Overview of Durable Medical Equipment Prior Authorization Process. April 28, 2016

Transcription

1 Overview of Durable Medical Equipmet Prior Authorizatio Process April 28, 2016

2 Objectives Improve uderstadig of the HUSKY Health Program s Prior Authorizatio process for Durable Medical Equipmet (DME) Describe ad use the Departmet of Social Services (DSS) Fee Schedule Review the MEDS Pricig Policy Reduce admiistrative burde associated with the prior authorizatio process Improve provider satisfactio with the prior authorizatio process 1

3 Overview All HUSKY Health members are eligible to receive healthcare goods or services from Coecticut Medical Assistace Program (CMAP) erolled providers Oly CMAP erolled providers will be reimbursed for goods or services provided to HUSKY Health members All orderig, prescribig, or referrig providers must be erolled as either a orderig/prescribig/referrig (OPR) or CMAP provider Determiatios are made o a case-by-case persocetered cliical assessmet of members ad their cliical eeds 2

4 Perso-Ceteredess Providig the member with eeded iformatio, educatio ad support required to make fully iformed decisios about his or her care optios ad to actively participate i his or her self-care ad care plaig Supportig the member, ad their desigated represetative(s) i workig together with his or her o-medical, behavioral health ad medical providers ad Care Maager(s) to obtai ecessary supports ad services Reflectig care coordiatio uder the directio of ad i partership with the member ad his/her represetative(s) that is cosistet with his or her persoal prefereces, choices ad stregths ad that is implemeted i the most itegrated settig 3

5 Prior Authorizatio Requiremets Required for the retal ad/or purchase of select DME Requests are reviewed i accordace with cliical criteria, guidelies or medical policies Coverage determiatio is based upo a cliical review of submitted case-specific iformatio with cosideratio for a perso-cetered approach Paymet based o the member havig active coverage, beefits, ad 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(a) 4

6 Defiitio of Medical Necessity Sectio 17b-259b(a) 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 that are defied as stadards based o: (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 5

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 6

8 DSS Fee Schedule 7

9 Locatig the DSS Fee Schedule Go to Click o Provider 8

10 Locatig the DSS Fee Schedule (cot.) Click o Provider Fee Schedule Dowload 9

11 Locatig the DSS Fee Schedule (cot.) Click o the I Accept butto at the bottom of the Licese Agreemet Choose the desired Provider Fee Schedule 10

12 Navigatig the DSS Fee Schedule The colums o the Fee Schedule are as follows: Procedure Code Proc Descriptio Mod1 Mod1 Desc Rate Type Max Fee Effective Date Ed Date PA Qty If there is a Y i the PA colum, the Prior Authorizatio is required for that item If a member eeds a larger quatity tha what is listed uder the Qty colum (eve if there is o Y listed), the prior authorizatio is required for that item 11

13 Required Documetatio Prior Authorizatio Requests Completed Outpatiet Prior Authorizatio Request Form Prescriptio for the goods/services siged by the orderig physicia Cliical documetatio from the orderig physicia supportig the medical ecessity of the requested goods/services 12

14 Outpatiet Prior Authorizatio Request Form Istructios Dowload Outpatiet Prior Authorizatio Request Forms from the HUSKY Health website: click For Providers 13

15 Outpatiet Prior Authorizatio Request Form Istructios (cot.) Click o the Providers tab 14

16 Outpatiet Prior Authorizatio Request Form Istructios (cot.) Click o Provider Bulletis & Forms 15

17 Outpatiet Prior Authorizatio Request Form Istructios (cot.) Click o Outpatiet Prior Authorizatio Request Form 16

18 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 17

19 Cliical Iformatio Required Referece Cliical Policies o the Policies, Procedures & Guidelies web page for iformatio o specific goods: 18

20 Maually Priced Goods Overview Actual Acquisitio Cost (AAC): Whe the maufacturer is ot the provider: AAC is the price paid by the provider to the maufacturer, or ay other supplier for orthotic or prosthetic devices, equipmet, or supplies Whe the maufacturer is the provider: AAC is the actual cost of maufacturig such orthotic or prosthetic devices, equipmet or supplies Maufacturer s Suggested Retail Price (MSRP): Maufacturer s suggested retail price or list price is the sellig price that the maufacturer recommeds that the seller or retailer receive for goods or services 19

21 Required Pricig Documets The DSS Pricig Policy for MEDS Items is foud o the Policies, Procedures & Guidelies web page uder the Cliical Policies sectio If a item requires maual pricig, a AAC ad MSRP MUST be submitted alog with the Prior Authorizatio request 20

22 Submit a Prior Authorizatio Request Providers may submit a Prior Authorizatio request by either of the followig methods: Clear Coverage Portal Cliical/pricig iformatio Fax: Completed form ad cliical/pricig iformatio 21

23 After a Prior Authorizatio Request is Submitted A pedig authorizatio umber is geerated If more iformatio is eeded, the cliical reviewer will cotact the provider via fax, phoe, ad/or or through their Clear Coverage accout; if additioal iformatio is required, the provider is give additioal time to submit the requested iformatio All requests for DME are reviewed withi 14 caledar days from the date of receipt A decisio must be made by the 20 th busiess day from the date of receipt 22

24 Request Approvals Approval letters are geerated withi 48 hours after request approval Approval letters are distributed by: Fax to DME Providers Mail to referrig physicias ad members 23

25 Request Deials Verbal otificatios provided to DME providers ad referrig physicias withi 24 hours after a decisio has bee made The verbal otificatio icludes a outlie of the appeal process Letters are mailed to DME providers, referrig physicias ad members withi 3 busiess days from the decisio date 24

26 Questios? 25