View
5
Download
0
Category
Preview:
Citation preview
ColoradoPAR Program
Pediatric Long Term
Home Health Services
(LTHH)
August 2015 http://co.eqhs.org http://co.eqhs.org
Agenda
• Introduction to eQHealth Solutions
• Scope of Services
• Overview of the PAR process
• eQSuite®
• Contacts and resources at eQHealth Solutions
• Key Dates for PAR’s during Transition period
• Questions & Answers
• Training Evaluation and Feedback
2 http://co.eqhs.org http://co.eqhs.org
Introduction to eQHealth
Solutions
•A non-profit population health management
and technology solutions company
• Selected by the Colorado Department of
Health Care Policy and Financing to prior
authorize services for Colorado Medicaid
clients
• Effective: September 1, 2015
3
http://co.eqhs.org http://co.eqhs.org
APPROACH Clinically Focused
Outcomes Oriented
Technology Driven
4 http://co.eqhs.org http://co.eqhs.org
HIGH TECH HIGH TOUCH
eQSuite® - Proprietary cloud-based
technology platform
Utilization Review/Prior
Authorization
Clinical Integration
Business intelligence
Denver based Project Director,
Medical Director, Clinical Nurse
Manager and Provider Education &
Outreach Specialist.
Colorado dedicated:
Customer Service staff
Provider website –
http://co.eqhs.org
(prior to 9/1/15)
http://coloradoPAR.com
(after 9/1/15)
General and customized webinar
training
Email communication specific to
service type
Scope of Services
Prospective PAR Determinations
• Diagnostic Imaging
• Durable Medical Equipment
• Physical & Occupational Therapy • Medical
– Transplants
– Surgical Procedures: such as Bariatric surgery
– Molecular Testing – BRCA1 and BRCA2
• Pediatric Long Term Home Health
• Private Duty Nursing
• Out of State Non-emergency Inpatient Stays
• Audiology
• Synagis®
• Vision
5 http://co.eqhs.org http://co.eqhs.org
Scope of Services
• 24 hour access for PAR submissions
• Provider Communication and Support
• Provider Education and Outreach
• Comprehensive Utilization Management Program
– Prior Authorization Review (PAR)
– Retrospective Reviews
– Reconsiderations and Peer-To-Peer reviews
– PAR Revisions
– Real time access to provider reports
6 http://co.eqhs.org http://co.eqhs.org
Scope of Services
Prior authorization through eQSuite® is required when
the item or service code requires an authorization as
defined by the ColoradoPAR program.
Please be sure to VERIFY the Client’s eligibility for CO Medicaid
and determine whether the service requires prior authorization
before submitting a PAR request.
Reminder: Prior Authorization does not guarantee Medicaid
payment for services.
7 http://co.eqhs.org http://co.eqhs.org
Long Term Home Health
The Home Health benefit provides services from a
licensed and certified Home Health Agency (HHA) for
clients who need Intermittent Home Health Services.
Home Health Services include:
– Skilled Nursing (RN/LPN)
– Certified Nurse Aide Services (CNA)
– Physical Therapy (PT)
– Occupational Therapy (OT)
– Speech/Language Pathology (SLP) services
8 http://co.eqhs.org http://co.eqhs.org
Medical Necessity
To meet the criteria for Medically Necessity the
services shall:
• Be reasonably expected to prevent, diagnose,
cure, correct, reduce or ameliorate the pain
and suffering, or the physical, mental,
cognitive, or developmental effects of an
illness, injury or disability. It may include a
course of treatment that includes mere
observation or no treatment at all;
• Be provided in accordance with generally
accepted standards of medical practice in the
United States;
9 http://co.eqhs.org http://co.eqhs.org
Medical Necessity
Continued • Be clinically appropriate in terms of type,
frequency, extent, site, and duration;
• Not be primarily for the economic benefit of the
provider or for the convenience of the client,
caretaker, or provider; and
• Be performed in a cost effective and most
appropriate setting required by the client’s
condition.
10 http://co.eqhs.org http://co.eqhs.org
PAR Required
Acute Home Health: 60 days or less– No PAR
required
Long Term Home Health Services – PAR required
– Pediatric recipients under the age of 21
– Services to be authorized: Skilled Nursing, Certified
Nursing Assistant, Physical Therapy, Occupational
Therapy, Speech Therapy
– Long Term home based therapy services are only
available to recipients 20 years of age or younger.
• Recipients ages 21 and older who continue to require therapy
after the initial Acute Home Health period may obtain Long-
Term Therapy Services in an outpatient setting
11 http://co.eqhs.org http://co.eqhs.or
g
• Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is a federal Medicaid regulation that requires the state Medicaid agency to cover services, products, or procedures for Medicaid clients ages 20 and younger if the service is medically necessary to correct or ameliorate the physical, mental cognitive or developmental effects of an illness, injury or disability.
• EPSDT covers most of the medical or remedial care a child needs to improve or maintain his/her health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.
• Under EPSDT, children ages 20 and younger are eligible for Home Health care with less restrictive limitations than adults over age 21.
Early and Periodic Screening,
Diagnosis and Treatment
12
Discipline Type of Visit Comments
RN/LPN • Standard Nursing Visit
• Brief Nursing Visit
• First nursing visit of
the day
• Multiple visits in one
day for uncomplicated
skilled tasks that can be
completed in a shorter
or brief visit
PT/OT/SLP Visit up to 2.5 hours For clients ages 20 and
younger.
CNA • Initial Visit
• Extended Visit
• One Hour
• For visits lasting
more than one hour,
extended units of 15-
30 minutes
LTHH Visit Types
13
All LTHH PAR submissions must include:
• The complete and current plan of care using the CMS-485 or other document that is identical in content which must include a clear listing of:
• Client’s diagnoses that will be addressed by Home Health, using V-codes whenever appropriate,
• The specific frequency and expected duration of the visits for each discipline ordered,
• The duties/treatments/tasks to be performed by each discipline during each visit,
• All other supporting documentation to support your request including physician’s orders, treatment plans, nursing summaries, nurse aide assignment sheets, medications listing, etc,
• Any other documentation deemed necessary by the Department or its authorizing agency.
LTHH PAR Submission Requirements
14
• Providers are required to submit the PAT Tool with PAR requests. Initially this will be done as a paper attachment.
• The score on the PAT tool is used as a piece of the necessary information by eQhealth reviewers to determine the medical necessity of requested Home Health services.
• When requesting additional services outside of those identified in PAT, provide additional clinical information demonstrating medical necessity.
Pediatric Assessment Tool (PAT)
15
PAR Required
A full list of codes requiring prior authorization can be found in the:
COLORADO MEDICAL ASSISTANCE PROGRAM
Home Health
Billing Manual
https://www.colorado.gov/pacific/hcpf/billing-manuals
16 http://co.eqhs.org http://co.eqhs.or
g
Prior Authorization
Requests
All prior authorization requests (PARs)
must be submitted via eQSuite®,
eQHealth’s proprietary, web-based
utilization management system.
17 http://co.eqhs.org http://co.eqhs.org
First Level Screening
Verification:
• The client is eligible for services on the
date of service requested.
• The request is for a benefit reviewed under
the ColoradoPAR Program.
• The request is not a duplication.
• The required supporting documentation is
complete, legible and conforms to all
Colorado Medicaid’s policy requirements.
18 http://co.eqhs.org http://co.eqhs.org
First Level Clinical
Review After submission through eQSuite®, the review goes
to a 1st level clinical reviewer who performs the
review by applying Colorado Medicaid approved
criteria.
Our 1st level reviewers are licensed registered nurses
who have at least 3 years of clinical experience who
are trained in Medicaid state specific regulations.
19 http://co.eqhs.org http://co.eqhs.org
First Level Clinical Review
Determinations First Level Clinical Reviewers may:
• Approve the service as requested based on
Department approved criteria.
• Pend if additional or clarifying information is
needed.
The requesting provider will be immediately notified by:
Receiving an eQSuite® email/notification
• Refer the request to a physician reviewer for review
and determination.
• Deny the request for non-compliance with HCPF
policy (technical denial).
First level clinical reviewers do not make medical necessity adverse determinations.
20 http://co.eqhs.org http://co.eqhs.org
Second Level Clinical
Review
Our 2nd level physician reviewers are licensed
physicians of Medicine or Osteopathy in active practice
and board certified in the specialty for the service they
are asked to review.
Physician peer reviewers base their determination on
generally accepted professional standards of care, on
their clinical experience and judgment and peer to
peer consultation with the ordering physician
21 http://co.eqhs.org http://co.eqhs.org
Second Level Clinical
Review Physician reviewers may:
• Approve the service(s) as requested
• Pend the review for additional information, including a request for a peer to peer consultation. If the request for additional information is not received and/or the peer to peer consultation is not completed within 4 business days, the physician reviewer will render a determination based on the information available.
• Render an adverse determination. An adverse determination may be a full or partial denial of the requested services or a reduction in services
Note: A peer to peer consultation will be attempted prior to an adverse determination
22 http://co.eqhs.org http://co.eqhs.org
PAR Determinations
PAR Determinations are completed within 4 business
days of receipt of all the required information.
Up to an additional 4 business days may be granted,
prior to an adverse determination, to complete a
peer to peer consultation.
Determination notification letters are mailed to the
provider and the client by the Department’s fiscal
agent.
23 http://co.eqhs.org http://co.eqhs.org
PAR Reconsiderations
• Both the ordering and treating provider may request a PAR
reconsideration of an adverse determination.
• PAR reconsiderations must be submitted within 10
calendar days of the adverse determination.
• PAR reconsideration requests may be submitted:
• Electronically (eQSuite®)
• Fax
• Phone
• eQHealth Solutions’ response time for Reconsiderations:
• Expedited - two business days
• Standard – four business days
24 http://co.eqhs.org http://co.eqhs.org
Timelines
25 http://co.eqhs.org http://co.eqhs.org
Submission eQHealth Response PAR Duration
Prior to delivery of
services
Expedited – 2 business
days
Standard – 4 business
days*
May be up to 364 days
(From and Through
dates)
Retrospective – client
was not eligible at the
time services were
provided and services
have ended.
4 business days
* An additional 4 days may be allowed for completion in order to complete a
peer-to peer review.
PAR Submission
When eQHealth is provided with the complete PAR request:
– On business days: • From 12:00 a.m. – 5:00 p.m.(MST) - it is considered
received that day
• After 5:00 p.m. thru 11:59 p.m. (MST) - it is considered received on the next business day
– On holidays - it is considered received on the next business day.
– On days following state approved closures, e.g., natural disasters - it is considered received on the next business day.
26 http://co.eqhs.org http://co.eqhs.org
Expedited Review
A PAR review that is required to be done on an
expedited basis because a delay could:
a) Seriously jeopardize the life or health of the client
or the ability of the Client to regain maximum
function, or
b) In the opinion of a physician with knowledge of the
Client’s medical condition, would subject the Client
to severe pain; and cannot be adequately managed
without the care or treatment that is the subject of
the claim.
27 http://co.eqhs.org http://co.eqhs.org
Lack of Information
If a PAR request is pended back to the requesting provider for additional or
clarifying information:
The requesting provider will be immediately notified by:
• Receiving an eQSuite® email/notification.
A follow-up phone call will be made to the requester prior to the request
being denied based on lack of information.
The additional information must be received within four business days
If the information is not received, the request will be denied for a
Lack of Information (LOI) and a new request must be submitted.
28 http://co.eqhs.org http://co.eqhs.org
Examples of Supporting
Documentation
REFER TO THE HCPF’S PROVIDER MANUAL FOR ITEM
SPECIFIC INFORMATION:
https://www.colorado.gov/pacific/hcpf/provider-forms
– PDN Acuity Tool
– Plan of Care (CMS-485) or other document with nursing assessment, hospital discharge summary, physician’s plan of treatment and orders and other documents to support the medical necessity and frequency of requested services.
29 http://co.eqhs.org http://co.eqhs.org
Change of Provider
If a change of provider is required after a PAR is
completed, assist the client in completing the
“Change of Provider Form” located on
(ColoradoPAR.com, Provider Resources, Forms and
Instructions)
– Faxed submissions – include the form with the Prior
Authorization Form.
– eQSuite® submissions:
• Fax the “Change of Provider Form” prior to
entering the review request in eQSuite®
• Include the form with the supporting
documentation.
30 http://co.eqhs.org http://co.eqhs.org
PAR Revisions
If a client’s needs change after a PAR review has been completed:
eQSuite® submitters can:
• Respond “yes” to the question “Is the request to modify a previously approved Treatment Authorization Number (TAN)?
• Enter the previous PAR number
• Proceed with the review request
Paper submitters:
• Submit a new Prior Authorization Request form
• Clearly document “revision” on the top of the form
All revision requests require clinical review.
Turn-around time for PAR Revisions is 4 Business Days
31
http://co.eqhs.org http://co.eqhs.org
eQSuite®
eQSuite® is eQHealth Solutions proprietary
web-based HIPAA compliant software system
that offers providers 24/7 accessibility to
the information and functions needed to
obtain prior authorizations.
32 http://co.eqhs.org http://co.eqhs.org
eQSuite®
eQSuite® features include:
• Create and submit electronic review requests
• Respond to requests for additional information
• Submit documentation
• Respond to adverse determination
• Search for previously submitted requests
• Real-time access to view and download reports
• Online helpline module for submission of inquiries and issues
• Update user profiles
33 http://co.eqhs.org http://co.eqhs.org
eQSuite®
Minimal Computer System Requirements
Any of the two most recent versions of:
Internet Explorer
Google Chrome
Mozilla Firefox
Safari
Broadband internet connection
34 http://co.eqhs.org http://co.eqhs.org
eQSuite® Login
35 http://co.eqhs.org http://co.eqhs.org
Login from coloradoPAR.com home page
eQSuite® Login
36 http://co.eqhs.org http://co.eqhs.org
eQSuite® Functions
37 http://co.eqhs.org http://co.eqhs.org
eQSuite® Home Page – To
create a New Review
38 http://co.eqhs.org http://co.eqhs.org
eQSuite® Home Page – To
create a New Review
39 http://co.eqhs.org http://co.eqhs.org
To create a New Review
40 http://co.eqhs.org http://co.eqhs.org
eQSuite® PAR Request
41 http://co.eqhs.org http://co.eqhs.org
eQSuite® PAR Request
Diagnosis
42 http://co.eqhs.org http://co.eqhs.org
eQSuite® PAR Request
43 http://co.eqhs.org http://co.eqhs.org
Item
s
eQSuite® PAR Request
44 http://co.eqhs.org http://co.eqhs.org
Dates Tab
eQSuite® PAR Request
45 http://co.eqhs.org http://co.eqhs.org
All Tabs for PDN review
eQSuite® PAR Request
46 http://co.eqhs.org http://co.eqhs.org
Uploading Supporting
Documentation
47 http://co.eqhs.org http://co.eqhs.org
Uploading Supporting
Documentation
48 http://co.eqhs.org http://co.eqhs.org
Submitting Supporting
Documentation
Please submit all supporting documentation electronically.
If unable to submit electronically, please submit by fax.
The review- specific fax cover sheets are available for download and print as soon as the review request is completed and entered into eQSuite®.
Each fax cover sheet includes a bar code that is specific to the particular recipient and the type of information required.
You must use only the assigned fax cover sheet for the specific type of supporting documentation.
Do NOT copy or reuse fax cover sheets!
49 http://co.eqhs.org http://co.eqhs.org
eQSuite® Attachments
50 http://co.eqhs.org http://co.eqhs.org
eQSuite® “Search”
51 http://co.eqhs.org http://co.eqhs.org
eQSuite® Reports
52 http://co.eqhs.org http://co.eqhs.org
Respond to Denial
53 http://co.eqhs.org http://co.eqhs.org
eQSuite® Online Helpline
54 http://co.eqhs.org http://co.eqhs.org
Getting Started
1. Complete the “Request for eQSuite® Users Form”. You can locate this
form by clicking on the link below or by visiting our website http://co.eqhs.org
http://co.eqhs.org/Portals/2/Request%20for%20eQSuite%20Access.pdf
Assign an eQHealth Liaison
Assign a System Administrator
Sign and date
Scan or fax
2. System Administrator
Assign logons to staff
Assign roles to staff based on job responsibilities
55
http://co.eqhs.org http://co.eqhs.org
eQSuite® User Administration
56 http://co.eqhs.org http://co.eqhs.org
eQSuite® Update my Profile
57 http://co.eqhs.org http://co.eqhs.org
ALL PARs must be submitted
via eQSuite® Exceptions to this requirement are only if:
– The provider is visually impaired, or
– The provider is out-of-state, or the request is
for an out-of area service, or
– The provider submits, on average, five or
fewer PARs per month and would prefer to
submit a PAR by telephone or facsimile.
The eQSuite® Exception Request Form can be downloaded from
our website, Provider Resources, Forms and Instructions.
58 http://co.eqhs.org http://co.eqhs.org
Transition
59 http://co.eqhs.org http://co.eqhs.org
Providers should continue to submit online PARs using the current provider portal, CareWebQI, until the following dates:
Last day to submit a new non-urgent PAR is
Tuesday, August 25th.
If a provider does not submit the new PAR by August 25th, the provider must wait until September 1st to submit the PAR via the eQSuite® PAR portal. The PAR may be backdated to August 26th.
Last day to submit an expedited PAR is Friday, August 28th.
Contact Us
60 http://co.eqhs.org http://co.eqhs.org
Customer Service –toll free Phone: 1-888-801-9355 (M-F, 8 a.m.-5 p.m., MST)
Fax: 1-866-940-4288
Jennifer Wick – Sr. Provider Relations Specialist 720.573.7935
co.pr@eqhs.org
Michael Modiz – Colorado Program Director
mmodiz@eqhs.org
Website effective now
http://co.eqhs.org
Website effective September 1st
http://coloradoPAR.com
eQHealth Solutions Colorado
303 East 17th Avenue, Suite 220, Denver, CO 80203
Recommended