PCS0080 (09/09)1 Presented by ADVANTAGE Care Select and MDwise Care Select Provider Relations

PCS0080 (09/09) 1

Presented by ADVANTAGE Care Select and

MDwise Care Select Provider Relations

PCS0080 (09/09) 2

Agenda

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

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Session ObjectivesSession ObjectivesFollowing this session, providers will be able to:• Identify the two care management organizations (CMOs)• Understand eligibility and its relationship to PA• Understand the suspended PA procedures when a member

switches health plans• Understand which contractor processes pharmacy PA requests• Common PA submission procedures by specialty• Common PA processing procedures by specialty• Understand the PA appeal process• PA contact information

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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 the member’s PA request 2. Member’s Care Manager3. Member’s Primary Medical Provider (PMP)4. CMO who processes restricted card information5. Where members can change PMP

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Care Select Eligibility ReviewReminders:• 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 requested from the member if he/she insists on receiving the service not authorized by the assigned PMP

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Prior Authorization

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

ADVANTAGE was selected to function as the Traditional Medicaid fee – for – service

Note: All PA for prescription drugs are processed and adjudicated by ACS and not the CMOs

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Prior AuthorizationGeneral Information

• The STATE plan requirements for Prior Authorization are the same for both Indiana Care Select and Traditional Medicaid (FFS)

• The CMO’s PA departments use OMPP approved criteria in addition to the Indiana Administrative Code (IAC), PA guidelines, and Indiana Health Coverage Programs (IHCP) bulletins, banner pages, and newsletters when considering PA requests

• The CMO’s PA Departments review all medical, facility, or dental PA requests

• Decisions to authorize, modify, or deny a PA 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

• For a full detailed explanation of PA processes and procedures, please refer to Chapter 6 of the 2008 IHCP Provider Manual

• Out of state providers must obtain PA prior to performing services (except emergencies)

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Prior AuthorizationMethods of Submission – All PAs are submitted to the plan the

member is assigned to

By Fax – Providers may fax the Indiana Prior Review and Authorization Request form along with supporting documents Note: CMO preferred method

By Web interChange - application on the IHCP website allows providers to submit non-pharmacy PA requests and to inquire on request via web interChange. Note: Providers must have administrator capability setup on Web interChange in order to submit PA or to perform PA Inquiry on Web Interchange

By Mail – Written requests for PA are submitted using an Indiana Prior Review and Authorization Request form along with supporting documents

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Prior AuthorizationWeb interchange

• 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

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CMO Prior Authorization Process• Use the fee schedule at www.indianamedicaid.com to locate services

which require PA due to State regulations for Care Select and Traditional Medicaid Reminder: Care Select service 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 6, Indiana Administrative Code, and bulletins, banner pages, and newslettersReminder: 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

• Indiana Prior Review and Authorization Request Form, System Update Form and Dental Prior Review and Authorization Request Form

– These forms are available on the Forms page of the IHCP Website at www.indianamedicaid.com.

Procedures

http://www.indianamedicaid.com/

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Prior Authorization Process

• 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

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

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

Request Sent to Wrong CMO

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Prior Authorization

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

• The receiving organization must honor PAs approved by the member’s previous 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 CMO must honor the approved PA for 30 days from November 14, 2007

Outstanding Prior Authorizations

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Suspended Prior Authorization

• PA requests are suspended when additional information is needed by the provider to determine medical necessity

• Requested documentation must be received within 30 calendar days

Member switches CMO’s

• Important: 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

which received the original PA request from the provider– Providers should verify member eligibility for the original PA

request date via web interChange prior to sending additional documentation

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Prior AuthorizationDoes 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)

• PA determines the medical necessity of a service or item

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Prior Authorization

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)• Note: The CMOs request that hospitals notify us via web

interChange, fax, or phone when one of our Care Select members becomes an inpatient so we can assist in planning patient discharge


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Prior Authorization

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

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Prior Authorization

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:

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Prior AuthorizationInpatient emergency services 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• Report emergency services to member’s PMP within 48 hours

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Prior Authorization

Non-Institutional PA Requirements (Physician)• Criteria used to process PA requests for non-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

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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

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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

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Prior Authorization Process – Physician

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

• Corrective features built into shoes for members younger than age 20

• Orthopedic shoes for members with severe diabetic foot disease• Palliative or hygienic care • Routine foot care in excess of six services per year for patients

with diabetes mellitus, peripheral vascular disease or preripheral deuropathy

• Podiatry services furnished during an inpatient stay requires PA

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Prior Authorization Process – Physician

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

• Reimbursement limited to 50 office visits or treatments per member per year (includes five office visits per year)

• New patient office visits are reimbursable once per provider per lifetime of the member

• Chiropractic services rendered without PA are subject to denial

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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

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Documentation Reviewed by the PA Department:• 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


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Documentation Reviewed by the PA Department continued: • 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)

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Prior Authorization Process – Home HealthDocumentation Reviewed by the PA Department continued:• 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

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Prior Authorization Process – Home HealthDocumentation Reviewed by the PA Department continued:

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

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Documentation Reviewed by the PA Department Continued:• 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

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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

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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

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Prior Authorization - TherapyPA not Required Continued:• 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

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Prior Authorization - Therapy

PA Criteria Continued:• 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

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Prior Authorization Process - TherapyAdditional Information:• 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

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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

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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

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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

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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

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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

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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


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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

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• 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

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• 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


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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

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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

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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)

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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

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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

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Prior Authorization Process – Genetic Tests

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

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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

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Prior Authorization – Summary

• Verify member eligibility• Verify member’s CMO affiliation on date of PA request• Verify if the service requires PA• Complete the PA request form for all PA requests• Complete with appropriate CPT/HCPCS codes• All out – of – state services providers must receive PA before

providing services (except designated IFSSA areas)• 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

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Questions

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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 – Provider Network Director, ADVANTAGE Care Select

Mark Willeman – PA Director, ADVANTAGE Care Select & FFS

Chris Kern – Provider Relations Manager – Care Select

Marcia Franklin – Senior Manager – Care Select Prior Authorization