HPHConnect for Providers. Skilled Nursing Facility Admission Authorization Requests User Guide

Transcription

1 HPHConnect for Providers Skilled Nursing Facility Admission Authorization Requests User Guide January 2016

2

3 HPHCONNECT SKILLED NURSING FACILITY INPATIENT ADMISSION USER GUIDE Table of Contents A. SKILLED NURSING FACILITY AUTHORIZATION REQUESTS OVERVIEW Introduction When to Use HPHConnect When Not to Use HPHConnect Notification/Authorization Requirements Submission Process Requesting Provider Servicing Provider B. SUBMITTING THE INITIAL TRANSACTION Admission Services Form Required Fields D. THE TRANSACTION RESPONSE Key Information Pended for Review Finalized Admission Transaction Print Referral Form E. REVISIONS TO AN ADMISSION TRANSACTION Guidelines Edit the Approved Transaction F. CANCELLING THE TRANSACTION When to Cancel a Transaction How to Cancel a Transaction APPENDIX HPHConnect Skilled Nursing Facility Inpatient Admission Quick Reference Guide HPHConnect Skilled Nursing Facility Inpatient Admission Tab Harvard Pilgrim Health Care HPHConnect iii January 2016

4 HPHConnect for Providers Skilled Nursing Facility Inpatient Admission User Guide Skilled Nursing Facility Authorization Requests Overview Introduction To submit transactions online, the provider must be contracted with Harvard Pilgrim and have a status of participating for the member s product. The user s access list determines which referral/authorization (RA) transactions can be viewed. Access to RA transactions is limited to those for providers on the user s access list who are the requesting provider, servicing provider or the patient s PCP. When to Use HPHConnect HPHConnect for Providers users can submit RA transactions and access two years of RA transaction history for Harvard Pilgrim HMO, POS, and PPO members online. You can also submit RA transactions and view RA transaction history for Harvard Pilgrim Choice Plus and Harvard Pilgrim Options members. When Not to Use HPHConnect HPHConnect for Providers is not used for transactions for members with the Choice or Choice Plus products offered through Passport Connect SM. For UnitedHealthcare s related policies/procedures, please go to or call , option 2. Notification/Authorization Requirements Prior authorization is required for inpatient admissions to skilled nursing facilities (SNFs). Authorization should be requested prior to the date of admission (at least one week prior in advance when possible) to allow Harvard Pilgrim time to evaluate member eligibility, level of benefits and medical necessity. Submit the authorization request: As soon as you are certain that the patient will be coming to your facility No later than one business day after the admission takes place Reminder: Failure to comply with Harvard Pilgrim Health Care authorization requirements will result in an administrative denial of the claim payment. Members cannot be held liable for claims denied for failure to meet these requirements. Submission Process Go to Click on log into HPHConnect and sign in. 1. Verify patient eligibility. Is the patient active with Harvard Pilgrim? If no, contact the patient for information. 2. Check Referrals/Auth status to see if a transaction is already in the system. If yes, review the Service Request Record Detail. 3. If the patient is eligible and no transaction exists, enter the Admission request. Requesting Provider The facility, the member s PCP or the specialist can submit the authorization request. Servicing Provider Two servicing providers are required on the admission transaction. The provider s name or NPI is required. Enter the providers in the following order: First the facility Second the clinician, either a primary care or specialist provider The provider s name or NPI is required. If the servicing provider is not contracted with Harvard Pilgrim, the transaction pends for review. Note: If the servicing provider is not contracted with Harvard Pilgrim, the transaction pends for review. (continued) Harvard Pilgrim Health Care HPHConnect 1 January 2016

5 Admission Services Form HPHConnect for Providers Skilled Nursing Facility Inpatient Admission User Guide Submitting the Initial Transaction Required Fields All required fields display a blue dot, and must be completed in order to process the request. In addition to the standard required fields, the requesting provider must supply contact information and auto-accident information, when applicable. All other fields are optional. Field Patient Requesting Provider Contact Name / Contact Number Diagnosis Servicing Provider Requested Service Requested Units Nsg Home Residential Status Level of Service Start Date End Date Requirement Name (pre-filled when the transaction is entered via Patient Management). Select from the drop-down list, if not pre-filled. This is helpful for the Harvard Pilgrim Case Manager when additional information is needed. At least one diagnosis code is required. Up to 12 can be submitted. Enter all that are indicated on the physician s orders. Two: Enter the facility 1st; the physician 2nd. Use the provider s name or NPI. Skilled Nsg Care Inpt Enter the number of days requested. Select the appropriate status code. This field is required for Skilled Nsg Care Inpt admission transactions. Elective, Emergency, or Urgent Date of admission. Expected discharge date. (continued) Harvard Pilgrim Health Care HPHConnect 2 January 2016

6 HPHConnect for Providers Skilled Nursing Facility Inpatient Admission User Guide Submitting the Initial Transaction, continued Field Related Cause Release of Information Requirement If the service requested is due to an automobile accident: Check Auto Specify the date of the accident and the state/province or country Select Informed Consent/Med Note: When entering text in the Remarks field, enter letters and/or numbers only; do not use punctuation marks or other keyboard characters. Harvard Pilgrim Health Care HPHConnect 3 January 2016

7 HPHConnect for Providers Skilled Nursing Facility Inpatient Admission User Guide The Transaction Response Key Information In the title bar, you will find the: Transaction number (e.g., HPA12345) Status of the transaction: approved, pended, or denied Member s name and member s ID# The requesting provider s and servicing provider s National Provider Identifier (NPI) display on both the transaction detail screen and the print referral. On approved SNF and rehabilitation facility admission transactions, the end date, # of units approved, and remarks indicating the level of care authorized will display. The Edit button only displays on approved transactions. The Cancel button displays on pended and approved transactions. Pended for Review All skilled nursing facility admission transactions pend for review, both initial requests and revision requests. When a transaction pends for review, the Harvard Pilgrim reviewer updates the Admission record to reflect the final status, Approved or Denied, within two (2) business days of receiving all information needed to complete the review. The requesting provider, the servicing provider and the member s PCP will receive notification of the changed status of the transaction via the Activity Summary, if enabled. Finalized Admission Transaction To print a copy of the response for your records, use the Browser Print option or the Print Referral link. JOHN DOE HP O1 JOHN DOE ACUTE ON CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE CRESENT MEDICAL CENTER (987654) ( NPI) CRESENT MEDICAL CENTER (987654) ( NPI) JANE SMITH (continued) Harvard Pilgrim Health Care HPHConnect 4 January 2016

8 HPHConnect for Providers Skilled Nursing Facility Inpatient Admission User Guide The Transaction Response, continued Print Referral Form When you access this screen, your printer dialogue window displays automatically. Click on Print to print the form. John Doe HP ACUTE ON CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE BEST SN FACILITY (AA12345) ( NPI) Harvard Pilgrim Health Care HPHConnect 5 January 2016

9 HPHConnect for Providers Skilled Nursing Facility Inpatient Admission User Guide Revisions to an Admission Transaction Guidelines Only the Requestor can Edit or Cancel a transaction. Only approved transactions can be edited. Only approved or pended transactions can be canceled. No changes can be made to the: - Type of request (outpatient, admission, specialist, home care, or transportation) - Patient, or - Service requested Note: if there is a change in the patient s level of care, a new transaction must be submitted. Edit the Approved Transaction Before the Start Date After the Start Date but prior to the End Date After the End Date Edits can be made to the following fields: Servicing provider Diagnosis code (add or change) Units Nursing Home Residential Status code Level of Service Start date (not prior to today s date) End Date Edits can be made to the following fields: Diagnosis code (add or change) Units End Date (not prior to today s date and not more than a year from the Start Date ) HPHConnect will not accept requests for edits after the end date of a record. Harvard Pilgrim Health Care HPHConnect 6 January 2016

10 HPHConnect for Providers Skilled Nursing Facility Inpatient Admission User Guide Cancelling the Transaction When to Cancel a Transaction The requestor or the servicing provider can Cancel a pended or approved transactions at any time if: The record was entered for the wrong patient. The wrong service type was selected in the original request. The wrong type of request was submitted, (e.g., specialist or outpatient rather than admission). To correct any of these errors, it is necessary to cancel the original record and enter a new one for the appropriate service. How to Cancel a Transaction 1. Click on the Cancel button at the bottom of the Detail screen. 2. When the Verification screen displays, click Yes to submit the cancellation request. 3. The transaction re-displays and the Status indicates Approved (Canceled), that is, the request to cancel the transaction was approved. Harvard Pilgrim Health Care HPHConnect 7 January 2016

11 Appendix Harvard Pilgrim Health Care HPHConnect 8 January 2016

12 HPHConnect Skilled Nursing Facility Inpatient Admission Quick Reference Guide Prior to submitting an Admission Transaction: 1 Check member eligibility. 2. When you are sure that you have the correct member, click on Select to add the member to the Patient list. 3. Check to see if an Admission authorization is already in place (See To search for Admission Transactions below) 4. Have your provider number (NPI). 5. Have the servicing provider s NPI, which you can find via the Office Management/Provider Directory. 6. Have the diagnosis code(s) (diagnosis codes are required for all rehabilitation admission transactions). You can pre-select diagnosis codes from the Office Management/Code Lookup. To submit an Admission Transaction: 1. Select the Admission tab. 2. Complete the required information for the Patient, Requesting Provider, and Servicing Providers (Always enter the Facility Servicing Provider first). 3. Provide Contact Name/Number and Requested Service information. 4. Complete additional optional fields, as needed. 5. Click on Submit. 6. The response will be returned to you directly and display the status, Pended (for review). 7. To print a copy or the response for your records, use the Print Referral link. To search for Admission Transactions: 1. In Patient Management, select the member from the Patient list. 2. Click on the Referrals/Auths link to access the Service Request Search Results screen that displays a list of the member s referrals/admissions. 3. (Optional) To sort the data on the Service Request Search Results screen, click on the column-heading link: single click for ascending order or double click for decending order. 4. Click on the Number link in the Service Request Number column to access the Detail of an existing record. 5. If no record exists for the service in question, click on Add to enter a new transaction. Helpful Hints: 1 Indicates required field. 2. To advance from field to field, use the TAB key instead of using your mouse. Do not hit Enter unless you need to search for the information for a field. 3. To move the cursor back a field, use the SHIFT + TAB keys together. 4. Approved rehabilitation admission transactions will display the end date, the # of units approved, and the level of care authorized. Troubleshooting problems: 1 If you receive an error message and need to correct data in one or more fields, click the Return to previous page link to correct the mistake(s) and resubmit the request. 2. If you receive the message, Your request has not been returned from the server. You will receive a communiqué shortly., click your browser s Back button to resubmit the request. 3. If you have not used HPHConnect for 15 minutes, you will need to Sign In again before you can create a new admission transaction. January 2016

13 HPHConnect Skilled Nursing Facility Inpatient Admission Tab 1. The Patient Name auto-populates from the Current Patient on today s list. 2. Requesting Provider The contracted facility, a PCP or specialist may initiate a request. Entering the name of the provider: a. When one provider is on the access list, the name of the provider auto populates. b. When 2-20 providers are on the access list, select the name of the requesting provider from the drop-down menu. c. When more than 20 providers are on the access list, a menu will not appear. Enter the name of the provider in the field. * When entering multiple diagnoses: If you don t know the correct names or terms for a field, you must search for each entry individually. a. Enter a partial name or number in the appropriate field. b. Click on the Search button at right. A list, beginning with the characters you entered, will appear. c. Select the correct item from the list provided. d. Repeat this process for each entry. 3. Enter Contact Name and Contact Number in the two corresponding fields. 4. Diagnosis You can enter up to 12 diagnoses. Search by code or by name. Be sure to include the decimal point if the diagnosis code requires one. If you know the correct codes, you can submit multiple entries at one time, separated by a semi-colon. If not, see below*. 5. Two Servicing Providers are required a facility (1st) and a physician (2nd). If you know the correct names or provider numbers, you can submit multiple entries at one time, separated by a semi-colon. If not, see below*. 6. Requested Service Select from the menu Skilled Nsg Care Inpt. 7. Requested Units Enter the number of days. 8. Nsg Home Residential Status Required for Skilled Nsg Care Inpt. 9. Level of Service Select Elective, Urgent, or Emergent. 10. Enter the Start Date of service. You can enter a date in the field or click on the Quick Calendar to select a date. 11. Enter the End Date of service. 12. A Delay Reason may be selected if the request for admission is submitted late. 13. Related Causes Check one or more boxes, as appropriate. If an automobile accident is indicated, the date of the accident must be given. Select the state in which the accident occurred from the drop down menu. 14. Release of Information Select: a. Informed Consent/Med, or b. Signed Statement/Claims 15. Remarks This is a message board to communicate information between the PCP, specialist and Harvard Pilgrim. January 2016