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2008 D&E WAIVER
Presented byNew Mexico Medicaid Utilization Review
Blue Cross Blue Shield of New Mexico
Prior Authorization RequestsUS Mail
P.O. Box 27950Albuquerque NM 87125-7950
Delivery Services (e.g., FedEx)4373 Alexander Boulevard NEAlbuquerque NM 87107
Hand-Carried and Drop Box Submissions4373 Alexander Boulevard NE Albuquerque NM 87107
Sending Prior Authorization Requests
Hand-Carried ReviewsIf you wish to personally deliver reviews, take them to:4373 Alexander Boulevard NE(Located just to the southwest of I-25 and
Montano)Signature receipts are available between 6:30 a.m. and 5:00 p.m., Monday through Friday
Sending Prior Authorization Requests
Drop BoxAlso located at the Alexander Boulevard address. Available 24-hours a day/seven days a week. Signature is not available at the drop box.
Completeness of Requests
Be sure request is clear and legible.Do not use arrows, scratch outs, etc.
Verify Demographic InformationUse the correct form.
Double check SSN and/or Medicaid Number.
Complete ALL required areas, including provider number(s).
Completeness of Requests
Be sure to include all applicable code(s).
Being thorough and very clear will avoid a request for information.
When changing providers, be sure to indicate units used to start/stop dates for existing and new services.
Revision Requests
End services with old provider information on one line:
Check for correct dates. Check for correct units.
Begin new provider services on the next line:Check for correct dates.Check for correct units.
Revision RequestsIf the units requested exceed the number of units already used (per Omnicaid) at the time of the review, the units will be adjusted if written permission to do so is included.If the request is received without written permission it will be returned to the provider for clarification.
Revision Requests
If requesting additional units or a reduction in units already approved, please indicate “increase to” and “decrease to” on the MAD-046.
For example, if there are already 500 units of homemaker hours approved and the request is for an additional 200 units, the request should read, “Increase to 700 units total.”
Required Documentation for a Successful ReviewObjective clinical/medical documentation is needed to justify services.
Each review must stand on its own.Diagnosis alone does not establish medical necessity.“Paint the picture!” by clearly illustrating why the client needs the services.
Required Documentation for a Successful Review
Remember that D&E recipients must meet Medical Eligibility Criteria for Nursing Facility Level of Care (8.312.2 UR).
Required Documentation for a Successful Review
Objective clinical/medical documentation is needed to justify services.
Describe the client’s functional limitations in accordance with activities of daily living (ADLs).
Demonstrate that the client requires daily (not intermittent or occasional) hands-on assistance with ADLs.
Mandatory Documentation
Current History and Physical
ISD-379, including physician’s signature and ordered level of care (LOC)
CIA (Comprehensive Individual Assessment)
MAD-046
Mandatory Documentation
ISP (Individualized Service Plan)
Homemaker Supplemental Hours form (if being requested)
Mandatory Documentation
ISD-379NO documentation made by the physician (such as physician’s orders and the ISD 379) can be altered, unless crossed through, initialed and dated by the physician.The ISD 379 and all doctor orders are considered legal documents.
Mandatory Documentation
MAD-046DO fill out all information on the left hand side of the form, including provider numbers and procedure codes. DO NOT write on the right hand side of the form.
Mandatory DocumentationIndividual Service Plan (ISP)
All requested services on the MAD-046 must be documented in the ISP.
When requesting the hours or units needed by the recipient. make sure they match the hours and units requested on the MAD 046.
Mandatory DocumentationSupplemental Homemaker Hour requests must be accompanied by:
A completed Supplemental Homemaker HoursPlan of Care form available at our website identifying both regular hours and the supplemental hours requested. This form must accompany any request for supplemental hours as of 9/1/07, otherwise your request will be returned to you.
Mandatory DocumentationMedical documentation to support the request for supplemental hours.
A plan of care listing specific duties to be performed by the homemaker.
The amount of time required to perform those tasks (15-30 minute increments).
Re-check all math. Avoidable math errors result in a large number of requests for information.
Mandatory Documentation
Comprehensive Individual Assessment (CIA)Complete each individual section, indicating a total score for each section.
Transfer the scores on each page of the CIA to Section X and indicate the total in line 5.
Check the appropriate Homemaker Hours box based on the score.
Mandatory DocumentationDocumentation in the CIA must be substantiated by the physician’s documentation on the history, physical, and the abstract (ISD 379).
Correctly identify the risk factor in Section 10 of the CIA.
This a common error when completing the assessment.
Mandatory Documentation
If they meet D & E Waiver criteria, recipient should always be “at risk for institutionalization.”
If there has been a change in the patient status and the recipient is reassessed, the CIA has to be completed again to reflect those changes.
The summary must also be modified to reflect that change in status.
Avoiding RFI’s
Include the case manager’s phone number on the documentation so that MUR can contact the case manager to possibly prevent a “request for more information”letter being sent via mail or fax machine.
Avoiding RFI’sSubmit mandatory forms and documentation for your D&E requests.
Current History and PhysicalISD-379 (including physician’s signature and ordered level of careMAD-046Comprehensive Individual Assessment (CIA)Individualized Service Plan (ISP)Homemaker Supplemental Hours form (if being requested)
Avoiding RFI’s
Make sure that all forms are COMPLETELY filled out.Make sure that the Medicaid/SS number is correct on ALL forms.The correct procedure/provider codes must be present on ALL forms.
Avoiding RFI’s
Ensure all required signatures and dates are submitted:
History and Physical, including a system’s review, must be current and signed/dated by the physician.
Level of Care orders with dates must be present on the ISD-379 and relevant to the time frame requested.
Avoiding RFI’s
Re-check the entire document before submitting.
Double check all mathematical calculations.
Homemaker assessment score
MAD-046 units/hours
Avoiding RFI’sUnderstand the criteria for the services being requested.
To be eligible for the Disabled and Elderly Waiver program, the client must meet criteria for placement in a nursing facility.
Submit all supporting documentation.Ensure that the information submitted is consistent and relevant to that specific request.
Avoiding RFI’sClarify the request:
What are you requesting?InitialAnnual ReassessmentReadmitRevisionRe-reviewReconsideration
Avoiding RFI’s
In the event you do receive a request for information be sure to return ALLrequested information with your response.
This will avoid subsequent requests for information.
Avoiding RFI’s Last, But Not Least…
If a request is unclear, please call customer service at 800-392-9019.
They will obtain the needed clarification and call you back.
The Appeal Process
The Appeal Process consists of several possible steps:
Re-reviewReconsideration Fair Hearing
Re-Review Process
Based on MAD regulations, the written request must be received within 10 calendar days from the date of the denial letter.
Requests will be processed within 15 calendar days of receipt.The abstract should be marked “RE-REVIEW”at the top.
Re-Review Process
The re-review request must include additional medical/clinical information (in addition to the initial information submitted) in order to meet the requirements for the re-review process.
Reconsideration ProcessThe request must be received within 30 calendar days from the date of the re-review denial. In order to meet the requirements for reconsideration, the request must include medical/clinical information in addition to any submitted initial and re-review information.
Reconsideration ProcessIf a re-review is unable to be requested within the mandated 10-days, a request may be made for a reconsideration (without benefit of a re-review). The request must be received within 30 days of the date of the original denial letter.“Reconsideration” should be indicated on the request.
The Fair Hearings Process
Requests for Fair Hearings are administered through the Administrative Hearings Bureau. A Fair Hearing request can be initiated by either the recipient or provider. (Sections 8.352.2 and 8.353.2 of the Program Manual).
Data Entry
All review-related information is keyed into the Omnicaid system.Initial reviews and annual reassessments will receive new authorization numbers.
Revisions will be added to the existing authorization; no new number will be generated.
Data Entry
Reviews are then keyed into the Medicaid Utilization Review system.
Customer service representatives use this system to track review information.
Customer Service
800-392-9019 (number is valid both in- and out-of-state)Customer Service hours are 8:00 a.m. to 5:00 p.m., Monday-Friday.ACD (Automatic Call Distribution) allows calls to be handled in the order received.MUR may also be contacted via the Internet.
Following up on SubmissionsPlease allow time for review to reach MUR before calling to ask if it has been completed.
MUR has 8 business days to complete reviews (per the HSD/MAD contract).
MUR’s imaging system allows the Customer Service representatives to view where the review is in the process (and when it was received).
What’s New! The New MUR Image--Abstracts are scanned into our Image program when they are received and then retained electronically
The abstracts are reviewed through the electronic Image system.
As MUR will no longer maintain paper copies of your abstract submissions and be able to supply copies to you, make sure you retain your originals.
La
What’s New!New Prior Approval Letters—
Instead of receiving copies of MAD or ISD forms with the approval information hand-written at the bottom of the forms, providers will now receive detailed prior approval letters.
Make sure you read the letter!! Don’t mistake it for a Request for Information (RFI) letter (or a RFI for an approval letter).
What’s New!Prior approval letters will contain all the necessary information, including:
The specific services approved
The certified approval date spans
The authorization number
A provider bulletin announcing the change was sent to all providers in late July, along with samples of the different letters.
What’s New!
Frequent BCBSNM-MUR Website Updates—Now THE provider’s resource for:
FORMS!! (MAD/ISD Forms can be downloaded from both the State and BCBSNM-MUR sites; forms are no longer being printed for mailing to providers)
General review information
What’s New!Frequent BCBSNM-MUR Website Updates—
Time frames for submissions
Monthly training schedules and provider training presentations
Frequently Asked Questions (FAQs)
THANK YOU
for your time and attention!Please don’t hesitate to let us know how we can
continue to improve our communication and services!
