Molina/BMS 2016 Fall Provider Workshops

Molina/BMS 2016 Fall Provider Workshops

Molina/BMS 2016 Fall Provider Workshops Updates October 2016 1 Whats New? APS Healthcare, Inc. was acquired in May 2015 by KEPRO. August 1, 2016 APS Healthcare, Inc. formally changed its company name to KEPRO to unite with its parent companys brand, mission and values. All future business activity will be conducted under the KEPRO name. 2 KEPRO Scope of Work Existing Programs Health Homes I/DD Waiver Services ADW Waiver Services Personal Care Services TBI Waiver Services Nursing Home PAS Review Behavioral Health Services Medical Services BHHF

BCF-Socially Necessary Services New Programs Non-EMERGENCY Ambulance Transportation (Not NEMT) 3 Websites/Direct Data Entry Portals If you have submitted requests via the direct data entry on one of APS web-portals, that web address has changed to reflect the name change to KEPRO. The submission process has NOT changed. Medical Requests: Health Homes:

Behavioral Health Nursing Home PAS Personal Care Aged & Disabled Waiver I/DD Waiver TBI Waiver 4 WV Medicaid Health Homes Program A Health Home provides a comprehensive system of care coordination for Medicaid members with chronic conditions. Health Home Providers coordinate all primary, acute, behavioral health and long-term services and supports to treat the whole person across a Medicaid members lifespan. Members are free to choose any provider for treatment services; therefore, your current patients can remain with you. Current Health Home member enrollment = approximately 700 members. There are currently seven (7) existing Health Homes Providers located in Cabell, Kanawha, Mercer, Putnam, Raleigh and Wayne counties: FMRS HEALTH SYSTEMS MARSHALL HEALTH PRESTERA CENTER FOR MENTAL HEALTH PROCESS STRATEGIES SOUTHERN HIGHLANDS COMMUNITY HEALTH CENTER WOMENCARE, INC. (FAMILY CARE)

WV HEALTH RIGHT 5 Health Homes Quality Measures During the SFY 2015, a total of 1,243 individuals received Health Homes Program services; 82 were new Medicaid members who had not received any Medicaid services in SFY 2014. 118 Health Homes Program members were reported as Hepatitis positive; 161 were identified at high risk for Hepatitis. 732 (59%) Health Homes Program members smoke/and/or use tobacco; 473 received smoking and tobacco use cessation. 100% of the enrollees age 12 and older were screened for depression; 79% were clinically depressed at the time of the screening. SFY 2015 emergency department costs were reduced by $17,639 for Health Homes Program members. A 42% reduction in the average length of stay in a hospital for all Health Homes Program members who had Medicaid coverage in both SFY 2014 and SFY 2015. Those members who were enrolled in a Health Homes for the entire year saw a decrease of 32% from SFY 2014. The decrease can be attributed to better discharge planning. Additional Health Homes Program information is available on the WV Bureau for Medical Services website: or KEPRO: Questions/concerns contact KEPRO at 304-343-9663 or 1-800-461-0655 6 Personal Care Services Update Policy manual revision posted 10/1/2016. PAS can now be signed by FNP/PA-C. Agencies are required to include all documentation in the request (POC and assessment required for all requests).

If services do not start within 60 days of authorization, reauthorization must be requested. For questions, contact the Bureau of Senior Services (304)558-3317; (877)987-3646 7 Traumatic Brain Injury (TBI) Waiver Updates 300 units per Calendar Month on Non-Medical Transportation Services Code Personal Attendant Services: Can be provided on the day of admission and the day of discharge from a nursing home, hospital or other inpatient medical facility. At no time may the time spent on Incidental services (changing lines, meal preparation and light housekeeping) exceed the amount of time spent on handson-personal acre assistance. KEPRO is able to verify the following to assist providers with denied claims: Authorization span KEPRO will correct or modify the authorization span, when applicable and appropriate. Authorization number(s) KEPRO will correct or modify the authorization number or create a new authorization number, when applicable and appropriate. Financial eligibility/Medicaid Benefit Plan coverage KEPRO will notify the provider of the issue; the provider must follow up with the member's local DHHR to have the coverage type corrected. 8 Reminders to Providers Submitting

Medical Prior Authorization Requests Remember to update your contact information when submitting via DDE (direct data entry). This should include extensions. Having the incorrect contact information can result in cases being closed and delaying services to the patient. Remember to make sure that the referring/servicing providers are active in Molina- KEPRO cannot export authorizations to Molina when the referring or servicing provider is termed. Just because a provider can be selected in our system does not mean the provider is active. Remember user log-ins are only to be used by the person they are assigned to. Each registered provider has an organization manager who can add a user. Password resets completed by KEPRO staff can only be done for the user to whom the log-in is assigned. Remember to Search by CPT/HCPCS Codes when selecting services-this will ensure that when services are grouped the correct group is selected. Remember to attach all clinical information referenced or required in the request if you indicate attached (e.g. diagnostic reports, H&P, imaging findings, lab results, etc.) Please remember that a case may be pended for additional information. You may want to check the C3 system to be sure no additional documentation has been requested. This will prevent closure of the request in the absence of the necessary clinical documentation. A facilitys IQ review does not replace clinical documentation. It is fine to include this with a request, but we must receive the appropriate clinical information to conduct a review. 9 Faxing Prior Authorization Requests or Attachments If faxing attachments for a request that has been submitted via Direct Data Entry (DDE), please make sure to use the proper fax cover sheet, and make sure you put the Authorization Request ID on the form. We cannot attach

information without that ID because a patient could have multiple requests and we wouldnt have any way of knowing which one it is for. If submitting an authorization request via fax, you MUST fill out the form in its entirety. UM Support staff who enter the requests are not authorized to guess on any information that is left blank. Any additional documentation needs to be submitted with the faxed request. Failure to do so could result in having the request faxed back to you or the request being closed because the information requested was not received in a timely manner. Providers who fax requests are still required to check the C3WV system to determine approvals/denials and to check status of the request. Diagnosis, CPT, or HCPC descriptions will not be accepted. UM Support staff cannot retrieve this information from the order/CMN. Please be sure that the start date listed on the form is correct. Failure to do so can result in a case being denied for retrospective policy. 10 Medically Urgent Prior Authorization Requests Definition of Medically Urgent A delay could seriously jeopardize the life or health of the consumer A delay could seriously jeopardize the ability of the consumer to regain maximum function In the opinion of a physician with knowledge of the consumers 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 drop-down. 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 reviewed as medically urgent. 11 Reminders Regarding Urgent and Phone Prior Authorization Requests Please only mark requests urgent when they meet the medically urgent definitions listed on the previous slide. Telephone requests are only entered for review types and circumstances listed and accepted as medically urgent. Requests can only be expedited when the two-day review timeline has passed AND when delaying the review can cause problems for the MEMBER. (e.g. A provider entering a request one day prior to an elective surgery and a possibility of having to reschedule is not a reason to expedite a request; a member with cancer does not necessarily need to have an imaging request expedited unless the request is already out of timelines and the procedure is scheduled for the next day, etc). DME requests are ONLY considered emergent when the members discharge order has already been signed and they cannot be released until the equipment is available OR for apnea monitors or nebulizers for children under three years-of-age.

Retrospective requests are not considered medically urgent. Although the study may have been medically urgent at the time, once the study is completed it is no longer an urgent request. 12 Vision Update The Bureau for Medical Services has reached a decision to remove the recent prior authorization requirement on the following CPT codes: 92002, 92004, 92012, 92014, 92018, and 92019. Effective September 1, 2016. As of September 1, 2016, we began faxing back requests for these Vision Codes. KEPRO removed these codes from their PRODUCTION system and from the listing of codes requiring prior authorization. KEPRO, Molina, and BMS will place announcements on their websites. BMS has updated the Vision Chapter in the Provider Manual to remove the Vision PA requirement on these codes. Molina has removed the PA requirement on these codes and will reprocess claims back to May 1, 2016. Adults 21 Years of Age or Greater: Eye Examinations are limited to comprehensive exam/evaluation for medical necessity only. Visual examinations to determine the need for eyeglasses are covered for children only. Additionally, diagnostic evaluations and examinations may be reimbursed when documentation in the medical record justifies the medical need for more frequent exams. The Provider Manual Vision Chapter 525.1.1 can be located at The Vision Webinar PowerPoint is available at

13 Laboratory Updates Points to Remember There is a proposal for an upcoming change effective January 1, 2017. Drug screening codes will require prior authorization for medical necessity after 2 units per calendar month. The list of codes requiring PA will be updated to reflect this change. Current requirement for prior authorization is 30 units per calendar year. Specimen validity testing is not eligible to be separately billed under any procedure code. The code description for G0477 G0483 indicates that this testing is included if it was performed. Drug confirmation testing is not eligible to be separately reported under any procedure code, unlisted or otherwise. This service is considered included in the presumptive or definitive drug testing procedure codes (G0477 G0438). Be on the look out for possible code change/update in 2017. 14 Laboratory Updates Criteria for Substance Abuse Treatment and Program Monitoring: Member non-compliance with prescribed drug regimen OR evidence of intoxication or behavior suggesting recent use; The provider believes a previous sample has been tainted; Reports from members support network OR other medical providers indicate that drug screening in excess of 30 in the calendar year are indicated; Chaotic or deteriorating function despite apparent treatment compliance;

Testing should be in compliance with the Federal opioid treatment standard (42 CFR 8.12) that states Opioid Treatment programs must provide adequate testing or analysis of drugs of abuse, including at least (6) random drug abuse tests per year (but no more than one test per month) for members maintenance treatment. Justification for medical necessity to exceed 30 drug screens in a calendar year must be provided to support the request. This includes but is not limited to: Progress notes indicating reports of non-compliance or abuse and treatment progress; Documentation of incidences of suspected intoxication; Member treatment plan indicating why more than 30 screens are indicated in a calendar year and anticipated outcomes specifically related to additional testing; Documentation of circumstances leading to suspicion of tainted sample(s); Documentation must support one of the criteria above and provide documentation that additional screens are not for confirmatory purposes ONLY Criteria for Emergency Drug Screening: Unexplained coma; Unexplained altered mental status in the absence of a clinically defined toxic syndrome; Severe or unexplained cardiovascular instability; Unexplained metabolic or respiratory acidosis; Seizures with an undetermined history. Prior authorization is ONLY required to EXCEED 30 drug screens in a calendar year. Prior Authorization requests to exceed 30 screens in instances where the member has used the allowable screenings only need to include the medical justification listed above AND should be submitted as EMERGENT requests. NOTE: Screening performed in the ER is part of the ER visit and does not require separate prior authorization. 15 Laboratory Updates Criteria for Drug Screening for Pain Management Programs: Testing is performed as a baseline screening before initiating treatment AND a plan is in place to

use the test findings clinically; Subsequent monitoring is done at a frequency appropriate for the risk level of the member. To determine a members risk, providers should use a validated screening tool. In addition, members should also be screened for behavioral health conditions that may increase their risk of misuse of controlled medications and/or overdose. In cases of use/abuse or monitoring suspected abuse, testing should be in compliance with the Federal opioid treatment standard (42 CFR 8.12) that states Opioid Treatment programs must provide adequate testing or analysis of drugs of abuse, including at least (6) random drug abuse tests per year (but no more than one test per month) for members maintenance treatment. Justification for medical necessity to exceed 30 drug screens in a calendar year must be provided to support the request. This includes but is not limited to: Progress notes indicating reports of non-compliance or abuse and treatment progress; Documentation of clinical findings from previous screens supporting the need for additional testing; Member treatment plan indicating why more than 30 screens are indicated in a calendar year and anticipated outcomes specifically related to additional testing as well as coordination with behavioral health programs if abuse is determined or suspected (including referrals and care coordination if member is receiving active treatment) 16 DMEPOS (Prosthetic & Orthotic) Prior Authorization Requests Incontinence supplies are not to exceed 200 diapers per month, 150 underpads per month, or combination of 250 per month with neither exceeding their individual service limit. DME providers must complete a written DME home assessment before authorization is requested, which includes, but is not limited to, the access to and physical layout of the home, doorway width, doorway thresholds, floor surfaces, and turning radius. The home must be

able to accommodate the DME. Providers must document in the medical record at each occurrence. If requests for equipment exceed service limits, medical documentation/justification is required as to why the limit needs exceeded. Vendors requesting items using a miscellaneous code (E1399 or K0108), as well as any item that requires a cost invoice, must provide a quote for the item(s) being requested. Back-up ventilators are only authorized for members who live 30 miles or greater from a trauma center or hospital that handles ventilators. Requests for DME to follow discharge from long-term care facility must include physiciansigned discharge order or physician-signed discharge summary. We are unable to accept clinical information older than 6 months (ex: sleep studies, oxygen saturations, office notes, hospital records, etc). To support a request for prior authorization. The quantities for each item must be submitted (whether it is documented in C3, or preferably listed on the CMN) because C3 defaults quantities to one, even if a different amount is submitted. 17 DMEPOS (Prosthetic & Orthotic) Prior Authorization Requests Manufacturers warranty for DME is required for not less than one year. When the item is under warranty and repair or replacement is required, the provider of the service is responsible to provide the repair and/or replacement. The warranty begins on the date of the delivery to the member. The original warranty must be given to the member and a copy is maintained in the members individual medical record. A copy of the warranty must also be provided to Medicaid or its designee upon request. For repairs of DME, vendors must provide: Written service tech evaluation form indicating specifically what is wrong with item/equipment, quote for parts, as well as quotes for repair versus replacement. Wheelchair requests with multiple accessories MUST have patient-specific justification for all

accessories. If a request for replacement wheelchair (ex: upgrading from manual wheelchair to PWC) within the service limits of 5 years; vendors must provide clinical documentation signed by the prescribing practitioner indicating how the member has changed functionally since placement of original wheelchair, to justify the need to exceed the service limits. The quantities for each item must be submitted (whether it is documented in C3 notes, or, preferably listed on the CMN) because C3 defaults the quantities to a specific amount which may be greater or less than the amount needed. For codes requiring Cost invoices- the cost invoice must be non-altered and specify the individual Medicaid member. We cannot accept quotes or screen-shots of shopping carts as invoices. The cost calculation form should match the pricing on the cost invoice. The requested codes should also be listed on the cost invoice. 18 Imaging Prior Authorization Requests Remember to attach or fax information to justify medical necessity. This is includes but is not limited to: Symptoms. Physical examinations. Previous imaging studies (MRI, CT, X-ray) with results and date(s) of procedures. Remember to report conservative treatment history (e.g. physical therapy/duration; home exercise/duration) and NSAIDS history (duration/dosages)- these are the two most commonly omitted items that are required for review. If these interventions are contraindicated specify reason in medical justification.

Remember to check the Mastercode List or search by the CPT code. There are some studies that do not require authorization. Do NOT just select a code description. Remember to include the number of needle placements needed for CT guided biopsies or ultrasonic guidance for biopsies. 19 OP Surgery Prior Authorization Requests Include all CPT codes and descriptions of service that is needed on the request. The primary procedure should be on the service request line-additional procedures may be placed in the annotation section. We do not select service codes for you! Be sure to include if an assistant surgeon is going to be used. Prior authorization requests require the clinical documentation to support medical justification: Office note(s), complaints or symptoms, physical exam findings, diagnostic testing (labs/x-rays), conservative treatment/medications. When applicable be sure to document which side (left or right), what level, upper or lower extremity, or if the request is bilateral. For services that require photographs and if you are not able to attach to request or fax, please mail to: KEPRO Medical Department 100 Capitol Street, Suite 600 Charleston, WV 25301 Please note if photographs need returned. 20

Dental/Orthodontic Prior Authorization Requests Please use the appropriate ICD-Diagnosis code when submitting requests via DDE. The general ICD-10 Code is R68.89 and can be used for dental requests. X-rays, photographs, periodontal scaling and other documentation may be required for review depending on what is being requested. If you are not able to attach to request or fax, please mail to: KEPRO Medical Department 100 Capitol Street, Suite 600 Charleston, WV 25301 21 If x-rays are mailed, please note if they need to be returned. Speech/Audiology Prior Authorization Requests Speech Therapy Services Short term goals must include baseline data. Parent Waiver Letter is required for school aged patients. A copy of this letter should be sent to the school district to notify them to

not seek Medicaid reimbursement for the relevant services. This must include: The current school year. County of school in which patient attends . Signature of guardian/parent. Please do not use N/A if patient is not in school. Documentation is needed if the patient has graduated, is homeschooled, currently not enrolled, etc. Orders must be for speech therapy, and include diagnosis code or description. Orders expire after one year and must cover timeframe being requested. If patient is part of the IDD Waiver Program and the request is for a chronic condition, the waiver budget should be utilized first. Once the budget is exhausted, authorization may be submitted through the C3WV portal. Hearing Aids/Cochlear Devices Replacement of cochlear accessories (headset, headpiece, microphone, transmitting coil and transmitter cable) is covered for Medicaid members up to 21 years of age AND Medicaid members 21 years of age and older IF the member received a cochlear implant and BMS paid for it before

they reached the age of 21 years. Service limits for hearing aids are one per five years. Just because it has been 5 years, does not mean a new set of hearing aids is necessary- medical necessity needs to be justified. Speech therapy and audiology services may be provided in an outpatient setting by Medicaid enrolled speech language pathologists and audiologists. Acute care and critical access hospitals are not eligible for direct reimbursement for outpatient therapy services or hearing aids. 22 KEPRO Contact Information Behavioral Health Local Line: 304.346.6732 Toll Free: 800.378.0284 Fax: 866.473.2354 Nursing Home PAS

Toll Free: 844.723.7811 Fax: 844.633.8425 General Email: [email protected] Aged & Disabled Waiver Toll Free: 844-723-7811 Fax: 866.212.5053 General Email: [email protected] Email to submit documentation: [email protected] I/DD Waiver Local Line: 304.380.0617

Toll Free: 866.385.8920 Fax: 866.521.6882 General Email: [email protected] TBI Waiver Toll Free: 866.385.8920 Fax: 866.607.9903 [email protected] Personal Care Toll Free: 844.723.7811 Fax: 866.212.5053 General Email: [email protected] Medical

Toll Free: 800.346.8272 General Email: [email protected] Faxes: 844.633.8426 - Bariatric/Inpatient/Inpatient Rehab Under 21/ Organ Transplants 844.633.8427 - Outpatient Surgery 844.633.8428 - Imaging/Radiology/Lab 844.633.8429 - Cardiac & Pulmonary Rehab/DME/Orthotics & Prosthetics 844.633.8430 - Home Health/Hospice/Private Duty Nursing 844.633.8431 - Audiology/Speech/Chiropractic/ Dental/Orthodontic/Podiatry/PT/OT/ Vision 866-209-9632 - Modification Requests/EPSDT/ Out of Network FQHC Toll Free: 888.571.0262 Fax: 866.438.1360 Social Necessity

Local Line: 304.380.0616 Toll Free: 800.461.9371 Fax: 866.473.2354 23 KEPRO Contact Information 1-800-346-8272 MEDICAL SERVICES GENERAL VOICEMAIL- EXT. 7996 MEDICAL SERVICES EMAIL: [email protected] HELEN SNYDER ASSOCIATE DIRECTOR [email protected] EXT. 4463 ANGELA HOBBS UM NURSE SUPERVISIOR [email protected] EXT. 4477 ALICIA PERRY



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