Provider Manual Prior Authorization Information

Transcription

1 Prior Authorization Information PRPRE

2 Amendment History Version Version Date Reason for Revision Section Page(s) /20/2013 Initial Release. Includes revised Prior Authorization Forms and incorporates changes to Prior Authorization processes as the result of transition to the new Administrative Services Organization (ASO). All All /14/2014 Update. Includes termination of Charter Oak Health Plan, change to prior authorization requirements for members with OI, and change in time allowed for processing of retrospective authorization requests for inpatient hospital stays /10/2015 Update. Reflects need for providers to submit additional pricing information when requesting authorization for manually priced MEDS items. 1.1, 1.3 5, , 21, 24 II

3 Table of Contents 1.1 Overview Professional and Miscellaneous Prior Authorization Hospital Inpatient Services Chronic Disease Hospital Services Laboratory Services Prior Authorization Radiology Services Prior Authorization III

4 V Overview 4

5 This chapter contains Prior Authorization (PA) information for services requiring authorization of services or goods prior to the service being performed or the goods being delivered. The chapter includes the new DSS standard Prior Authorization Request Form, instructions for completing the form and Prior Authorization submission guidelines. The chapter also identifies the appropriate entity that is responsible for making the Prior Authorization determination. The information in this chapter is important for the proper adjudication of claims submitted by providers that participate in the Connecticut Medical Assistance Program. Prior Authorization means the approval from DSS or its contracted administrative services organization (ASO), for the provision of a service or the delivery of goods from the department before the provider actually performs the service or delivers the goods. To receive reimbursement from the Department of Social Services, a provider must comply with all Prior Authorization requirements. The Department of Social Services has sole discretion to determine what information is necessary to approve a Prior Authorization request. Obtaining PA does not guarantee payment or ensure client eligibility. It is the responsibility of the provider to verify client eligibility for the appropriate date(s) of service. Authorization when Clients have Other Insurance (OI) or Medicare Effective for dates of service May 1, 2014 and forward, providers are required to obtain authorization prior to the service being rendered when the client has OI. Prior authorization is not needed when the client has Medicare as their primary insurance. Dates of services prior to May 1, 2014 can still be submitted to CHNCT for retrospective review if the OI denied or paid less than the Medicaid rate. Providers should submit a completed PA Form, the explanation of benefits (EOB) from the other insurance company and medical records to substantiate the medical necessity of the requested service to CHNCT. PA will be authorized retroactively on a case by case basis and if approved, the PA will be backdated to the date of service. 5

6 1.2 Professional and Miscellaneous Prior Authorization 6

7 V 1.0 Overview The term Prior Authorization (PA) refers to approval from the Department of Social Services (DSS), or the Department of Social Services ASO, for a service or the delivery of goods before the provider actually performs the service or delivers the goods. To receive reimbursement from DSS, a provider must comply with all Prior Authorization requirements. The Department of Social Services has sole discretion to determine what information is necessary to approve a Prior Authorization request. PA does not guarantee payment or ensure client eligibility. It is the responsibility of the provider to verify client eligibility on the date(s) of service. The Department of Social Services requires providers to complete the Prior Authorization Request Form for pre-approval of the following selected services for HUSKY Health clients. All of the Prior Authorization requests in this section are reviewed and processed by the Department s ASO Community Health Network of Connecticut (CHNCT). Note: Prior authorization (PA ) requests for Behavioral Health, Non-Emergent Transportation and Dental services are reviewed and processed by different ASOs. PA instructions for these services can be found via the following links: Behavioral Health: Prior Authorization requests for behavioral health services, those services where a behavioral health diagnosis is the primary reason for the service (diagnosis codes ), must be obtained from Value Options (VO). Please refer to the Connecticut Behavioral Health Partnership (CT BHP) section in Chapter 9. This chapter is available at by selecting Information>Publications and then scrolling down to Chapter 9 Prior Authorization. Non-Emergency Transportation: The Department of Social Services contracts with LogistiCare to coordinate all non-emergency medical transportation services for HUSKY A, HUSKY C and HUSKY D clients. Please refer to the Transportation Services section in Chapter 9 for prior authorization requirements for nonemergency transportation. This chapter is available at by selecting Information>Publications, and then scrolling down to Chapter 9 Prior Authorization. **Note: Non-emergency medical transportation is not a covered service for HUSKY B clients. Dental: Prior Authorization requests for dental services for HUSKY A, HUSKY B, HUSKY C, and HUSKY D clients should be submitted to the Connecticut Dental Health Partnership (CTDHP). Please refer to the CTDHP section in Chapter 9. This chapter is available at by selecting Information>Publications, and then scrolling down to Chapter 9 Prior Authorization Waiver Programs: Prior Authorization Requests for members in the following programs must continue to be submitted to Hewlett Packard (HP): Home Care Program for the Elders Money Follows the Person The prior authorization submission instructions for HP are available by going to and selecting Information>Publications, and then scrolling down to Chapter 9 Prior Authorization>Section 9.2>page 10 The following providers or services have Prior Authorization requirements: Durable Medical Equipment (DME)* Durable Medical Equipment (DME) Customized Wheelchairs* Hearing Aids 7

8 Home Health* (requests for Money Follow the Person and Home Care Program for the Elders must continue to be submitted to HP) Hospice* Laboratory* Medical/Surgical Supplies* Occupational Therapy* Orthotics & Prosthetic Devices* Oxygen* Physical Therapy* Professional/Surgical Services*(when service performed on an outpatient basis) Radiology Services* Speech/Audiology Therapy* Vision Care Services *The providers or service types above with an asterisk indicates that there are additional instructions that apply to these provider or service types on the following pages. The services listed above will be authorized by CHNCT. Requests for authorization can be made via the secure web portal. CMAP enrolled providers may submit requests for the following authorizations via the web: Home Health Care Services Orthotic and Prosthetic Devices Oxygen Medical/Surgical Supplies Hearing Aids Durable Medical Equipment Professional/Surgical Services Physical, Occupational and Speech Therapies performed by independent therapists, rehabilitation clinics and hospital outpatient programs Providers may use the web portal to view the status of their request online, verify eligibility, and attach documents to support requests for authorization. 1. For technical questions (access, user IDs, passwords, connection to system), please call or and choose the prompt for Clear Coverage. 2. For questions on the status of an authorization or clinical questions about an authorization call option #2 for authorizations. Providers may also call in their request for authorization to the Prior Authorization Intake Unit at option 2 or submit the request via fax to the medical ASO at

9 Services Requiring Prior Authorization Benefit and authorization grids providing a general summary of benefits and authorization requirements for the HUSKY Health Program are located on the HUSKY Health Program website. Please refer to either of the following website for information on benefit or authorization requirements: From either of those websites, click For Providers followed by Benefits & Authorizations. For a definitive list of benefits and limitations please review the CMAP fee Schedules and regulations at For fee schedule Information, click on Provider, followed by Provider Fee Schedule Download. For Regulations, click on Information, then Publications and view Chapter 7. How to Obtain Prior Authorization Form for Professional and Miscellaneous Services Providers can obtain the Prior Authorization Request Form by downloading the form from the Web portal at click on For Providers, Providers Bulletins, Updates and Forms and then accessing the Outpatient Authorization Request Form, or by telephoning CHNCT Provider Assistance Center at (in-state toll free) between the hours of 8:00am-7:00pm Monday through Friday, excluding holidays. Where to Send Completed Prior Authorization Form Providers submitting for initial Home Health, Occupational, Physical and Speech/Audiology Requests when the primary reason for the visit is not behavioral health related (diagnosis codes ) must fax their requests to: (203) Note: Prior Authorization requests for home health services must be received prior to the first visit. Authorization requests for service performed after hours, on a weekend or holiday must be received on the next business day. Prior Authorization requests with a behavioral health primary reason for the visit (diagnosis codes ) must be obtained from ValueOptions (VO). The prior authorization submission instructions for Value Options are available by going to and selecting Information>Publications, and then scrolling down to Chapter 9 Prior Authorization>Section 9.5>page 43 Providers submitting for in-patient Hospice Care beyond the fifth day of care and DME urgent requests must fax their requests to: (203) All other providers, including those submitting for reauthorization of Home Health Agency Services with a primary reason for the visit other than diagnosis codes , should fax their requests to CHNCT. (203) Request for changes to existing home health authorizations must be faxed to CHNCT at: (203)

10 For additional detailed instructions for professional or miscellaneous services, please refer to the Instructions for Specific Professional or Miscellaneous Services or Provider Types located below. Upon receiving the completed PA form and all the necessary supporting information, CHNCT reviews the information and either approves or denies the PA request. 10

11 ! OUTPATIENT PRIOR AUTHORIZATION REQUEST FORM BILLING PROVIDER INFORMATION MEMBER INFORMATION 1. Medicaid Billing Number: 7. Member ID Number: 2. Billing Provider Name: 8. Member Name (Last, First): 3. Address: 9. Address: 4. City, State Zip: 10. City, State, Zip: 11 Fairfield Blvd., Suite 1 Wallingford, CT Fax a. Contact Name/Telephone Number: 11. Date of Birth (MM/DD/YYYY): 12. Sex: Male Female 5b. Contact Fax Number: 13. Primary Diagnosis Code: 6. Name, Address and Medicaid ID Number of Referring MD: 14. Estimated Delivery Date (DME ONLY) (MM/DD/YYYY): 15. Authorization Service Requested (Check only one from the list below): Customized Wheelchair DME Genetic Testing/Lab Services Hearing Aids Home Care Program for Elders Initial Re-Auth Home Health Initial Re-Auth Hospice Medical/Surgical Supplies Money Follows the Person (MFP) Occupational Therapy Orthotic & Prosthetic Physical Therapy Oxygen Initial Re-Auth Devices Initial Re-Auth Professional/Surgical Services Speech Therapy Initial Re-Auth Vision Care Services Independent Chiropractic Evaluation Initial Re-Auth 16. Dates of Service 17. Line Item Start Date (MM/DD/YYYY) End Date (MM/DD/YYYY) Place of Service Proc/RCC Code/List 19. Mod Mod Mod Units 23. Total Cost Dollars 24. Clinical Statement: Include a prognosis and rehabilitation potential in the space provided below. A current plan of treatment and progress notes as to the necessity, effectiveness and goals of service requested must be attached. Signature of Clinical Practitioner: Date: 25. Certification Statement: This is to certify that the requested service, equipment or supply is medically indicated and is reasonable and necessary for the treatment of this patient and that a prescribing practitioner signed order is on file (if applicable). This form and any statement on my letterhead attached hereto has been completed by me, or by my employee and reviewed by me. The foregoing information is true, accurate and complete, and I understand that any falsification, omission or concealment of material fact may be subject me to civil and criminal liability. Signature of Billing Provider:! This form may be filled out by typing in the field, or printing and writing in the fields. Please fax completed form to CHNCT at Please call CHNCT s provider line at with any questions. Date: 11

12 ! 11 Fairfield Blvd., Suite 1 Wallingford, CT Fax PRIOR AUTHORIZATION REQUEST FORM INSTRUCTIONS # Field Name Description 1 Medicaid Billing Number Enter the provider s NPI number or the CMAP identification number (AVRS#) that has been issued to the provider upon enrollment in the Medicaid Program, if the provider is unable to obtain an NPI. 2 Billing Provider Name Enter the billing provider s name. 3 Address Enter the billing provider s street address. 4 City, State Zip Enter the billing provider s city, state and zip code. 5a Contact Name/ Enter the billing provider s contact name and telephone with area code. Telephone Number 5b Contact Fax Number Enter the billing provider s fax number with area code. 6 Name, Address and Enter the full name, address and CMAP identification number (AVRS#) of the Referring MD Medicaid ID Number of Referring MD 7 Member ID Number Enter the member identification number as it appears on the member s CONNECT Card or as obtained from the Automated Eligibility Verification System (AEVS). 8 Member Last Name Enter the member s name as it appears on the member s CONNECT Card or from AEVS. 9 Address Enter the member s address. If the member resides at a facility or institution, document that information in this field. 10 City, State Zip Enter the member s city, state and zip code. If the member resides at a facility or institution, enter that facility or institution s city, state and zip code. 11 Date of Birth Enter the member s date of birth in the MM/DD/YYYY format. 12 Sex Select the member s gender. 13 Primary Diagnosis Code Enter the member s primary diagnosis code. 14 Estimated Delivery Date Enter the estimated date of DME delivery in the MM/DD/YYYY format. 15 Authorization Service Requested Select the appropriate prior authorization type being requesting, checking only one. For outpatient therapy requests (occupational, physical and speech), be sure to indicate whether requested services are for initial or re-authorization. For Home Health and Home Care Program for Elders requests, be sure to indicate whether requested services or for initial, re-authorization or MFP requests. For independent chiropractic service requests please be sure to indicate whether requested services are for evaluation, initial or re-authorization. 16 Dates of Service Enter the requested start and end dates for the requested services in the MM/DD/YYYY format. 17 Place of Service Enter the place of service where the procedure or service will be provided; no code is needed just a description of the place of service. 18 Proc/RCC Code/List Enter the code/list for the procedure/revenue center code (RCC) for the service. Note for Home Health Providers, Independent Therapists, Physician Therapy Groups and Rehab Clinics Note for Genetic Testing Please refer to following link for codes and instructions: Outpatient Authorization Request Form Instructions (If you are on a PC, ctrl + click the link to download the instructions. If you are on a Mac, single click the link.) In Line Item #1 enter the new 2012 Molecular Pathology CPT Code, e.g., , which will have 1 unit (Field #22). In Line Item 2-8 enter the stacked codes for the test being requested, e.g., 83890, 83891, etc., one code per line, the number of units for each code entered in Field #22. Where more than one 2012 CPT code in the range is being requested, append an attachment providing code, the linked stacked codes, and units. If no new code, leave line #1 blank Mod 1, Mod 2, Mod 3 Enter first, second and third modifier code(s) for the procedure required, if applicable. 22 Units Enter the number of units requested. 23 Total Cost Dollars Enter the total amount, in dollars, for the units of service requested if applicable. 24 Clinical Statement/ Signature of Clinical Practitioner 25 Certification Statement/ Signature of Billing Provider The Clinical Practitioner should enter a comprehensive statement indicating the clinical necessity, the plan of treatment, and the desired outcome for the services requested. The Clinical Practitioner should sign and date the PA Request Form. Signature stamps are unacceptable. For initial home health and therapy requests, this signature is optional. For general inpatient hospice requests beyond 5 days, explain why pain control or acute or chronic symptom management cannot be managed in other settings. For Medicaid members only: For hospice services that exceed a period of 12 months, explain why the continuation of the hospice benefit is clinically indicated for this patient given that hospice services are generally indicated for clients with a life expectancy of 6 months or less. Enter the full name signature for the billing provider and corresponding date. Signature stamps are unacceptable. A request form without original signature will be rejected. Field 18 Footnote for Outpatient Authorization request Form Instructions: 12

13 Rehabilitation Clinic, Independent Therapy, Physician Therapy and Home Health Prior Authorization Instructions Rehabilitation Clinics: When requesting authorization for therapy services performed in a rehab clinic, please request authorization using code group number and number of units. Example: If a physical therapist will be performing units and units, initial request would be made using Code Group RCPTI with 4 units. Claim would still be submitted with CPT Code(s), Modifier(s) and number of units. Code Group Benefit CPT Codes/Modifiers RCSTI ST Initial 92507, 92508, 92521, 92522, 92523, 92524, RCSTR ST Re- authorization RCPTI PT Initial 29125, 29126, 29131, 29260, 29280, 29540, 64550, 90901, 97001, 97002, , 97026, , , , 97542, , (all RCPTR PT Re-authorization with modifier GP or all with modifiers GP and 59 ) RCOTI RCOTR OT Initial OT Re-authorization 29125, 29126, 29131, 29260, 29280, 29540, 64550, 90901, 97003, 97004, , 97026, , , , 97542, , (all with modifier GO or all with modifiers GO and 59) For services performed in a rehab clinic not included in the table above (HCPCS codes 94664, S5105, S9446 and T1025), please request authorization using the applicable CPT or HCPCS code. If services described by CPT/HCPCS codes and V5010 are performed more than once per year by the same provider, prior authorization will be required. Submit requests using the applicable CPT or HCPCS code. Audiology evaluations in excess of one per year will require prior authorization. Please submit authorization requests using the applicable CPT codes as listed in the DSS Rehab Clinic Fee Schedule. Independent Therapy Providers: When requesting authorization for therapy services performed in an independent setting, please request authorization using code group number and number of units. Example: If a physical therapist will be performing units and units, initial request would be made using Code Group INPTI with 4 units. Claim would still be submitted with CPT Code(s) and number of units. Code Group Benefit CPT Codes INSTI ST Initial 92507, INSTR ST Re-authorization INPTI PT Initial 97002, , 97530, 97542, 97760,

14 INPTR PT Re-authorization INOTI OT Initial 97004, , 97530, 97542, 97760, INOTR OT Re-authorization Physician Therapy Providers: When requesting authorization for therapy services performed by a physician group, please request authorization using code group number and number of units. Example: If physician will be performing units and units, initial request would be made using Code Group MDPTI with 4 units. Claim would still be submitted with CPT Code(s) and number of units. Code Group Benefit CPT Codes MDPTI Physician Therapy Initial MDPTR Home Health: Physician Therapy Re-authorization , When requesting authorization for skilled home health services, please request authorization using code group letters and number of units: Example: If a member is prescribed medication administration for 3 months, a typical request would include two skilled nursing visits and twice daily medication administration visits, request would be made using Code Groups SN - 2 units and MA units. Claim would still be submitted with HCPCS Code(s), Modifier(s) and number of units. Code Group Benefit HCPCS Codes/Modifiers SN Skilled Nursing S9123, S9124, S9123-TT, S9124-TT CN Complex Nursing S9123-TG, S9124-TG TE, S9123-TG TT, S9124-TG TE TT ON Obstetrical Nursing S9123-TH, S9124-TH, S9123-TH TT, S9124-TH TT MA Medication Administration T1502, T1502-TT, T1503, T1503-TT **When requesting authorization for the services of a home health aid or services performed by physical therapists, occupational therapists and speech therapists in a home setting, please request authorization using code T1004 and number of units or revenue codes 421, 431 or 441 and number of units. ***Extended nursing is not a covered benefit for Husky B clients. 14

15 Inquiries Regarding Providers with questions regarding the PA process for services listed above Service Requests should contact CHNCT provider services at (800) Approval Denial Correction Procedures When a PA request is approved, an approval letter is sent to the referring provider, the rendering provider and the client indicating the details of the prior authorized service. When a PA request is denied, a denial letter is sent to the referring provider, the rendering provider and the client indicating the reason(s) for the denial. If the form is not completed correctly, CHNCT returns the request for authorization, and the provider is asked to resubmit a corrected, completed form. The provider must make the corrections indicated and resubmit all supporting documentation. Once a PA letter is sent from CHNCT the provider should verify the information on the PA form to confirm the approval or reason for denial. If any information on the PA letter conflicts with information on the provider s copy of the original PA form, the provider should contact CHNCT at Appeals If a PA request is denied, the client has the right to appeal the decision and request a Fair Hearing within 60 days from the date of notice. A request for a Fair Hearing must be made in writing to the following address: Department of Social Services Administrative Hearings and Appeals 25 Sigourney Street Hartford, CT Retroactive Authorization Retroactive authorization may be granted for clients who have applied for HUSKY A, HUSKY B, HUSKY C, or HUSKY D eligibility after services are performed. The provider must complete and send a PA Request Form to CHNCT indicating "Pending on date of service" in the Clinical Statement field (field # 24). Medicare and/or Third Party Liability If a provider chooses to submit Prior Authorization paperwork for a HUSKY A, HUSKY B, HUSKY C, or HUSKY D client who also has Medicare or Third Party coverage, the request will not be denied on the basis that Medicare or Third Party coverage determination has not been made prior to the submission of the request for Prior Authorization. 15

16 Instructions for Specific Professional or Miscellaneous Services or Provider Types Chiropractic Services Medically necessary independent chiropractic services are available for HUSKY Health members under the age of 21 only as EPSDT special services, as well as for HUSKY B members with prior authorization. Prior authorization must be requested and approved before providing services under EPSDT special services or HUSKY B, otherwise the claim will deny. When requesting prior authorization under EPSDT special services or HUSKY B the following must be submitted: An order provided by a physician licensed pursuant to Sec of the Connecticut General Statutes, APRN, or PA who is enrolled with the CT Medical Assistance Program A description of the outcomes of any alternative measure tried; Any other documentation reasonably requested by the department or any designated agent of the department which may be required to make a decision Fax all requests, including the order from the licensed physician, APRN, or physician assistant to CHNCT at (203) As outlined in PB , for dually eligible HUSKY Health members, independently enrolled chiropractors may submit claims for the deductible or co-insurance as outlined in Chapter 5, Claims Submission - Section 5.7. Please note: if Medicare denies a chiropractic claim for a dually eligible member, these services will not be covered under the HUSKY Health program. Durable Medical Equipment Estimated Delivery Date FAX Requests Providers are required to include an estimated delivery date when submitting a Prior Authorization request for all durable medical equipment, allowing CHNCT up to twenty business days to process the request. CHNCT in turn, shares that estimate with the client so that expectations for service delivery can be clear. Durable Medical Equipment providers may fax a PA Request Form to CHNCT at (203) to facilitate the client s discharge from an institution or to prevent hospitalization. Durable Medical Equipment requiring prior authorization For all Durable Medical Equipment (DME) that requires prior authorization, the following must be submitted with the request: Prior Authorization Request Form Physician s prescription The request meets the definition of Durable Medical Equipment (DME): [Reference: Regulations Connecticut State Agencies 17b (5)] 16

17 o can withstand repeated use; o is primarily and customarily used to serve a medical purpose; o generally is not useful to a person in the absence of an illness or injury; and o is nondisposable The request is supported by a physician s prescription. The DME provider submits a detailed product description and quotation including manufacturer, model/part number, product description, HCPC code, unit(s), quantity, Medicaid allowable price, actual acquisition cost (AAC) and manufacturer s suggested retail price (MSRP). The clinical documentation must include an explanation why the requested DME is medically necessary for the client s specific clinical situation includes establishing the severity of the individual's condition, the immediate and long-term need for the equipment, and the therapeutic benefits that the client is expected to realize from its use. A claim of therapeutic effectiveness or benefit based on speculation or theory alone cannot be accepted, as indicated in the definition of medical necessity. When restoration of function or bodily function is cited as a reason for use of DME, the exact nature of the deformity or medical problem should be evident from the clinical evidence submitted and how the DME will restore or improve the clients bodily function. This documentation must validate that the client received an objective, onsite evaluation by a licensed health care profession, including the provision of actual DME trials and simulations and a comparison of various DME options If the request is for a replacement, the following information is required: 1) Specifications of current DME including manufacturer, model, and date of purchase; and 2) the reason for replacement; e.g., change in physiological/functional status; change in size where current DME cannot be modified; irreparable condition of the current DME. The DME request must meet the criteria for medical necessity: For purposes of the administration of the medical assistance programs by the Department of Social Services, "medically necessary" and "medical necessity" mean those health services required to prevent, identify, diagnose, treat, rehabilitate or ameliorate an individual's medical condition, including mental illness, or its effects, in order to attain or maintain the individual's achievable health and independent functioning provided such services are: (1) Consistent with generally-accepted standards of medical practice that are defined as standards that are based on (A) credible scientific evidence published in peer-reviewed medical literature that is generally recognized by the relevant medical community, (B) recommendations of a physician-specialty society, (C) the views of physicians practicing in relevant clinical areas, and (D) any other relevant factors; (2) clinically appropriate in terms of type, frequency, timing, site, extent and duration and considered effective for the individual's illness, injury or disease; (3) not primarily for the convenience of the individual, the individual's health care provider or other health care providers; (4) not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the individual's illness, injury or disease; and (5) based on an assessment of the individual and his or her medical condition. [Reference: CHAPTER 319v MEDICAL ASSISTANCE; Section 17b-259b re: definition of "medically necessary" and "medical necessity" of Connecticut State 17

18 Agencies] All final determinations of medically necessity must be based upon this statutory definition. Orthotics Other than foot orthotics and FES Walkaide requests must submit the following: A documented comprehension evaluation by either Connecticut licensed/certified orthotist (C.O), or licensed/certified prosthetist-orthotist (C.P.O.). This documentation must explain the medical necessity of each item requested and must include the client s current use of orthotics and other DME, as relevant to the specify request. This explanation must be based on and related to the Client s medical condition and their typical activities of daily living. Foot Orthotics Prior authorization is required for foot orthotics including inserts, arch supports, and modifications to orthopedic shoes. Foot orthotics can be considered medically necessary for clients who meet the specific criteria and for whom other treatment methods have been ruled out prior to recommending foot orthotics, as documented in the Foot Orthotics Clinical Guideline located on the HUSKY Health Program website at FES Walkaide Prior authorization is required for FES Walkaide requests. FES Walkaide(s) can be considered medically necessary for clients who meet the specific criteria and for whom other treatment methods have been ruled out prior to evaluating for a FES Walkaide, as documented in the FES Walkaide Clinical Guideline located on the HUSKY Health Program website at Determinations of coverage of FES for the foot and ankle will be made in accordance with the DSS definition of Medical Necessity. Coverage determinations will be based upon a review of requested and/or submitted case-specific information to include evidence-based evaluations, both qualitative and quantitative, performed in the individual s customary environment(s) (including use on varied terrain). A two-week trial will be utilized to assess patient compliance prior to purchase. Information Required for Initial Review: 1. Prescription/ signed letter of medical necessity; 2. Completed State of Connecticut, Department of Social Services Outpatient Prior Authorization Request Form; 3. Current list of ambulatory aids/orthotics with current skill level for each; 4. Patient s self-assessment of current health status, functional abilities, level of activity and level of comfort; 5. Treatment history; 6. Clinical assessment to include: Primary diagnosis leading to foot drop Possible contraindications (e.g. seizures, pacemaker) Current indications Mini-Stim assessment 18

19 Current range of motion Current muscle strength Observational gait assessment (swing and stance phase) Gait speed (with and without FES device) Timed walk endurance evaluation (with and without FES device) in all three evaluation sessions and 7. Other pertinent information as requested by CHNCT. Review Process: 1) Requests for the FES device will be reviewed by CHNCT in accordance with procedures in place for reviewing requests for DME. 2) If approved, a rental trial period will allow the member to use the device for 14 days within their customary environment(s). 3) After the 2 week period, the member will return to the DME provider for an evaluation of the benefits/limitations of the trial and the level of compliance with the device. The resulting data will be compared to the data obtained during the initial evaluation session. 4) The DME provider may request a prior authorization for an additional 2-week rental, pending the functional results of the first 2 week trial. 5) CHNCT will review the results of the entire evaluation trial period after the rentals are complete to determine if the purchase of the FES device will be authorized. Determinations for medical necessity are based upon a comparison of the baseline data and two subsequent evaluations, given two 2-week trials within the member s customary environment(s). 6) The rental fee for each two-week period is typically $ per device. This fee will be deducted from the purchase price, if CHNCT approves the purchase. Durable Medical Equipment - Customized Wheelchairs under Department of Social Services Customized Wheelchair in Nursing Facilities regulation (Sec d-46) Authorization Requirements Prior Authorization requests for the purchase of a customized wheelchair for patients in a Nursing Facility or ICF/MR must include: Prior Authorization Request Form Customized Wheelchair Prescription Form, W-628 completed by the 1) Patient s attending physician, 2) A physician who is board certified in orthopedics or physiatry, 3) A Connecticut licensed physical therapist or a licensed registered occupational therapist, and 4) A representative of the professional nursing staff of the facility (R.N. or L.P.N.) Documented history and physical examination performed by the attending physician within one (1) year prior to receipt of the request, and attending physician notes within ninety (90) days of receipt of the request, if necessary. (If history and physical examination are done within ninety (90) days of receipt of request, additional notes are not required). A documented examination by either an orthopedic physician or a physiatrist. The examinations shall be part of the facility medical record as well as the submission to the Department and must have been completed within 3 months prior to the date of receipt of the request for a customized wheelchair. The examinations must document the results of 19

20 films and/or x-rays, as deemed appropriate by the attending physician and the physiatrist or orthopedic physician. A comprehensive rehabilitative assessment by either a physical therapist or occupational therapist, as it relates to the custom wheelchair request. The examinations shall be part of the facility medical record as well as the submission to the Department and must have been completed within 3 months prior to the date of receipt of the request for a customized wheelchair. Documentation by the evaluating occupational or physical therapist explaining the medical necessity of each item ordered on the W-628 form. The specification sheet for the wheelchair and each accessory/component must include an explanation of why the wheelchair and each custom accessory are necessary. This explanation must be based on and related to the Member s medical condition. When/if the Member previously received a custom wheelchair under Department of Social Services Customized Wheelchair in Nursing Facilities regulation (Sec d-46) documentation of the current 24-hour positioning plan must be submitted with the new wheelchair request. Additionally: Any modification with a price of $1000 or more requires the added signature of the physiatrist or orthopedist in addition to a therapist, attending physician and nurse on the W-628 form. For other modifications, signatures of a therapist, attending physician and nurse are sufficient. In situations where the original component is not usable by the client, the Department requires the replacement item with the same procedure code to be swapped at no cost to the Department within 90 days of purchase. For example, if the initial headrest ordered is deemed to be inappropriate for the client, the replacement headrest should not be billed. In situations where the replacement component required necessitates the use of a different procedure code, it is viewed as a modification of the original prior authorization (PA) and the Department should be billed for the net difference between the cost of the original and the replacement components. Please note that the nursing facility or ICF/MR, not the vendor, is responsible for: 1. identifying potential recipients who may require customized wheelchairs; 2. initiating and conducting an interdisciplinary team (IDT) assessment, incorporating this assessment into the patient care plan and completing the W628 form; 3. upon completion of 1 and 2, contacting the wheelchair vendor and ordering the custom wheelchair as appropriate; 4. implementing a 24 hour positioning plan; 5. implementing a monitoring program that includes monthly nursing progress notes and quarterly therapy progress notes; 6. documenting the in-service training; and 7. maintaining all of the above in the medical record. 20

21 The vendor should obtain quotes from manufacturers and submit a prior authorization (PA) request to CHNCT only after the prescribing practitioner has signed the prescription that details the specifications of the custom wheelchair. The DME provider submits a detailed product description and quotation including manufacturer, model/part number, product description, HCPC code, unit(s), quantity, Medicaid allowable price, AAC (actual acquisition cost) and MSRP. PA requests must be faxed to CHNCT at (203) Overview W-628 Form The Customized Wheelchair Prescription form, W-628 accompanies the comprehensive patient assessment submitted by the Interdisciplinary Team (IDT). The provider may obtain the Customized Wheelchair Prescription form from the Department of Social Services. This one page prescription form is to be completed by the IDT and the provider, and submitted as described below. How to Obtain Form W-628 The form and instructions are provided in this section of the Provider Manual and can also be downloaded or printed from the Web site under Information > Publications, and then accessing the W- 628 form under the Forms section. Forms>Authorization/Certification Forms. Where to send the Completed Form Providers may fax the completed Customized Wheelchair Prescription form, W-628 with the comprehensive patient assessment, other required documentation, and the Prior Authorization request form to CHNCT at (203)

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23 Instructions for Completing the Form The following page provides detailed instructions for completing the Customized Wheelchair Prescription form, W-628. No Name Description 1. PATIENT NAME/ADDRESS Enter the client s name (first name, middle initial, last name), and full address. 2. PATIENT DIAGNOSIS Enter all diagnoses pertaining to the prescribed equipment. 3. FACILITY NAME Enter the complete name of the facility where the client resides. 4. PATIENT MEDICAL I.D. NO. Enter the client s 9-digit Connecticut Medical Assistance Program ID number exactly as it appears on the CONNECT Card or as communicated by the Automated Eligibility Verification System (AEVS). 5. D.O.B. Enter the patient s date of birth using the MM/DD/CCYY format. 6. LENGTH OF NEED Enter the length of time the wheelchair is needed. 7. WHEELCHAIR DESCRIPTION IN DETAIL 8. DATED SIGNATURES OF ALL IDT MEMBERS WITH APPROPRIATE TITLES ARE MANDATORY Enter the full description of the wheelchair, including all individual components, and any specific changes or adaptive improvements that are necessary to meet the client s needs. Each Interdisciplinary Team (IDT) member must enter their printed name and title with signature and date on the corresponding line provided. Addresses of both signing physicians are also required. 9. WHEELCHAIR PROVIDER NAME 10. AUTHORIZATION REQUEST NO. Not required. This section to be completed by the wheelchair dealer. Enter the name of the company supplying the wheelchair. 23

24 Durable Medical Equipment - Customized Wheelchairs for Clients living at home Authorization Requirements Prior Authorization requests for the purchase of a customized wheelchair for patients living at home must include: Prior Authorization Request Form A documented comprehensive rehabilitative examination by either Connecticut licensed physical therapist or licensed occupational therapist, as it relates to the custom wheelchair request. Documentation by the evaluating occupational or physical therapist explaining the medical necessity of each item requested. The specification sheet for the wheelchair and each accessory/component must include an explanation of why the wheelchair and each custom accessory are necessary. This explanation must be based on and related to the Client s medical condition and their typical mobility-related activities of daily living. A evaluation/assessment by the physical or occupational therapist must accompany the request. The evaluation must include: Documentation that the wheelchair is able to be maneuvered within the confines of the living space. Trial of the proposed wheelchair/similar wheelchair by the Member and must demonstrate that the client has the cognitive ability to operate the proposed wheelchair in the home. Documentation that comparability of various mobility devices has been considered. The evaluation must be conducted within six (6) months prior to the date of the request for a custom wheelchair for members who reside in the community. A physician s prescription dated with 6 months of the prior authorization request. Additionally: In situations where the replacement component required necessitates the use of a different procedure code, it is viewed as a modification of the original prior authorization (PA) and the Department should be billed for the net difference between the cost of the original and the replacement components. The vendor should obtain quotes from manufacturers and submit a prior authorization (PA) request to CHNCT only after the prescribing practitioner has signed the prescription that details the specifications of the custom wheelchair. The DME provider submits a detailed product description and quotation including manufacturer, model/part number, product description, HCPC code, unit(s), quantity, Medicaid allowable price, AAC (actual acquisition cost) and MSRP. PA requests must be faxed to CHNCT at (203) Home Health Services Home Health providers and Access Agencies must contact ValueOptions (VO) for services to Husky Health, including Waiver and Money Follows the Person (MFP), requiring PA when the primary diagnosis necessitating 24

25 treatment is between diagnosis codes Providers may call the Connecticut Behavioral Health Partnership (CT BHP) at for additional information. All Home Health Care requests for medical services (other than diagnoses ) are authorized by CHNCT. The following information is related to Home Health Medical Services authorized by CHNCT: Initial Authorization Home Health providers must fax a completed PA form to CHNCT at (203) to obtain authorization to begin home health services. Providers must be sure to use the updated PA form which can be obtained online at to indicate that the PA request is an initial request in field 15 of the PA form and include supporting clinical documentation to support the requested service. Home Care Prior authorization requests are submitted to CHNCT via either: Clear Coverage secure web portal Phone (Monday through Friday from 8 a.m. to 7 p.m.), or Fax at utilizing the Authorization Request Form, which can be found online at Extension of Treatment Home Health providers must complete the PA Request Form and fax that request to CHNCT at (203) when requesting an extension of treatment after the initial authorization. Providers must be sure to use the updated form to indicate that the PA request is a reauthorization request in field 15 of the PA form and include documentation to support the clinical statement. The PA Form must be submitted one month prior to the completion of the authorized service and may be granted for up to one year. Providers should review their PA online at using their secure provider ID and password to determine if their request has been approved, denied or modified. Providers will receive a written Notice of Action in response to their request. Modification in Treatment To request an increase in services or a change in treatment during the current authorized time period, or to submit clinical documentation to support requests for an increase or change in home care services, the provider must fax their request/supporting documentation to (203) This must be done prior to the initiation of the modified plan. Providers DO NOT have to forward the paper PA Request Form to CHNCT.. A written Notice of Action will be sent to the provider confirming the approval or denial of the request. Providers are reminded to review the status of their PA via their provider secure Web account to ensure all requests have been entered prior to claim submission. Hospice Care Authorization Prior Authorization is required for General Inpatient Care (GIP) beyond the fifth day of care and for hospice services for HUSKY A, HUSKY B and HUSKY D clients that exceed a period of twelve months. Note: For Hospice Services for dually eligible clients that exceed a period of 12 months, providers must submit an extension for hospice care online transaction via the Hospice provider s secure Web account. Detailed procedures can be found in Chapter 8.2 of the Hospice Provider Manual. 25

26 Written Notification Fax Notification Instructions for Field 24 All Hospice transactions for Husky Health clients must be submitted online via the Hospice provider s secure Web account. For extensions of General Inpatient Care which may be time sensitive in nature, providers must fax their PA requests to (203) In field 24 on the PA form, for GIP beyond 5 days, explain why pain control for acute or chronic symptom management cannot be managed in other settings. For hospice services for Husky Health clients that exceed a period of 12 months, explain why the continuation of the hospice benefit is clinically indicated for this patient given that hospice services are generally indicated for s with a life expectancy of 6 months or less. This explanation is in lieu of the customary clinical statement. Medical/Surgical and MiscellaneousSupplies Prescription Requirement Medical /Surgical and miscellaneous supplies in excess of the monthly quantity limits on the DSS fee schedule require Prior Authorization. All services provided continue to require a prescription from a prescribing practitioner, even if Prior Authorization is not required for provision of a product or service. A detailed prescription signed by a physician who specifies the need for that product or service must still be obtained by the MEDS provider before the product or service is provided. The Department may request a copy of the prescription at any time. Products or services provided to clients have been, and continue to be, subject to Department audit. Prior authorization of diapers and incontinence supplies is required for Husky A, C and D members between the ages of 3-12 years. Prior authorization is required for clients 13 years of age and over for supplies which exceed the monthly quantity limits. Diapers and incontinence supplies are not a covered benefit for children ages 0-2. Diapers and incontinence supplies are not covered for clients enrolled in the Husky B Program, regardless of age. All requests will be reviewed based on the DSS definition of medical necessity and must be in direct accordance with a signed prescription from the member s ordering physician. Supplies that are authorized by CHNCT must be purchased within six (6) months of the date of authorization. Occupational, Physical, and Speech Services Initial Authorization HUSKY B Clients Occupational, Physical, and Speech Therapy providers should fax a completed PA form to CHNCT at (203) to obtain authorization to begin these therapy services. The PA request form must be signed by the individual completing the form or by the prescribing provider when there is no supporting clinical documentation with the signature of the prescribing provider. Initial Therapy PA requests are not accepted via telephone. Providers must be sure to indicate that the PA request is an Initial request. The PA may be granted for up to three months. Upon receiving prior authorization approval,providers will receive a written Notice of Action in response to their faxed request. HUSKY B clients are restricted to a 60 day plan of care. PA is required for all procedure codes. 26