1 Innovative Resource Group d/b/a Innovative Resource Group, Inc. d/b/a Improving the health of those we serve. We are a specialty health services company that focuses on communication and technology to develop a more effective and efficient system of care for West Virginia. We work in conjunction with the Bureau for Medical Services, the Bureau for Children & Families, and the Bureau for Behavioral Health & Health Facilities The APS-West Virginia Office is located in Charleston, West Virginia, with field staff working throughout the state.
2 CONTRACT HISTORY August December 2009 Present APS Healthcare Administrative Services for Medicaid Behavioral Health O/P, MR/DD Waiver, BCF Socially Necessary Services & BHHF Charity Care & Federal Block Grant Reporting WVMI Utilization Management of Medicaid Medical Services Behavioral Health Inpatient, Aged & Disabled Waiver, and Nursing Home Admission & Re-Evaluation Screenings APS Healthcare DHHR combined the APS & WVMI Contracts into one inclusive Contract, which was awarded to APS in late 2009: Medicaid Medical & Dental Services Medicaid Behavioral Health In/Outpatient Medicaid MR/DD Waiver Program Medicaid Aged & Disabled Waiver Program Medicaid & Non Medicaid Nursing Home Bureau for Children & Families: Socially Necessary Services & Out of State Services BHHF Charity Care, Block Grant Reporting and Select Administrative Services All programs are fee for service, not risk based.
3 OVERVIEW OF PROGRAM APS Healthcare is implementing a Direct Data Entry system (DDE) for all areas of medical necessity review. Prior Authorization Requests will be submitted through the DDE system Medical Care Connection or by faxing updated UMC forms that mimic the DDE requirements.
4 AUTHORIZATION RULES Requirements include all data elements for submission of Prior Authorizations by review area per specifications approved by BMS. Requirements are derived from the BMS Manual Chapters/UMC forms and review criteria. Medical CareConnection data elements include required fields and criteria specific fields to improve accuracy and completeness of submissions. NOTE: Utilizing existing clinical review protocols, criteria, and manual requirements to prevent disruption to the service delivery system. These will be updated as criteria, manual chapters and guidelines are updated.
5 Areas of Medical Review Medical Necessity Reviews will be conducted by the UMC in the following areas: Inpatient Services Inpatient Medical Rehabilitation <21 Cardiac Rehab Pulmonary Rehab Chiropractic Dental and Orthodontic Services Durable Medical Equipment (DME) Home Health Hospice Private Duty Nursing Lab Radiology Imaging Occupational Therapy Physical Therapy Speech Therapy Audiology Outpatient Surgery Podiatry Vision Out-of-Network Services Orthotics/Prosthetics
7 WV Medical CareConnection - Provider Portal Provider Portal is the mechanism by which DDE requests for prior authorization are made The system allows the provider logging in to perform actions based on their user role and provider type (e.g. DME provider can make DME requests only but Hospital may be able to make many types of requests based on the services they provide) Business rules prompt the appropriate workflows based on the provider type and the services requested Validation rules ensure mandatory information is complete before submission Requests submitted via DDE go directly to the appropriate WVMI work queue and are reviewed on a first in/first out basis (requests are date and time stamped upon submission)
8 Eligibility Check It is responsibility of provider to verify Medicaid eligibility and type of Medicaid coverage ( e.g. MCO/PAAS/Traditional) APS will check member eligibility for the requested service start date and provider eligibility per a file from Molina
9 Benefits of DDE Efficiencies in process, provider input time and future submissions for same member Decreased physician time and denials Faster receipt of prior authorization resolutions Makes tracking much easier
10 Log-in Screen
11 Home Screen- Welcome Page
12 Search Member Screen
14 Create New Request
15 Demographic Screen
16 Provider Screen
17 Administrative Screen
18 Service Selection Screen
19 Diagnostics Screen
20 Diagnosis Screen
21 Evaluation Screen
23 Submit to APS
24 Means of Submission Division Direct Data Entry Cardiac & Pulmonary Services Y Y N Fax Phone Postal * Chiropractic Y Y N * Dental & Orthodontics Y Y N * Durable Medical Equipment Y Y N Except Apnea and Nebulizers for Age 3 and under Home Health/Hospice/PDN Y Y N Inpatient Rehab <21 Y Y N Inpatient Services Y Y N Except Urgent Lab/Imaging/Radiology Y Y N ** Medical Case Management N/A N/A N/A Orthotics & Prosthetics Y Y N Out-of-Network Y Y N Outpatient Surgery Y Y N Physical/Occupational Therapy Y Y N Podiatry Y Y N Speech & Audiology Y Y N Vision Y Y N *NOTE When materials for the prior authorization request cannot be sent by other means (e.g. x-rays, dental molds, etc.)
25 WVMI Medical Necessity Review Reviews are submitted via DDE or fax DDE will validate the information for submission Request forms submitted via fax must be legible & complete or will be returned Only medically urgent reviews will be accepted via phone
26 Definition of Medically Urgent Case Review a) a delay could seriously jeopardize the life or health of the consumer or, b) the ability of the consumer to regain maximum function or, c) in the opinion of a physician with knowledge of the consumer s medical condition, would subject the consumer to severe pain that cannot be adequately managed without the care or treatment that is the subject of the case.
27 Provider Registration First groups to register are: Inpatient Acute Services, Inpatient Rehab <21, PT, OT, Speech & Audiology Registration is necessary to receive and view prior authorizations Provider Type Registration Testing Implementation/ Go-Live Acute Inpatient October 2011 Inpatient Rehabilitation<21 Occupational Therapy Physical Therapy Speech Audiology All referring and Service Providers- August/September 2011 All referring and Service Providers- August/September 2011 All referring and Service Providers- September 2011 All referring and Service Providers- August/September 2011 All referring and Service Providers- August/September 2011 All referring and Service Providers- August/September 2011 September 2011 September 2011 October 2011 Maintenance Post-go-live Post-go-live October 2011 November 2011 Post-go-live October 2011 November 2011 Post-go-live November 2011 November 2011 December 2011 December 2011 Post-go-live Post-go-live
28 WHAT TYPES OF USER ROLES CAN I ELECT TO HAVE FOR MY ORGANIZATION? Organization Manager: at least one individual with this role must be designated. This user type can add and delete users for the organization, and can perform administrative functions within the application for the organization as well as perform all of the functions of other user roles. UM Manager: This user role can perform oversight functions for provider users who only have read, write privileges and can submit requests to APS. This user role can also provide oversight functions related to management and tracking of UM requests for those areas of the organization to which they have been given access. Provider: Can create, submit (if designated), request modification (if so designated) and search requests they have submitted. This user only has access to those records that they have created or that are assigned to them by a UM Manager. Other Users: Nurse/consultant Reviewer, Physician Reviewer, BMS User
29 PA Notification Files A flexible method of informing providers of the prior authorization resolution that can be utilized by billing departments to import authorizations into existing systems. Providers are notified electronically: either by individual search or daily uploaded batch file Faxed resolutions will no longer exist Process is easy
30 Notification of Denial, Reconsideration Members/Consumers: US Mail Referring Providers: DDE, Fax or US Mail Servicing Provider: DDE, Fax or US Mail
31 Denials Different Types: -Medical Necessity Denials No medical necessity per criteria and/or physician review -Policy Denials Not a covered service or age parameters not met Retrospective PA request not within policy parameters Invalid or incomplete information on faxed prior authorization request
32 Notification Letters Specific Manual Citations What Members need to do What Providers need to do Updated and better organized based on feedback
33 Timeframes of Reviews Urgent- 24 hours ( 1 business day)-for requests that meet the definition of urgent. Non-Urgent- 48 hours (2 business days) from the request submission to completion of review. Physician Review- 24 additional hours (1 business day)-reviews that do not meet medical necessity criteria upon review by nurse. Retrospective Review- 72 hours if request meets policy. Reconsiderations- 14 calendar days. Must be requested and submitted with all pertinent documentation within 60 calendar days from member/provider notification of the service denial. NOTE: Requests submitted after 3PM will be addressed the next business day. These requests will be processed as submitted and addressed sooner if practicable.
34 Criteria by Provider Type Review Area BMS Manual Chapter Inpatient/Acute Care 510 Adult, Child, and Procedures Inpatient Medical Rehab <21 InterQual Criteria Smart Sheet Guidelines Y State Criteria: Botox 510 N/A N Medicare: Rehabilitation Care Laboratory 529 N/A N State Criteria: BRAC 1 & 2 Imaging/Radiology 528 UMC Imaging Criteria Y State Criteria: Portable X- ray Outpatient Surgery Cardiac/Pulmonary Rehab 510 Adult, Child, Pediatric, and Procedures: Specialty Referral Y State Criteria: Dorsal Column Stimulators and Botox 527 Rehabilitation Criteria N Rehabilitation and State Criteria DME 506 DME Y State Criteria: Oxygen and Incontinence Medicare: Wheelchairs Orthotics/Prosthetics 516 DME N Dental and Orthodontic 505 N/A N American Academy of Dentistry and American Academy of Pediatric Dentistry
35 Criteria, cont Review Area BMS Manual Chapter InterQual Criteria Smart Sheet Guidelines Chiropractic 504 Outpatient and Rehabilitation Criteria N Podiatry 520 Specialty Referral N Speech/Audiology 530 Home Care: Speech and Language Pathology Adult & Child N Vision 525 N/A N Physical/Occupational Therapies 515 Home Care: Physical & Occupational Therapies N Home Health 508 Home Care N Hospice 509 Home Care, Acute: Adult & Child N Private Duty Nursing Home Care: Skilled Nursing N Medicaid Program Instruction MA-01-21; Medicare OASIS
36 InterQual Criteria/SmartSheets WVMI will utilize InterQual criteria, where available, for review of medical necessity SmartSheets, are available to physicians and DME vendors Providers must visit WVMI website to enroll For further assistance contact.. Melissa Nichols, ext. 3233
37 General/Targeted Policy Updates Program policies are located in the BMS manual chapters. BMS will update manuals with new, revised, or clarified information, as applicable and the UMC will perform required updates to the DDE system as applicable. Changes and updates will be noted on the APS and WVMI websites. We will update providers as soon as practicable to give as much advance notice of an upcoming change or addition as possible. CPT code changes are reflected in the Master code List based on 2011 updates. Covered services requiring prior authorization coincide with current manual requirements for each area of review. Master code List will be updated if updated manuals in any program area add or delete codes requiring prior authorization. Please reference Chapter 100, topic "Manual Updates for these updates. Specific workflows and data demands have been developed to accommodate EPSDT and Out-of- Network requirements. For the purpose of the initial DDE implementation the following is a summary of changes by review area: Dental: Updated Manual Chapter 505 was implemented November 1, 2010 all relevant requirements, codes and UM forms are incorporated in the DDE system. Retrospective review policy was modified to allow 10 days to request retrospective reviews for urgent dental situations. Speech: Manual Chapter 530-in the process of being updated- it is proposed that therapists must bill under individual NPI number rather than under facility
38 Updates continued Occupational and Physical Therapies: Manual Chapter 515- in the process of being updatedproposed changes will require an initial authorization for the first 6 visits requiring a minimal amount of patient information. Subsequent authorizations will require the full clinical information required to apply criteria. Occupational and Physical therapists must enroll and bill using individual NPI numbers. Chiropractic: there are no changes to this manual- DDE system for PA requests reflects the current manuals and codes requiring PA. Enhancements to request screens highlight data required per criteria. Radiology/Imaging: there are no changes to this manual- DDE system for PA requests reflects the current manuals and codes requiring PA. Enhancements to request screens highlight data required per criteria. Laboratory: there are no changes to this manual- DDE system for PA requests reflects the current manuals and codes requiring PA. Limited genetic screening labs require prior authorization. Podiatry: there are no changes to this manual- DDE system for PA requests reflects the current manuals and codes requiring PA have been updated to mirror requirements in the Molina system. Vision: Manual Chapter 525- in the process of being updated- possible changes to PA requirement for some codes, addition to codes available to adults and changes in requirements for prior authorization after service limits. Outpatient Surgery: there are no changes to this manual- DDE system for PA requests reflects the current manuals and codes requiring PA. There are some services that are now covered in an outpatient setting that were previously only covered inpatient. There are some codes deleted from the PA requirement. The Master Code List reflects these changes. Enhancements to request screens highlight data required per criteria.
39 Updates continued Durable Medical Equipment (DME): there are no changes to this manual- DDE system for PA requests reflects the current manuals and codes requiring PA. Enhancements to request screens highlight data required per criteria. Orthotics & Prosthetics: there are no changes to this manual- DDE system for PA requests reflects the current manuals and codes requiring PA. Enhancements to request screens highlight data required per criteria. Cardiac & Pulmonary Rehabilitation: There are no changes in coverage for the traditional Medicaid population. Review criteria are the same as required for this service in Chapter 527- Mountain Health Choices. Request screens highlight data required per criteria. Inpatient Services/Inpatient Medical Rehabilitation <21: there are no changes to this manual- DDE system for PA requests reflects the current manuals and codes requiring PA. Enhancements to request screens highlight data required per criteria. Home Health: Manual Chapter 508-Updated Manual effective July 1, 2010-Prior Authorization required after 60 visits-requirement will not be implemented until DDE system is implementeddate to be announced. Home Health will require an initial authorization for the first 60 visits requiring a minimal amount of patient information. Hospice: Implementation of this area will coincide with the effective date of the updated Manual Chapter 509: Hospice Services. The updated chapter requires prior authorization of these services and the DDE workflow and data elements reflect the requirements of the updated manual chapter. Private Duty Nursing: DDE system for PA requests reflects the current policy and codes requiring PA. Enhancements to request screens highlight data required per criteria.
40 Retrospective Review Policy Retrospective review is available in the following instances: 1. Weekends or holidays, or at times when APS/WVMI is closed. Retrospective reviews must be initiated on the first APS/WVMI business day following the service 2. Member eligibility has been back-dated and must be within 12 months of the date of service 3. A procedure/service denied by the member s primary payer provided all requirements for the primary payer have been followed including the appeals process. Note: Dental providers have been granted a provision to request prior authorization within 10 days of the procedure, for procedures that in the practitioner s opinion are medically necessary and in the best interest of the patient should be performed before prior authorization can be sought. This provision is being considered for other areas of review as well (e.g. inpatient, imaging).
41 Out of Network Any service provided to a West Virginia Medicaid member by an out-of-network provider must have a prior authorization in order for payment to be processed unless its an ER service or a foster child placed out of state or it is a policy exception per the BMS Manual Chapter Medical Necessity Review for requests for out-of-network services follow all requirements of the relevant manual chapter AND the UMC evaluates whether the service can be provided by an in-network provider. Referrals (Referring Providers): sent from a WV Medicaid enrolled provider for a WV Medicaid member to receive services from an out-of network provider. Providers (Servicing Providers): Facility or provider to which the member is being referred is confirmed as out-of-network. The provider needs to enroll prior to receiving authorization and instructed to contact Fiscal Agent for enrollment. Deny request letter to member and provider No Is Service Available In Network? No Is Medical necessity criteria met? Yes Is Referring Provider in Network? Issue call tracking ticket to Molina who sends enrollment letter/aps holds PA unless urgent * Molina process starts Provider enrolled within 30 days? Yes Yes Does provider have an Out of Network contract? No APS issues Authorization and close call tracking Provider Out of Network Referrals Yes No Yes No Yes Close call tracking Is Member Medicaid Eligible? No Start Referring provider makes referral to O-O-N Provider Request Closed Referring provider and member notified (letter sent) End Conduct Medical Necessity Review per appropriate criteria/workflow End
42 Medical Case Management Automatically triggered for Inpatient: Organ Transplant & Bariatric Procedures, Private Duty Nursing & Inpatient Medical Rehab <21 for coordinating and managing the authorized service and outpatient services following discharge. Medical Case Management is also provided for members identified by the Bureau for Medical Services to monitor progress during or following delivery of intensive or high cost services. Members with active authorizations whose Medicaid provider discontinues enrollment in WV Medicaid are managed through transition. The member and the referring physician are informed that the service is being provided.
45 Materials Available to Providers Master Code List UM Guidelines Frequently Asked Questions Policy Updates Step by Step Instructions for requesting & navigating Medical UM Review in CC
46 Master Code List Master Code List includes all services requiring prior authorization (PA) by review area This document will be located on the APS, WVMI, BMS and Molina websites.
47 MASTER CODE LIST
48 UM Guidelines Contains: Summaries of BMS Manual Chapters (with disclaimer that the provider is responsible for complying with requirements of relevant Medicaid chapters for the service(s) being requested) Workflow Prior Authorization Requirements Authorization/Review Criteria Review timelines Helpful Tips
49 Frequently Asked Questions A listing of frequently asked questions from training sessions will be posted on the APS and WVMI websites. FAQ s from the Molina Provider Training Workshops have been posted on the APS & WVMI websites. A listing of questions from these trainings and subsequent training will also be posted on our websites for your review.
50 Communications APS will communicate changes, updates and training opportunities by way of trade and professional publications, announcements and postings on the APS, WVMI, Molina, and BMS websites. Please make sure we have your contact information in order to best communicate with you!
51 QUESTIONS? Contact Us. APS Healthcare Telephone: Medical Services: ext Web Address: General Medical Helen Snyder, Associate Director ~ ext Heather Thompson, UM Nurse Reviewer ~ ext Sherri Jackson, Office Manager~ ext Denise Burton, Administrative Assistant~ ext WVMI Telephone: Management Web Address: click on the link under Medicaid Information John Marks, Director of State Services, ext Stacy Holstine, RN, BA, CPUM, Project Manager, ext Melissa Nichols, Support Staff Supervisor, ext. 3233
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