ColoradoPAR Program Pediatric Long Term Home Health ...coloradopar.com › Portals › 2 › LTHH PAR Presentation.pdf · Expedited – 2 business days Standard – 4 business days*

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


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

http://co.eqhs.org/

http://coloradopar.com/

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


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


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.


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


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;


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.


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

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• 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

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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

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Prior Authorization

Requests

All prior authorization requests (PARs)

must be submitted via eQSuite®,

eQHealth’s proprietary, web-based

utilization management system.


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.


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.


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.


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


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


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.


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

• Mail

• Phone

• eQHealth Solutions’ response time for Reconsiderations:

• Expedited - two business days

• Standard – four business days


Timelines


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.


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.


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.


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.





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.


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


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.


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


eQSuite®

Minimal Computer System Requirements

Any of the two most recent versions of:

Internet Explorer

Google Chrome

Mozilla Firefox

Safari

Broadband internet connection


eQSuite® Login


Login from coloradoPAR.com home page

eQSuite® Login


eQSuite® Functions


eQSuite® Home Page – To

create a New Review


eQSuite® Home Page – To

create a New Review


To create a New Review


eQSuite® PAR Request



Diagnosis




Item

s



Dates Tab



All Tabs for PDN review



Uploading Supporting

Documentation


Uploading Supporting

Documentation


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!


eQSuite® Attachments


eQSuite® “Search”


eQSuite® Reports


Respond to Denial


eQSuite® Online Helpline


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/Portals/2/Request for eQSuite Access.pdf

eQSuite® User Administration


eQSuite® Update my Profile


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.


Transition


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


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

[email protected]

Michael Modiz – Colorado Program Director

[email protected]

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

mailto:[email protected]

mailto:[email protected]

http://co.eqhs.org/

http://coloradopar.com/

Documents

ColoradoPAR Program Pediatric Long Term Home Health ...coloradopar.com › Portals › 2 › LTHH PAR Presentation.pdf · Expedited – 2 business days Standard – 4 business days*