Medical Necessity and the Retrospective Review Process

Transcription

1 Medical Necessity and the Retrospective Review Process

2 Medicaid Retrospective Therapy Review Medicaid contracted with QSource of Arkansas to perform post-payment audits Random quarterly selection across the board- - by beneficiary NOT provider

3 Medicaid Retrospective Therapy Review - Continued Child eligible for selection only every 12 months per Medicaid request Based on claims billed and paid in the previous quarter

4 QSource Therapy Review Services Last therapy chart requests happened in October. All charts due 30 calendar days from requested date. All necessary directions for chart submission are included with request. Anyone that wishes to hand deliver records will be welcome to at our QSource of Arkansas office.

5 Therapy Review Services Continued All chart submissions must be mailed or hand delivered to QSource. Faxed chart submissions will not be accepted or reviewed.

6 Submitting Requested Charts For Review Therapy Chart Request Reference Sheet Master List Check to see that you have received all the Therapy Request Cover Sheets listed If you have more than 1 provider number MAKE SURE you have all requests under each number. Call us if you are unsure.

7 Therapy Chart Request Form

8 ARKANSAS MEDICAID PROVIDER CRITERIA: Therapy Review & Prior Authorization for Personal Care follow the criteria outlined in Arkansas Medicaid s Provider Manuals. Processes are also outlined on QSource of Arkansas website. Section 214.xxx covers Occupational,Physical, & Speech Therapy Services

9 Review Review all documentation for completeness before submitting Check Prescriptions Check Evaluations Annual Updates Check Progress Notes Check Signatures full name and credentials Legible Copies

10 Scanning Highlight in yellow only Legible copies

11 DMS 640 Completion Minutes per week and duration for each discipline ordered Under other information, for public schools Medicaid requests that the school year be listed in order to use the DMS-640 i.e., school year Child s diagnosis on DMS-640 must support the type of therapy being given Physician s signature and date of signing stamped signatures or dates are not accepted

12 Example of DMS Minutes and duration is required For school districts providing therapy services in accordance with the child s IEP, a PCP referral is required at the beginning of each school year.

13 Evaluations Date evaluation was performed Child s name and date of birth Pertinent medical/background history Standardized test results, including all subtest scores (if applicable)

14 Evaluations cont. Public schools evaluations are valid for 3 years annual update required. Must be age appropriate Test results reported as standard scores, Z scores, T scores, or percentiles

15 Evaluations cont. Age equivalent scores and percentage of delay cannot be used to qualify for services Functional hearing ability of the child must be reported speech therapy IQ scores for children ages 10 and up when language therapy is being addressed

16 Plan of Care must include: Entire plan of care, or pages 1, 2, goals / objectives pertinent to therapy Signature page of the IEP, IFSP, or IPP

17 Progress Notes Child s name Date of service Time in / out Objectives addressed

18 Progress Notes cont. A specific description of therapy services provided, activities and some form of measurement Legible copies Full name and credentials of the providing therapist

19 Prescription Errors that Lead to Denials Check boxes on DMS-640 not checked No Medicaid number documented No minutes &/or duration of therapy Diagnosis doesn t support treatment type Physician did not date &/or sign

20 DMS-640 form Instructions Located on Arkansas Medicaid website, under Therapy Provider Manual Section II: Print out both pages of the DMS-640 form Instructions are on the back of the DMS-640 which can assist you in completing the form accurately.

21 Evaluation Errors that Lead to Denials No evaluation submitted Missing date tests were administered Tests used not on Medicaid approved list without documentation justifying reason. (update 09/01/2008) Test scores non-qualifying

22 Evaluation Errors Continued Missing functional hearing information Missing pertinent medical/background history Two language tests not given (speech therapy)

23 Reconsideration of Denials What is a Reconsideration How to request a Reconsideration

24 Reconsideration of Denials cont. Reconsideration of Therapy Denials for Medicaid Beneficiaries Under the Age of 21 years A reconsideration review is always an option in the event a therapy provider receives a denial notification. For either a medical necessity or utilization denial, the provider is allowed 35 calendar days from the date on the denial letter to submit additional information for reconsideration. The request must include a copy of the denial letter and additional supporting documentation. It is extremely important to remember that only ONE reconsideration review is allowed per denial; therefore, providers should ensure that ALL documentation available for reconsideration of the denial is submitted. Reconsideration requests must be mailed to: QSource of Arkansas Therapy Review 124 West Capitol Ave., Ste.900 Little Rock, AR Records will not be accepted via facsimile or . As in the past, providers may check the status of all mailed records at: QSource is available to provide clarification or answer any questions for Occupational, Physical, and Speech Therapy providers regarding the retrospective review process. For any questions or comments, please contact Kay Ewalt at or review@qsource.org

25 Medicaid Fairness Act / Fair Hearings Date: LTR04TPY Patient Name: Medicaid ID# QSource of Arkansas Control # Provider # Service Dates: Re: Denial of Therapy QSource of Arkansas is under contract with Arkansas Medicaid to review therapy services delivered to Medicaid beneficiaries to determine if those services: (1) are provided economically; (2) only when, and to the extent, medically necessary; (3) meet professionally recognized standards of care; and (4) are supported by documentation in the medical record. [See 42 U.S.C. Sections 1396, 1396a (a) (30) (A), 1320c-5; 42 C.F.R. Sections 456.1, ; Arkansas Medicaid Manual Sections (D), IV-9; Social Security Act Section 1156 (a) (1) (2) (3)]. QSource of Arkansas physician advisors have reviewed the documentation provided by the therapist or therapy clinic and have determined that the therapy provided during the time period mentioned below was not medically necessary. [Drop in procedure codes/dates of service] This determination was based on the following physician reviewer rationale: [Insert rationale here] Your therapy provider has been notified of the specifics of this denial and has been provided an opportunity to provide more information to substantiate the need for therapy. You cannot be billed by the therapy provider for these denied services. In the event you wish to request a hearing to appeal this decision, please note the instructions below which will explain how you may take action. If the denial was upheld by QSource of Arkansas in whole or in part, your request for a hearing must be received within thirty (30) calendar days of the date of this notice. NOTICE TO MEDICAID RECIPIENT: YOU OR YOUR HEALTHCARE PROVIDER MAY APPEAL THIS DECISION. A. The following appeals are available in response to an adverse decision: 1. A beneficiary may appeal on his or her own behalf 2. A provider of medical assistance that is the subject of the adverse action may appeal on the beneficiary s behalf 3. If the adverse action denies a claim for covered medical assistance that was previously provided to a Medicaid-eligible beneficiary, the provider of such

26 Medicaid Fairness Act / Fair Hearings To request a fair hearing, you must do so in writing. Please send your request to: Appeals and Hearings Section PO Box 1437, Slot N401 Little Rock, AR

27 Therapy Review Status System QSource would like to ensure that all therapy providers are aware of the RECON IN PROCESS option located on the QSource Therapy Review Status System webpage. Following a chart denial, this option enables providers to check that submitted reconsideration documentation has been received and is being processed. The website provides the following responses: Chart Not Received Review In Process Approved Partially Approved Denied Recon In Process Recon Approved Recon Denied Recon Partial As in the past, providers will check the status of records at by entering the control number. QSource is striving to meet the needs of therapy providers by continuing to make available the online opportunity to review the status of all submitted records. If you have questions regarding the Therapy Review Status System, please call Kay Ewalt at

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29 Approved Reviews Child qualifies for therapy per Medicaid guidelines Progress notes and billing match Review approved

30 Thank You! QSource of Arkansas Address: 124 W. Capitol, Suite 900 Little Rock, AR Contact: Kay Ewalt, Therapy Review Manager Phone: (501)