1/ OCTOBER 2008 Presented by ADVANTAGE Care Select and MDwise Care Select Provider Relations

1 / OCTOBER 2008

Presented by ADVANTAGE Care Select and MDwise Care Select Provider Relations

2 / OCTOBER 2008

Agenda

• Welcome• Session Objectives• Eligibility Review – The Key to Success• The Prior Authorization (PA) Process• Questions/Answers

3 / OCTOBER 2008

Session ObjectivesSession ObjectivesFollowing this session, providers will be able to:• Identify the two care management organizations (CMOs)• Understand eligibility and its relationship to PA• Common PA submission procedures by specialty• Common PA processing procedures by specialty• PA contact information

4 / OCTOBER 2008

Care Select Eligibility ReviewVerify eligibility using web interChange, OMNI or Automated Voice

Response (AVR)

• Always verify the Care Select member’s eligibility• Review the entire eligibility record to determine the

member’s Care Management Organization (CMO)• The member’s CMO affiliation determined on the date of

eligibility verification determines everything:1. Which CMO receives a PA request 2. Member’s Care Manager3. CMO who processes restricted card information4. Where members can change primary medical providers

(PMP)

5 / OCTOBER 2008

Care Select Eligibility Review

Reminders:

• Know the member’s assigned PMP and contact information• Providers rendering services that require the PMP’s two

character certification code must obtain that certification code prior to rendering the service (see BT200804 for a list of services requiring the certification code)

• Services where the PMP declines to provide the certification code are non – covered by the Indiana Health Coverage Programs (IHCP)

• A patient waiver as described in Chapter Four, Section 5 of the IHCP Provider Manual can be used if the member insists on receiving the service not authorized by the assigned PMP

6 / OCTOBER 2008

Prior Authorization Process

Two health plans were selected to function as CMOs for the Care Select program

– ADVANTAGE Health Solutions, Inc.sm

• www.advantageplan.com/advcareselect• 1-800-784-3981 – Care Select PA• 1-800-269-5720 – Traditional PA

– MDwise, Inc.

• www.mdwise.org• 1-866-440-2449 – Care Select PA

7 / OCTOBER 2008

CMO Prior Authorization ProcessGeneral Information• The STATE plan requirements for Prior Authorization are the

same for both Indiana Care Select and Traditional Medicaid (FFS)• The Indiana Care Select CMOs PA departments use the OMPP

approved internal criteria in addition to the IAC, PA guidelines, and IHCP bulletins, banner pages, and newsletters when considering PA requests

• PA’s for members belonging to Indiana Traditional Medicaid and ADVANTAGE Care Select are processed by ADVANTAGE

• PA’s for members belonging to MDwise Care Select are processed by MDwise

• The Indiana Care Select CMO’s PA Departments review all non-pharmacy PA requests

• ACS processes pharmacy PA requests• Decisions to authorize, modify, or deny a given request is based

on medical reasonableness, necessity, and other criteria outlined in 405 IAC 5-3 and reflects the current standards of practice in the provider community

8 / OCTOBER 2008

CMO Prior Authorization Process• Submit the PA request to the CMO the member is affiliated with on

the date of requestReminder: ADVANTAGE Health Solutions processes PA requests for Traditional Medicaid members

• Services which require PA due to State regulations are discussed in the IHCP Provider Manual Chapter 6 (Also refer to handout)Reminder: Care Select PA rules are not the same as Hoosier Healthwise PA requirements – don’t get them confused

• Services which require PA are processed according to the guidelines specified in the IHCP Provider Manual Chapter 6Reminder: Do not submit PA requests to a MDwise HHW Delivery System

• New services require a new Prior Authorization request formReminder: Providers may not add new services to an existing PA request as this constitutes a new PA request

Procedures

9 / OCTOBER 2008


Suspended PA Procedures:• Providers have 30 days to submit additional information for a PA that

is suspended

Reminder: Submit this documentation to the CMO you originally sent the PA request to

• Suspended PA requests are denied in 30 days

Reminder: Respond to suspended PA requests timely and if that PA request is denied for timeliness, submit a new PA request

• The preferred method to submit PA requests is via fax or web interChange

Reminder: Submit PA requests in writing or via web and not via phone

10 / OCTOBER 2008


• PA requests are suspended when additional information is needed by the member and/or provider

• Requested documentation must be received within 30 calendar days

• Suspended requests that are later approved are authorized with the dates of service indicated on the original request

• When a member is re-assigned to a different CMO after a PA request is suspended:

– Providers must send the added documentation to the CMO to which the member is re-assigned

– Providers should verify member eligibility via web interChange prior to sending documentation

Suspended Requests

11 / OCTOBER 2008

Prior Authorization ProcessDoes the service require PA under the State Plan?• Examples of general services the State requires PA for:

1. Transplants2. Outpatient surgeries3. Home Health - No inpatient discharge4. Durable Medical Equipment and Home Medical Equipment5. Inpatient psychiatric admissions, inpatient surgeries,

rehabilitation, burn and substance abuse6. Therapies (Physical, Speech, and Occupational) – No inpatient discharge7. Transportation (>20 one way trips or >50 miles one way)8. Outpatient Mental Health (>20 visits)9. Psychiatric Residential Treatment Facility (PRTF)

• Check the fee schedule at www.indianamedicaid.com to determine if a code requires PA

12 / OCTOBER 2008


General Institutional PA Guidelines• Criteria used to process PA requests for institutional services are

located in 405 IAC 5• Inpatient services that require PA are substance abuse, inpatient

psychiatric, surgical procedures, rehabilitation, and certain burn cases

• Days that are not approved by PA are non – covered by the IHCP• The PA Request Form is always required when submitting a PA

(located at www.indianamedicaid.com)

13 / OCTOBER 2008


Note: Free-Standing Inpatient Psychiatric Hospitals or Acute Care Hospital Psychiatric Units

• Pre-certification must be phoned in for all emergent and non-emergent requests

• The Division of Family Resources 1261A must be submitted within 10 days of a non-emergent request and 14 days of an emergent request

• Recertification as specified by the State for continued inpatient psych admissions

• Reimbursement is not allowed if pre-certification and the Form 1261 A are not completed within the time frames specified

Supporting Documents Necessary for Institutional PA Requests

14 / OCTOBER 2008


Psychiatric Residential Treatment Facility (PRTF)

Supporting Documentation Requirements:• Intake Assessment• Form 1261A• Physician History• Physical• Current Inpatient Treatment Plan• Physician Progress Notes• Inpatient Nursing Notes• Physician Recommendation Letter

Psychiatric Residential Treatment Facility PA requests must include the PA request form and the following:

15 / OCTOBER 2008

Prior Authorization ProcessInpatient Emergency Admissions requiring PA• Reported to CMO within 48 hours of admission• See Chapter 8 of the IHCP Provider Manual for a list of

applicable emergency diagnosis codes.• Complete the PA Request form if applicable• Report emergency services to member’s PMP within 48 hours

16 / OCTOBER 2008


Non-Institutional PA Requirements• Criteria used to process PA requests for institutional services are

located in 405 IAC 5

• Practitioners:• Doctor of Chiropractic Medicine• Medical Doctor• Doctor of Osteopathy• Doctor of Podiatric Medicine• Health Services Provider in Psychology• Optometrist

17 / OCTOBER 2008


• Paper and faxed requests are rejected– Requesting provider will receive a decision letter advising of rejected status

• PA requests sent electronically via the 278 transaction are rejected with reason code 78 – Subscriber/Insured not in Group/Plan identified

– Requesting provider will not receive a decision letter

• Providers will need to resubmit the PA request to the appropriate CMO

• PA requests sent via web interChange are systematically routed to the correct CMO

Request Sent to Wrong CMO

18 / OCTOBER 2008


• The following provider types can submit PA requests via web interChange:

– Chiropractor– Dentist– Doctor of Medicine– Doctor of Osteopathy– Home Health Agency (authorized agent)– Hospice– Hospitals– Optometrist– Podiatrist– Psychologist endorsed as a Health Service Practitioner in Psychology (HSPP)– Transportation providers

web interChange

19 / OCTOBER 2008


• Members can change between traditional Medicaid fee-for-service, Hoosier Healthwise, and Care Select

• The receiving organization must honor PAs approved by the prior organization for the first 30 days following the re-assignment, or for the remainder of the PA dates of service, whichever comes first

Example:

Member transitions from Hoosier Healthwise MCO to a Care Select CMO on November 14, 2007. The MCO approved PA for dates of service 10/22/07 through 12/13/07

The Care Select CMO must honor the approved PA for 30 days from November 14, 2007

Outstanding Prior Authorizations

20 / OCTOBER 2008

Prior Authorization Process – Hearings/Appeals

• Procedures for hearings, appeals, and administrative review remain unchanged

• Providers may exercise PA appeal rights to the CMO that denied the PA request

– If the member is re-assigned to another program after the PA request is denied, the provider may send a PA request to the new organization, or appeal to the organization that denied the request

– Appeals sent to the wrong CMO are returned to the provider unprocessed

• Refer to Chapter 6 of the IHCP Provider Manual as well as each CMO’s Provider Manual regarding the hearing, appeal, and administrative review procedures

Hearing, Appeal and Administrative Review

21 / OCTOBER 2008

Physician PA requirements found in 405 IAC 5-25• Bariatric surgery• Blepharoplasties• Bone marrow or stem cell transplants• Brand name medically necessary drugs• Genetic testing for detection of cancer• Home health services• Intersex surgeries• Long-term acute care hospitalization• Mastectomies for gynecomastia• Maxillo-facial surgeries related to diseases of the jaw and

contiguous structures• Organ transplants

Prior Authorization Process - Physician

22 / OCTOBER 2008

Prior Authorization Process - Physician

Physician Services:• PA required for Evaluation and Management (E&M) services that

exceed 30 visits per member per rolling calendar year:

E&M Codes subject to PA after 30 visits:

99201 – 99205 99211 - 99215 99241 - 99245

99381 - 99387 99391 - 99387 99401 - 99429

• Please note: Physician services rendered during an inpatient stay that do not receive PA are not reimbursable

23 / OCTOBER 2008

Prior Authorization Process – Physician

PA requirements for podiatry services are found in 405 IAC 5-26

• Podiatry services rendered during inpatient or outpatient stays that were not require PA

PA requirements for chiropractic services are found in 405 IAC 5-12

• Chiropractic services rendered without PA are subject to denial

24 / OCTOBER 2008

Prior Authorization Process – Home Health

PA criteria for home health services located at 405 IAC 5-16

Note: PA is required for home health services except for those services ordered in writing by a physician before the patient’s discharge from a inpatient stay that do not exceed 120 hours within 30 days of discharge provided by:

• Registered nurse• Licensed practical nurse• Home health aide• PA requests submitted must include the following:• Appropriate home visit nursing level code – 99600 TD-Unlisted

home visit, service, or procedure-registered nurse

25 / OCTOBER 2008

• Copy of written plan of treatment signed by attending physician, current through date of request that documents effectiveness of treatment

• Estimate of costs for the required services ordered by the physician and signed by the physician reflected in plan of treatment

• Number and availability of non-paid caregivers that assist in member care (even if none available)

• Number of members in household receiving home health services to coordinate care efficiently

• Number of hours of service per day, number of visits per day, and number of days per week the service is to be provided


26 / OCTOBER 2008


• Home health visits greater than three per day provided to the same household or member

• Other non-IHCP home health services provided to the member including Medicare, CHOICE, Waiver, private insurance, private pay, school system, and other paid caregivers (include number of hours per day and number of days per week for each service)

• Encounter – direct personal contact between patient and authorized person to furnish services to patient

• Frequency of visits is the number of encounters in a given period between patient and person authorized to furnish services (specific number of range)

27 / OCTOBER 2008


• Prescribed in writing by physician (medically confined to home)• Medically necessary and reasonable• Less expensive than alternative modes of care• Progress notes detailing patient evaluation and physical involvement

by physician to document acute needs

28 / OCTOBER 2008


Medical plan of care must be developed with home health agency and in consideration of all pertinent diagnoses, includes the following:

• Mental status• Types of services/equipment• Frequency of visits• Prognosis• Rehabilitation potential• Functional limitations• Activities permitted

29 / OCTOBER 2008


• Nutritional requirements• Medications and treatments• Safety measures to protect against injury• Instructions for timely discharge or referral• Specific procedures/modalities to be used along with

frequency, amount, and duration of each

Note: The medical plan of care must be reviewed by the practitioner at least every two months

Note: A written summary by the agency must be sent to the practitioner every two months

30 / OCTOBER 2008


New authorization requests for home health services must include:• The clinical summary of PA form must be updated to reflect any

change in patient’s status (as documented in the patient plan of care)

• Non-covered services under home health benefit:• Homemaker• Chore services• Sitter/companion services

31 / OCTOBER 2008

Prior Authorization Process - TherapyGeneral Information

Criteria for therapy services is located in 405-IAC 5-22-6 through 405-IAC-5-22-11

Note: Therapy service PA requests may be submitted by home health agencies or individual therapy providers (See BR200831) for limitations

• PA is not required for:• Initial evaluations• Emergency respiratory therapy• Therapy services ordered in writing by a physician at inpatient

discharge, up to 30 hours, sessions or visits in 30 calendar days

32 / OCTOBER 2008

Prior Authorization - Therapy• Deductible or co-payment for services covered by Medicare• Therapy services provided by a nursing facility of ICF/MR which are

included in the facility’s per diem rate• PA criteria for occupational, physical, respiratory, or speech therapy• Written evidence of physician involvement and patient evaluation

needed to document acute needs• Current plan of treatment• Physician order

33 / OCTOBER 2008

Prior Authorization - Therapy

• Current plan of treatment and progress notes documenting necessity and effectiveness of therapy

• Qualified therapist or qualified assistant under supervision of therapist must provide therapy

• Therapy must be of a level of complexity and sophistication and the condition of the member must be such that judgment, knowledge, and skills of a qualified therapist are required

• Medically necessary• Rehabilitative service covered for a member no longer than two years

from initiation of therapy unless a significant change in medical condition is noted

34 / OCTOBER 2008

Prior Authorization Process - Therapy

• Maintenance therapy not covered• Progress evaluations not separately reimbursable and are covered

as part of the therapy program• One hour of therapy must include minimum of 45 minutes of direct

patient care with balance spent in patient related services• Therapy services not approved for more than one hour per day per

type of therapy• Duplicate therapy services are not covered

35 / OCTOBER 2008

Prior Authorization Process – Mental Health

Mental health PA criteria are listed in 405 IAC 5-20-8

PA required for mental health services provided in an outpatient or office setting that exceed 20 units per member, per provider, per rolling 12-month period

Criteria reviewed:• PA request form• Current treatment plan• Progress notes – necessity and effectiveness of therapy

36 / OCTOBER 2008


Note: PA required for neuropsychological and psychological testing and includes 96101 – psychological testing, 96111 – developmental test extended, and 96118 – neuropsychological testing battery

• PA not required:• 2 units of psychiatric diagnostic interview allowed per 12 months per

member, per provider if a physician or HSPP and a mid level practitioner separately evaluate the member (90801)

• Medicaid Rehabilitation Option (MRO) services are not subject to PA as outlined in 405 IAC 5-21

37 / OCTOBER 2008


Assertive Community Treatment (ACT)

PA is required for ACT services covered by the IHCP per 440 IAC 5.2-2-3 and PA requirements in 405 IAC 5-21-8(d)

• Required Documents:• Assessment of current medical status• Psychiatric history• Status at time of review for ACT• Treatment goals reviewed by ACT team psychiatrist

38 / OCTOBER 2008


Note: Care Select members can self refer to any IHCP enrolled mental health provider. However, mental health services furnished to members by providers enrolled with specialties other than mental health must contact the member’s assigned MDwise Care Select PMP to obtain that PMP’s two character certification code

• All services billed to EDS as fee for service• The CMO’s do not retain a mental health benefits administrator for

their respective Care Select products

39 / OCTOBER 2008

Prior Authorization Process – DME/HME

Medical Supplies and Equipment

Criteria for medical supplies, durable medical equipment, and home medical equipment can be found in 405 IAC 5-19

• PA is not required for the following items:• Cervical collars• Back supportive devices• Hernia trusses• Oxygen, supplies, and equipment for its delivery for nursing facility

residents• Parenteral infusion pumps used with parenteral hyperalimentation• Eyeglasses

40 / OCTOBER 2008


Chapter 6, section 5 details other DME and HME which does not require PA. Also, see the IHCP fee schedule at www.indianamedicaid.com

Oxygen:• All oxygen equipment and supplies require PA for members in a

home setting• Physician order required• Note: DME/HME that is purchased and require repair also require

PA

41 / OCTOBER 2008


A Medical Clearance Form is required for certain types of DME, HME or medical supplies and must accompany the PA request form

Note: The medical clearance form is used to justify the medical necessity of certain DME, HME, or medical supplies:

• Augmentative communication systems – Augmentative Communication System Selection form

• Certificate of Medical Necessity (CMN) for home oxygen therapy – Certificate of Medical Necessity: Oxygen form

• CMN parenteral or enteral nutrition – Certificate of Medical Necessity: Parenteral or Enteral form

42 / OCTOBER 2008


• Audiometric tests for hearing aid fitting – Medicaid Medical Clearance and Audiometric Test form

• Hearing Aids – IHCP Medical Clearance and Audiometric Test form

• Hospital beds – Medical Clearance Form: Hospital and Specialty beds

• Motorized wheelchairs or other power-operated vehicles – IHCP Medical Clearance for Motorized Wheelchair Purchase form

• Negative pressure wound therapy – IHCP Medical Clearance form for Negative Pressure Wound Therapy

43 / OCTOBER 2008


• Non-motorized wheelchairs – IHCP Medical Clearance form for Non-motorized Wheelchair Purchase

• Standing equipment – Medical Clearance Form: Physical Assessment for Standing Equipment

• Transcutaneous electrical nerve stimulator (TENS) – Medical Clearance form for TENS Unit

Note: All forms are available in the IHCP Provider Manual or by contacting EDS Customer Service at 1-800-577-1278 or at www.indianamedicaid.com

44 / OCTOBER 2008

Prior Authorization – DME/HME

PA request for DME and HME are reviewed on a case-by case basis based on the following:

• The item must be medically necessary for the treatment of an illness or injury or to improve the function of a body part

• The item must be adequate for the medical need; however, items with unnecessary convenience or luxury features are not allowed

• The anticipated period of need, plus the cost of the item is considered in determining whether the item is rented or purchased

45 / OCTOBER 2008

Prior Authorization – DME/ HME

Traditional Medicaid members – Nursing home benefits and DME/HME

Note: The IHCP case mix rate for long term care facilities includes costs for the following and cannot be separately authorized or billed to the IHCP:

• Medical and non-medical supplies• Mental health service• Nursing care• Room and board• Therapy services• Transportation• Habilitation

46 / OCTOBER 2008

Prior Authorization - Transportation

PA criteria for transportation services are found in 405 IAC 5-30

PA is required for:• Transportation trips exceeding 20 one – way trips per member, per

rolling 12-month period (exception: emergency ambulance, transport to or from a hospital admission or discharge, patients on dialysis, and patients in nursing homes)

• Trips 50 or more miles one way• Out – of – state or non – designated trips• Airline or air ambulance by a provider located out-of-state or in a

non – designated area• In – state bus or train services• Family member transportation (authorized by the county office of the

DFR)

47 / OCTOBER 2008

Prior Authorization

• Advantage Health Plan (Traditional Medicaid)P.O. Box 40789Indianapolis, IN 46240800-269-5720

• MDwise – CMOP.O. Box 44214Indianapolis, IN 46244-0214866-440-2449

• Advantage Health Plan – CMOP.O. Box 80068Indianapolis,IN 46280800-784-3981

• ACS866-879-0106866-780-2198 (Fax)

Contact Information

48 / OCTOBER 2008

Prior Authorization Process - TransportationSubmit the following information:• PA form• Proper procedure codes• Member’s age, diagnosis, and condition• Level of service needed• Reason for and destination of service• Frequency of service• Duration of service• Total mileage for each trip• Total wait time for each trip

Note: PA not required for accompanying parent or attendant unless the trip exceeds 50 miles one - way

49 / OCTOBER 2008

Prior Authorization Process – Genetic Tests

• Genetic testing for breast and ovarian cancer• Documentation required:• PA request form• Appropriate procedure codes• Medical necessity documentation

50 / OCTOBER 2008

Prior Authorization – Summary

• Verify member eligibility• Verify member’s CMO affiliation (No Delivery Systems in Care

Select)• Verify if the service requires PA• Complete the PA request form for all PA requests• Complete with appropriate CPT/HCPCS codes• Fax PA form and supporting documentation to appropriate CMO

MDwise: 877-822-7186 or 317-822-7515ADVANTAGE Care Select: 800-689-2759ADVANTAGE Traditional Medicaid: 800-689-2759

• Verify PA status using web interChange PA inquiry• Finalize all PA requests (including suspended PAs) with CMO

receiving original PA request

51 / OCTOBER 2008

Questions

52 / OCTOBER 2008

ADVANTAGE Traditional Medicaid PAP.O. Box 40789Indianapolis, IN 46240

ADVANTAGE Care Select PAP.O. Box 80068Indianapolis, IN 46280

MDwise Care Select PAP.O. Box 44214Indianapolis, IN 46244

Presentation by ADVANTAGE Health Solutions, Inc. and MDwise, Inc. Provider Relations Team in cooperation with each organization’s PA Department

Kelvin Orr – Director of Network Development, ADVANTAGE Care Select

Amy Brown – Executive Director, ADVANTAGE Care Select

Chris Kern – Provider Relations Manager – Care Select

Marcia Franklin – Senior Manager – Prior Authorization