TENS Unit Prior Authorization Process

Transcription

1 TENS Uit Prior Authorizatio Process

2 Objectives Uderstad the HUSKY Health program s prior authorizatio process for TENS uits (Trascutaeous Electrical Nerve Stimulatio) Access the DSS Fee Schedule Reduce admiistrative burde associated with the prior authorizatio process Improve provider satisfactio with the prior authorizatio process 2

3 Prior Authorizatio Itroductio All HUSKY Health members are eligible to receive healthcare services or goods from Coecticut Medical Assistace Program (CMAP) erolled providers Oly CMAP erolled providers will be reimbursed for services or goods provided to HUSKY Health members All orderig, prescribig or referrig providers must be erolled as either a OPR or CMAP provider 3

4 Prior Authorizatio Itroductio (cot.) Commuity Health Network of Coecticut, Ic. (CHNCT) has up to 14 caledar days to review the prior authorizatio request ad otify the provider of their decisio If additioal iformatio is requested by CHNCT, the provider has up to 20 busiess days to submit the requested iformatio Determiatios are made based o a idividual cliical assessmet of the member ad his/her cliical eeds 4

5 Prior Authorizatio Requiremets Required for the retal ad purchase of TENS uits Requests for TENS uits are reviewed i accordace with cliical criteria ad guidelies Determiatio is based upo a review of submitted case-specific cliical iformatio utilizig a perso-cetered approach Paymet is based o the member havig active coverage ad beefits, ad the policies i effect at the time of service All determiatios are made o the basis of medical ecessity ad must be i compliace with the Defiitio of Medical Necessity, Regulatio 17b-259b 5

6 Defiitio of Medical Necessity Sectio 17b-259b Medical Necessity (or Medically Necessary ) meas those health services required to prevet, idetify, diagose, treat, rehabilitate or ameliorate a idividual s medical coditio; icludig metal illess, or its effects, i order to attai or maitai the idividual s achievable health ad idepedet fuctioig provided such services are: 1) Cosistet with geerally-accepted stadards of medical practice which are defied as: a) Credible scietific evidece published i peer-reviewed medical literature that is geerally recogized by the relevat medical commuity b) Recommedatios of a physicia-specialty society c) The views of physicias practicig i relevat cliical areas d) Ay other relevat factors 6

7 Defiitio of Medical Necessity (cot.) 2) Cliically appropriate i terms of type, frequecy, timig, site, extet ad duratio, ad cosidered effective for the idividual s illess, ijury or disease 3) Not primarily for the coveiece of the idividual, the idividual s healthcare provider or other healthcare providers 4) Not more costly tha a alterative service or sequece of services at least as likely to produce equivalet therapeutic or diagostic results as to the diagosis or treatmet of the idividual s illess, ijury, or disease 5) Based o a assessmet of the idividual ad his/her medical coditio All fial determiatios of medical ecessity must be based upo this statutory defiitio 7

8 Medical Necessity Deial All Prior Authorizatio Requests for DME must meet the followig requiremets: Defiitio of Durable Medical Equipmet (DME) Defiitio of Medical Necessity 8

9 Lack of Iformatio Deial A Lack of Iformatio Deial (LOI) will result whe attempts to obtai additioal required cliical iformatio to perform a medical ecessity review have bee usuccessful A LOI Deial will be issued by the medical reviewers o the 20th busiess day from the origial request submissio After a LOI Deial is issued, providers may submit a ew prior authorizatio request oce the ecessary cliical iformatio is obtaied The ew prior authorizatio request will go through the complete review process for medical ecessity 9

10 TENS Uits TENS Uits require prior authorizatio A TENS Uit must be iitially Reted for a 3 moth period prior to request for Purchase 10

11 TENS Uit Retal Prior authorizatio form must iclude the appropriate modifiers for retal Refer to the DSS Fee Schedule for mothly retal allowable 11

12 TENS Uit Retal Documetatio Required Documetatio Requiremets Fully completed Prior Authorizatio Request Form Prescriptio for a TENS Uit Cliical documetatio from the Orderig Physicia: Cliical office otes outliig the member s medical coditio Referece to the legth of time the member has experieced pai Documetatio regardig what pai medicatios AND other opharmacological pai relief modalities the member has trialed prior to requestig a TENS uit 12

13 TENS Uit Purchase A TENS Uit may be coverted to purchase after a member has had success with pai maagemet documeted durig the retal period Prior authorizatio form must iclude the appropriate modifiers for purchase Refer to the DSS Fee Schedule for allowable purchase 13

14 TENS Uit Purchase Documetatio Required Documetatio Requiremets Fully completed Prior Authorizatio Request Form Prescriptio for a TENS Uit Cliical documetatio from the Orderig Physicia: Cliical office otes dated [a miimum of 30 days] after member received the retal TENS Uit Documetatio regardig the effectiveess of the TENS Uit ad frequecy per day the member is usig the TENS Uit 14

15 Request Form Istructios Prior authorizatio request forms are located o the HUSKY Health website: click For Providers 15

16 Request Form Istructios (cot.) Click o the Providers tab 16

17 Request Form Istructios (cot.) Click o Provider Bulletis & Forms 17

18 Request Form Istructios (cot.) Click o Outpatiet Authorizatio Request Form 18

19 Outpatiet Prior Authorizatio Request Form Full istructios o Page 2 of form All boxes must be completed i order for your request to be cosidered for coverage 19

20 DSS Fee Schedule DSS Fee Schedule ca be foud at 20

21 Locatig the DSS Fee Schedule Click o Provider 21

22 Locatig the DSS Fee Schedule (cot.) Click o Provider Fee Schedule Dowload 22

23 Locatig the DSS Fee Schedule (cot.) Click o the I Accept butto at the bottom of the Licese Agreemet The choose the appropriate Provider Fee Schedule 23

24 Questios? Thak you for your time! 24