 79
80 A Helpful Transition Aide for December 1, 2013 Do not use existing DOM Dental or Orthodontia forms eqsuite replaces DOM forms. Our web site ms.eqhs.org has a sample copy of all 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 80
81 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 81
82 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 82
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85 For additional training and links to resources: Visit our Web site at ms.eqhs.org 85
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87 Thank you for attending.. 87
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