Frequently Asked Questions

Transcription

1 Frequently Asked s Regarding Rehabilitative Services Authorization Change effective Dec. 1, How is the authorization process changing? The initial evaluation for Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) does not require an authorization. The following CPT Codes indicate the initial evaluation: PT 97001, OT ST As of Dec. 1, 2012 all visits other than an evaluation will require prior authorization. 2. What about members in treatment prior to Dec. 1, 2012 who do not have an authorization on file for treatment after the Dec. 1, 2012 date? Therapy that is not complete by December 1, 2012 requires a new prior authorization for treatment. 3. If a visit is missed, can it be made up without an additional authorization? 4. If a Member changes to a new therapist, is an authorization necessary for evaluation and/or continued treatment? Yes. A visit may be made completed within the dates listed on the original prior authorization. Any visits outside the dates listed within the original prior authorization require an extension to the authorization. Yes. An authorization is necessary for the evaluation to be conducted by the new provider along with any recommended treatment UHC2198c 1

2 Frequently Asked s (page 2) Are re-evaluations different from evaluations? Yes. A re-evaluation may be periodically indicated during an episode of care when the professional assessment of a clinician indicates a significant improvement, decline or change in the member s condition or functional status that was not anticipated in the plan of care for that interval. Evaluations are completed usually at the 180 day mark from the start of care. 6. Which CPT Codes indicate a reevaluation? PT OT ST S Are authorizations per unit or per visit? Your authorization approval letter will state the number of visits approved. One unit equals one visit (unit/visit), typically an hour in duration. 8. Is there a maximum number of units/visits allowed? 9. What is the recommended format to write out frequency in the authorization request? No. Number of units/visits allowed are based on medical necessity. units/ visits- visits visits/week/month x length of certification: 2visits/week x 6 months is also an acceptable method. 2

3 Frequently Asked s (page 3) 10. May therapy be authorized to occur in the member s home? Yes. If it meets medical necessity for home bound members. This should be requested separately from therapy performed at a facility. 11. What items are required for authorization? An order signed and dated by a physician familiar with the member s clinical situation (i.e. PCP, Orthopedic, or Neurologist). A referral is not required for in-network providers and a member may self refer. Therapist s evaluation and Plan Of Care are required along with documentation of rehabilitation potential, goals and progress toward those goals. An Authorization form in addition to the order, to include the ordering physician s name and contact information. 12. Is a prior authorization form required? Yes. A form is available on UHCCommunityplan.com (Health Professionals >TX >Provider Forms). You may also enter a request online if registered at UnitedHealthcareonline.com or call for prior authorization, however additional documentation must be faxed. 13. What is the best method for authorization requests: online or fax? Fax ( ). This enables clinical information to be submitted at the same time as the request. 3

4 Frequently Asked s (page 4) 15. What is the authorization turn-around-time? Decisions are made within 3 business days from the time of a request as long as information is available to complete the review. For members under the age of 21, we allow up to 7 days for the requested information from the ordering physician. Lack of supporting documentation may result in a denied authorization. 16. Where can I find covered CPT codes? Utilize the Texas Medicaid Manual posted at Texas Medicaid and Healthcare Partnership (TMHP) or refer to UnitedHealthcareonline.com 17. Can authorizations be amended to allow for a frequency change or to add an additional CPT code? 18. What medical criteria guidelines are available for PT.OT.ST.? Yes. Changes to an already approved authorization will require medical necessity review and approval. Only authorized services will be covered. Claims submitted that do not match will deny as not authorized. Milliman Care Guidelines 4

5 Frequently Asked s (page 5) Claims / Appeals 19. How can we view current claims? Register to view claims at UnitedHealthcareonline.com 20. Which billing form should I use? Follow Centers for Medicare and Medicaid Services (CMS) guidelines regarding the proper billing form for your provider type. CORF/ ORF providers must bill on UB-04 forms. 21. How should corrected claims be resubmitted? (Note: a corrected claim should be submitted in the event that you discover that the claim was incorrectly submitted and you need to make a correction to the bill to request payment). Corrected claims billed on a CMS 1500 Form should include in box #22 the original claim number. Note it is a corrected claim. This will help avoid having your claim reprocessed as a duplicate. Corrected claims billed on a UB-04 Form will denote if the claim is a resubmission by the last digit of the bill type. Corrected claims may be submitted via 1. (CMS 1500 Form only) 2.Paper claims mail to UnitedHealthcare Community Plan STAR and CHIP PO BOX 5270 Kingston, NY Submit via electronic data interchange (EDI) vendor 5

6 Frequently Asked s (page 6) 22. Which National Provider Identification (NPI) or Texas Provider Identification (TPI) number should I use? 23. When can claims be submitted for reconsideration? (Note: A claim submitted for reconsideration could be for previously denied claims for the following reasons: exceeds filing time or additional information needed. Additionally, the claim being resubmitted could have been previously processed as rate applied incorrectly resulting in over/underpayment or as bundled claim and other reasons for denial you feel are incorrect. Claims submitted for reconsideration are not considered an appeal. If an appeal is to be pursued, a reconsideration would be a necessary first action.) If you are contracted as a group use the group NPI and TPI number. If you are contracted as an individual use the individual NPI and TPI number. The Reconsideration Form located at UHCCommunityPlan.com is to be used when a claim is Previously denied as Exceeds Filing Time Previously denied for Additional Information Previously processed, rate applied incorrectly resulting in over/underpayment Previously processed as Bundled claim Reconsiderations need to be submitted as paper claims to the following address: STAR PO Box Salt Lake City, UT

7 Frequently Asked s (page 7) 24. How do I appeal a denied authorization (pre-service)? Providers do not have appeal rights with regard to pre-service authorization. Members are forwarded the resolution letter showing the denial, with a copy sent to you. Pre-service denials must be appealed within 30 days of the denial. You may represent members in their appeal; however, written correspondence must be received from the member designating you, the provider as his/her representative. Appeals should be forwarded to: Community and State Appeals P.O Box Salt Lake City, UT How do I appeal a claim denied (post-service)? You have 120 days to appeal a claim denials. For those appeals which continue to be upheld and for which you believe there is a medical necessity issue, you have the opportunity to request a specialty review. Specialty review information is included in the appeal resolution letter. Appeals should be forwarded to: Community and State Plan Appeals PO Box Salt Lake City, UT In Texas UnitedHealthcare Community Plan of Texas, L.LC. is UnitedHealthcare Community Plan. 7