Molina/BMS 2013 Provider Workshops IRG d/b/a APS Healthcare, Inc. Updates

Transcription

1 Molina/BMS 2013 Provider Workshops IRG d/b/a APS Healthcare, Inc. Updates

2 Provider Registration with APS v. Molina WV Medicaid Enrollment ALL Review areas for Medicaid services requiring prior authorization are currently in the APS Medical CareConnection if you are a Medicaid provider who makes prior authorization requests you should already be registered with APS.

3 Registration Continued Providers must register specifically with APS Healthcare in order to access the Medical CareConnection Providers must be WV Medicaid enrolled in order to register with APS- providers enroll in WV Medicaid through Molina Providers who try to register with APS and ARE NOT WV Medicaid enrolled will be unable to submit prior authorization requests

4 APS Registration Process There is a self-registration portal available at on the log-in page select self-enrollment Brief instructions on registration are in your packet- for more detailed instructions go to (medical providers online prior authorization link) or contact us at: [email protected]

5 Courtesy Review Courtesy Reviews allow providers to enter prior authorization requests for members they believe to have active Medicaid, although the Medicaid ID number is not yet active in Molina. The request will be reviewed for medical necessity and if approved, when the Medicaid ID is available in Molina, it will be attached and a Prior Authorization number will be assigned. Retrospective Courtesy Reviews are not allowed. If the member cannot be found in our system, their Medicaid ID is not active during that time span. The provider will need to wait until the retroactive Medicaid eligibility is present in our system and then submit their request. Keep in mind that if a Molina linkage is not made within 30 business days of the actual Courtesy Review, the request will be closed and the provider will be notified that WV Medicaid coverage could not be located for the indicated member.

6 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. NOTE: Some review areas do not recognize medically urgent requests. In these instances it is not a choice in the admission type dropdown. For those review areas that recognize medically urgent (e.g. inpatient) each admission type has a medically urgent choice (e.g. direct admission OR direct admission-medically urgent). Requests not meeting the medically urgent definition WILL NOT be clinically reviewed as medically urgent.

7 Retrospective Review Policy- NEW 72 Hour Policy WV Medicaid Prior Authorization Retrospective Review Policy that currently requires a timely 24-hour prior authorization submission for all admissions, including weekend and/or holiday admissions, which must be submitted on the first business day following the weekend or holiday. Due to the repeated expression of difficulty with meeting this requirement, APS has provided the Bureau for Medical Services (BMS) your provider/submitter comments and concerns about the current policy. After careful consideration, BMS has listened to your feedback, and has agreed to eliminate the 24-hour timeline, and instead, adopt a 72-hour prior authorization timeline in its place. NOTE: After the 72 hour period has elapsed from the selected service start date prior authorization is NOT available as a selection and retrospective review must be selected.

8 Out-of-Network Requests Only an enrolled WV Medicaid provider may request an out-of-network service for a WV Medicaid member (this is why the referring provider must always be an enrolled WV Medicaid provider). For servicing provider select Out-of-network OR select the specific Out-of-network provider if they appear in the service provider table (e.g. Out-of-Network- Geary Hospital). An out-of-network provider found in the provider list merely indicates they have enrolled in WV Medicaid as out-of-network and have not termed. This does not guarantee that the authorization request will be processed if the requested service is available in-network. If the review determines that the service is medically necessary AND not available in-network, the out-of-network provider will be notified that they must enroll with Molina and a notice that medical necessity is met awaiting provider enrollment will be assigned. If the provider has previously enrolled to provide out-of-network services AND enrollment has not termed the prior authorization number is assigned. If medical necessity is not met (denial) there is no need for the provider to enroll and the member and referring provider are notified of the denial. If the provider is not enrolled as out-of-network, call tracking is opened with Molina and kept open until APS is notified the provider has enrolled. The authorization number is posted at the time of enrollment and sent to Molina. The out-of-network provider may then view the authorization request and bill Molina using the assigned prior authorization number.

9 Denials and Reconsiderations Status can be seen at the authorization record level OR in reports. Denial letters are always found on the Summary & Submit page of C3. If you entered the prior authorization request in C3, you will be messaged to your C3 inbox. If you are the referring or servicing and did NOT enter the request you will be messaged if you are a C3 user OR a copy of the letter will be faxed or mailed (if no other means is available). Reconsiderations are requested from the action menu for requests that have been denied for medical necessity. Providers have 60 days to request reconsideration, so make sure all appropriate information is provided at the time of the reconsideration request. If you mail your reconsideration chart, wait until it is mailed prior to requesting in system and indicate in the note that the record has been mailed (or faxed if you do not attach at the time of reconsideration request).

10 Timeframes for Reconsideration Provider must request and submit reconsideration with all pertinent documentation within 60 calendar days from member/provider notification of the service denial. The reconsideration request is initiated by selecting reconsideration from the action menu when the authorization request is open in the Medical CareConnection. Additional materials and clinical information can be attached and or faxed. Providers are encouraged to wait until all diagnostic and clinical information necessary for the medical necessity review is available before requesting the reconsideration.

11 Attachments How To: Click on the Browse button in the Annotations: Notes section on the screen you want the information to be placed. Find the document you want to attach and double click on it. Click on the blue Save button within the notes section. Where: Either on the applicable screen (ex. MAR on the Medications screen) or on the Summary and Submit screen Files Accepted:.txt, \.vsd, \.png, \.gif, \.bmp, \.jpg, \.jpeg, \.doc, \.xls, \.pdf, \.TIF, \.TIFF Size Accepted: up to 4.8 MB only. Larger files need to be compressed or separated. Please do not attach the same document more than once on the request. This only causes the reviewer to spend extra time looking at documents already viewed.

12 Faxed Additional Information We would like to inform you about timelines for sending in additional clinical information, whether it be faxed, or mailed additional information, for any case, to WVMI. In order for your requests to be processed in a timely, efficient manner, WVMI needs to receive information in a timely manner. If you enter requests via the CareConnection system, and want to fax the clinical information to WVMI, the faxed information needs to be received by WVMI within 2 business days from the submission of the request. If you enter a reconsideration request into the system, and mail the additional clinical information, WVMI needs to receive this information within 5 business days. NOTE: A pre-prepared fax cover sheet is available on the APS and WVMI websites. If the information is not received within the allotted timeframe, your request will be closed administratively, and you will have to re-submit your request, which could cause you to miss the 72 business hour timeline, for a timely submission. Leniency will NOT be given in these cases.

13 When in Doubt: What to Do When things aren t working correctly in C3, there are a few things you can do to make sure it s not on your end. 1.) Is your Provider Organization registered with us? 2.) Is your Provider NPI number attached? Cannot create request if not 3.) Do you have the user role of AUM Manager? Need this role to submit requests 4.) Are you on the correct site? 5.) Are you using Internet Explorer 8? C3 is not compatible with Google Chrome 6.) Have you cleared your cache/cookies? Tools: Internet Options: Delete Browsing History: Everything Except Preserve Favorites: Delete 7.) Have you checked your queue? Lost requests are often found here If you have checked these items and are still having difficulties contact APS for technical assistance!

14 What do I do if I can t find a code in the code list or in C3? The Master Code List is an effort to inform providers of codes requiring prior authorization either from first service (listed as required) or after a specified service limit has been reached (beyond service limits) If you think a code requires PA and cannot find it on the list you can contact APS or WVMI for verification. The codes requiring PA that were added or deleted January 1, 2013 are highlighted in yellow on the list The BMS Manual Chapters indicate covered services that require prior authorization. If you should receive a denial for a service NOT on the list OR find a service listed in the manual as requiring PA but not on the list please contact APS as soon as possible so we can determine if the PA requirement is in force. If it is we will add the code to the listing.

15 Review Area Updates: Orthotics & Prosthetics Last review area to go live in C3 system We do not have a go live date yet Continue to request prior authorizations the way you always have until you hear from us Future Trainings will be offered Please sign contact sheet if you are not registered with us

16 Review Area Updates Laboratory Services: there are a number of genetic tests added effective January 1, 2013 that require PA. Please check the published code list for a list of these services and requirements. Nerve Conduction Studies: CPT Codes are new codes added 1/1/13 and REQUIRE PA. If you have received denials for these services you need to contact APS to get prior authorizations. The EMG codes and are add-on codes that do not require PA. Physical/Occupational Therapy: The new PT/OT manual is not yet effective. Until the effective date of this manual providers may continue to use the WVMI system OR may use CareConnection to request prior authorization per requirements of the existing manual.

17 Review Area Updates Dental and Orthodontic: The orthodontic criteria are now available on a separate form available on the APS and WVMI websites. This criteria form must be completed and attached to all orthodontic requests. Failure to attach the form will result in a delay in reviewing the request. DME: While the system allows 3 days (72 hours) from SSD to initiate prior authorization before being considered a retrospective request the POLICY MANUAL (Chapter 506) indicates prior authorization must be obtained BEFORE service provision/equipment placement. This administrative feature DOES NOT override policy. The exceptions are apnea monitors, O2 systems and nebulizers as outlined in policy.

18 Review Area Updates Acute Inpatient: Admissions for labor and delivery DO NOT require prior authorization. A list of DRG s related to labor and delivery has been added to the Master code list for provider reference. Admissions for a medical condition (other than those exempted) require prior authorization within 72 hours of admission even if the member is pregnant. Acute Inpatient: When requesting prior authorization for Medicaid members involved in a motor vehicle accident an accident/police report IS NOT required. In these cases the request must indicate in the notes section that the admission is attendant to a MVA.

19 FAQs Who do I contact with questions and concerns? A: Clinical inquiries will continue to be handled by WVMI, technical inquiries (log-on, passwords, registration, C3 assistance, etc.), training requests and questions about CareConnection will be handled by APS. Complaints should be directed to APS and will be routed to the appropriate parties for follow-up. APS- Medical Services: ; [email protected] Who do I contact if I have a question about a prior authorization? A: If you are trying to determine if the case has been denied or approved, first look in the C3 system. If you do not know how to do this, please call APS and we will teach you how. If you have faxed a request to WVMI, are registered with APS and do not see it in the C3 system, call WVMI. If you are not registered with APS, call APS to get registered. What do we do if we realize the date of service is wrong? A: Contact APS either by phone or explaining what the correct date of service should be, the authorization request ID, and any other pertinent information related to the case. APS will issue an IT ticket and within 72 hours, you will be able to re-submit your bill. Where do I find what covered services are available to members? A: BMS Manual Chapters are available on the BMS website at

20 APS Contact Information Main Telephone: Medical Services ONLY: Local: Voic ONLY: ext Fax: Web Address: General Medical Services Helen Snyder, Associate Director ~ [email protected] ext Heather Thompson, UM Coordinator~ [email protected] ext Sherri Jackson, Office Manager ~ [email protected] ext Denise Burton, UM Coordinator ~ [email protected] ext Alicia Perry, Eligibility Specialist ~ [email protected] ext Jackie Harris, Eligibility Specialist ~ [email protected] ext LeAnn Phillips, Eligibility Specialist ~ [email protected] ext. 6906