Transcript Helen Snyder APS Authorization Process

Presentation for
WV HFMA
Revenue Cycle
Workshop
October 23,
2013
PROVIDER
REGISTRATION
WITH
APS
VS.
MOLINA
WV MEDICAID
ENROLLMENT
ALL MEDICAL
review areas
for
WV Medicaid services requiring
prior authorization
are currently in the
APS Medical CareConnection® C3
Provider Portal
YOUR FACILITY
MUST BE REGISTERED
with
APS
and be actively enrolled as a WV
Medicaid Provider
with Molina
to have prior authorization requests
processed
and claims approved.
https://c3wv.apshealthcare.com
Each organization and/or department must register
specifically with APS Healthcare in order to access the
Medical CareConnection® C3 Provider Portal System—
regardless of how you submit (electronically, fax, or mail)
The system allows you to configure your registration to meet
the needs of the facility—whether one registration that houses
ALL users and ALL prior authorization requests, or various
departments within the organization register independently
and only manage their staff and their requests—this is
plausible even when all departments are linked to the same
NPI.
SUBMITTING ELECTRONICALLY ON C3
 Gives
you the ability to quickly
check WV Medicaid Member
Eligibility.
 Create prior authorization requests
that bypass the clerical team and
go straight into queue to be
reviewed for medical necessity.
 Permits you to track your request
every step of the way
 Allows for a faster turnaround time
on determinations
ATTACHMENTS
Attaching supporting clinical documentation for C3 Prior Authorization
Requests can save you bundles of time by not having to manually enter each
data set (i.e. H&P, Diagnostic Results, MAR)—you simply make a statement to
see attached clinicals and then include all relevant information up to 50 pages
and/or 4.8MB per attachment.



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
How To: Click on the ‘Browse’ button in the Annotations: Notes section
on the screen you want the information to be placed. Find the
document you want to attach and double click on it. Click on the
blue ‘Save’ button within the notes section.
Where: Either on the applicable screen (ex. MAR on the Medications
screen) or on the Summary and Submit screen
Files Accepted:.txt, \.vsd, \.png, \.gif, \.bmp, \.jpg, \.jpeg, \.doc,
\.xls, \.pdf, \.TIF, \.TIFF
Size Accepted: up to 4.8 MB only. Larger files need to be compressed
or separated.
Please do not attach the same document more than once on the
request. This only causes the reviewer to spend extra time looking at
documents already viewed.
NO SCANNER? NO E-RECORDS?
NO PROBLEM!
FAX YOUR ADDITIONAL INFORMATION

A FAX COVER (preferred) has been devised to assist you, as well as
the WVMI review team, when your supporting clinical
documentation cannot be attached directly to the C3 record
created electronically. For a copy of this form, please contact APS.

Timelines for sending in additional clinical information, whether it be
directly attached, faxed, or mailed to WVMI, is 2-business days from
the date the request was successfully submitted on C3.

If the information is not received within the allotted timeframe, your
request will be closed administratively. You would be required to
recreate a new request with clinicals after an administrative closure.
When resubmitting a closed case, please submit within the 72-hour
timely submission criteria.
10-day
Retrospective Review
Submission Policy
WV Medicaid Prior Authorization Retrospective Review
Policy previously required a timely 24-hour submission
timeframe for all admissions which included weekend
and/or holiday admissions. This policy meant all requests
must be submitted by the first business day following the
admission. Due to the repeated expression of difficulty with
meeting this requirement, APS provided the Bureau for
Medical Services (BMS) your comments and concerns and
after careful consideration, BMS agreed to eliminate the
24-hour timeline, and instead, adopt a 10 day prior
authorization timeline in its place.
NOTE: After the allowable period has elapsed from the
selected service start date prior authorization is NOT
available as a selection and retrospective review must be
selected. The
Retrospective Review Policy is not
applicable to all review types you must refer to the POLICY
MANUAL for specific requirements (e.g. DME requires PA
before placement of equipment except apnea monitors).

a) a delay could seriously jeopardize
the life or health of the consumer or,

b) the ability of the consumer to regain
maximum function or,

c) in the opinion of a physician with
knowledge of the consumer’s medical
condition, would subject the consumer
to severe pain that cannot be
adequately managed without the care
or treatment that is the subject of the
case.

NOTE: Some review areas do not
recognize medically urgent requests. In
these instances it is not a choice in the
admission type dropdown. For those
review areas that recognize medically
urgent (e.g. inpatient) each admission
type has a medically urgent choice
(e.g. direct admission OR direct
admission-medically urgent). Requests
not meeting the medically urgent
definition WILL NOT be clinically
reviewed as medically urgent.
ONLINE COURTESY REVIEW
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
Courtesy Reviews allow providers to enter prior
authorization requests for members they believe to
have active Medicaid, although the Medicaid ID
number is not yet active in Molina.
The request will be reviewed for medical necessity
and if approved, when the Medicaid ID is available in
Molina, it will be attached and a Prior Authorization
number will be assigned.
Retrospective Courtesy Reviews are not allowed. If the
member cannot be found in our system, their
Medicaid ID is not active during that time span. The
provider will need to wait until the retroactive
Medicaid eligibility is present in our system and then
submit their request.
Keep in mind that if a Molina linkage is not made
within 30 business days of the actual Courtesy Review,
the request will be closed and the provider will be
notified that WV Medicaid coverage could not be
located for the indicated member.
WHO IS WVU Hospitals?
WVU is your SERVICING PROVIDER on C3 for
Inpatient Admissions, Outpatient Surgeries and Diagnostic
Tests (e.g. imaging). When completing a faxable form or
creating a request online YOU MUST earmark the NPI for
WVU Hospitals (ACUTE) when the service is rendered at this
location. It is fiscally vital that the location and
corresponding facility NPI be selected as servicing. If the
prior authorization is linked to an incorrect NPI (e.g. the
physician group) WVU cannot be paid.
NPI: 1841271459
ONE C3 REQUEST TWO AUTH NUMBERS
OP SURGERY
AUTHORIZATION NUMBERS
ARE NOW INDIVIDUALIZED
THE FACILITY
RECEIVES A
PA# UNDER
THEIR NPI
For either party to receive payment from
Molina the C3 authorization number
assigned to the approved member
services must match the
NPI provided on the request.
THE SURGEON
RECEIVES A
PA# UNDER
THEIR NPI
Please follow WVU policy for communicating facility authorization numbers.
OP SURGERY AUTHORIZATION
NUMBERS ARE NOW INDIVIDUALIZED
C3 DENIALS & RECONS

Status can be seen at the authorization record level OR in
reports. Denial letters are always found on the Summary &
Submit page of the C3 request.

If you entered the prior authorization request in C3, you
will also be messaged a coy of the denial to your C3 inbox.

If you are the referring or servicing and did NOT enter the
request a copy of the letter may be mailed to you (if no
other means is available).

A reconsiderations of the initial denial are requested from
the “action” menu for each not meeting medical necessity.
Untimely submissions do not have a reconsideration
option.

Providers have 60 days to request reconsideration, so
make sure all appropriate information is provided at the
time of the reconsideration request.

If you mail your reconsideration chart, wait until it is mailed
prior to requesting in system and indicate in the note that
the record has been mailed (or faxed if you do not attach
at the time of reconsideration request).
Currently C3 is built to generate separate Prior Authorization
Numbers for each procedure/service code for OP Surgeries and
Diagnostic Tests for each corresponding NPI listed.
In the event that your Servicing Provider requires one synchronized
PA# for all testing performed same day, upon C3 review completion,
you will need to contact APS to have a single number manually
generated and sent to Molina.
You must submit the request on C3 to be reviewed for medical
necessity, receive a Review Complete status prior to contacting APS.
Please follow these instructions until further notice.

Only an enrolled WV Medicaid provider may
request an out-of-network service for a WV
Medicaid member. The enrolled provider
makes a hard-copy request with APS unless
it is an emergency situation that would result
in a hospital admission at an out-of-network
facility.

If the OON case review determines that the
service is medically necessary AND not
available in-network, the out-of-network
provider will be notified that they must enroll
with Molina and a notice that medical
necessity
is
met
awaiting
provider
enrollment.

If the provider has previously enrolled to
provide OON services AND enrollment has
not termed the prior authorization number is
assigned immediately. If medical necessity is
not met (denial) there is no need for the
provider to enroll and the member and
referring provider are notified of the denial.

If the provider is not enrolled as out-ofnetwork, call tracking is opened with Molina
and kept open until APS is notified the
provider has enrolled. The authorization
number is posted at the time of enrollment
and sent to Molina. The out-of-network
provider may then bill Molina using the
assigned prior authorization number.

TO OBTAIN AN OON REFERRAL PACKET
PLEASE EMAIL:
[email protected]
What do I do when I do not see
the service code listed on C3
or the MCL?



When creating a service specific request on C3,
you will receive a “Service Preview” that allows
for a quick visual of codes currently requiring
prior authorization (PA).
The Master Code List (MCL), an MS Excel
spreadsheet is an effort to inform providers of
codes requiring PA either from first service
(listed as required) or after a specified service
limit has been reached (beyond service limits)
that are currently residing on C3.
What do I do when the
authorized service code
on C3 changes?

Once a service code has been authorized on C3 but
another code that requires an authorization occurs—
the submitting C3 Organization must contact APS
within 3-business days from the service start date.

APS will validate the necessary action on a case-bycase basis.

In the event, you think a code requires a PA but
cannot find it on either list you can contact APS,
Molina, or WVMI for verification.
If the procedure code is outside of the C3 “bucket” the
submitting C3 Organization may need to resubmit the case in
full (referring to the previous case & authorization), listing all
procedure codes with supporting clinicals and list reasoning
as to why there is now a new submission for medical
necessity review. This must transpire successfully within 3business days from the service start date.
If the procedure codes are within of the C3 “bucket” the C3
Organization and Servicing Provider will not be required to
resubmit.
EXAMPLE:
162 Surgeon
271 Facility


Also, the BMS Manual Chapters indicate
covered services that require prior authorization:
http://www.dhhr.wv.gov/bms/Pages/ProviderMan
uals.aspx

If you should receive a denial for a service NOT
on the list OR find a service listed in the manual
as requiring PA but not on the list please contact
APS as soon as possible so we can determine if
the PA requirement is in force. If it is we will add
the code to the listing.

If the additional procedure codes do not require an
authorization, you will not need to make any changes to the
existing C3 request.
REVIEW AREA
UPDATES



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
Laboratory Services: there are a number of genetic testing service codes added (effective January 1,
2013) that now require PA. Please check the published MCL for a list of these services and
requirements. S3854 is now covered (Oncotype) and may be requested retrospectively (back to a
service start January 1, 2013) until December 31, 2013.
Nerve Conduction Studies: CPT Codes 95907-95913 are new codes added January 1, 2013 and
REQUIRE PA. If you have received denials for these services you need to contact APS to get prior
authorizations processed. The EMG codes 95885 and 95886 are add-on codes that do not require PA.
Physical/Occupational Therapy: The new PT/OT manual is not yet effective. Until the effective date of
this manual providers may continue to use the WVMI system OR may use CareConnection® to
request prior authorization per requirements of the existing manual. When using CareConnection
select ESTABLISHED for patients since they have already received the allowable services without
prior authorization (per current manual).
DME: While the system allows a period from service start date (SSD) to initiate prior authorization
before being considered a retrospective request the POLICY MANUAL (Chapter 506) indicates prior
authorization must be obtained BEFORE service provision/equipment placement. This administrative
feature DOES NOT override policy. The exceptions are apnea monitors, O2 systems and nebulizers as
outlined in policy.
Acute Inpatient: Admissions for labor and delivery DO NOT require prior authorization under the
WV001 Inpatient DRG. A list of DRG’s related to labor and delivery have been added to the MCL for
provider reference. Admissions for a medical condition (other than those exempted) require prior
authorization within 72 hours of admission even if the member is pregnant.
Acute Inpatient: When requesting prior authorization for Medicaid members involved in a motor
vehicle accident an accident/police report IS NOT required. In these cases the request must indicate
in the notes section that the admission is attendant to a MVA.





All AUM Managers have access to the
C3 Reports feature—this can assist in
tracking WV Medicaid members who
have received determinations on
completed C3 requests when the
binding “Servicing Provider” NPI is linked
to your C3 account and is listed as the
“Servicing Provider” on a request by
any C3 submitter.
C3 Reports are exported into a MS
Excel spreadsheet that can be
engineered to suit the needs of the
AUM Manager’s scope of work (i.e.
Service Start Date, Service Type,
Provider)
The Reports are only a summary of the
request on file and the Servicing
Provider Report does not give full
access to the actual request built in C3.
If you are NOT the submitting C3
provider (the party that entered the
request) you MUST utilize REPORTS to
obtain the PA number for the member.
When the wrong NPI is selected or
inadvertently left off the AUM Manager
at the “Servicing Provider” cannot
access any information on that
member—dependent upon the policy
of your “Servicing Provider” a delay in
services could occur.
You will need to follow the policy of
each
“Servicing
Provider”
when
communicating the determinations.
Mock Report
Service Service End
Units
Review Date Service Code
Start Date
Date
Approved
Prior Status
Service Service
End
Review 337 Service
Units
2012-02-20 2012-03-20
2/17/2012
30
Approved
Prior Status
Start Date
Date
Date
Code
Approved
2012-02-20 2012-03-20
2/17/2012
2011-11-26 2011-11-29
2011-11-26 2011-11-29
2012-02-24 2012-03-24
337
WV001
WV001
Meets Medical
Meets Medical
Servicing
Authorization2048246064
Servicing Provider
ABC HOSPITAL
CurrentApproved
Status Current Reason
Provider
Number
Name
Medicaid ID
Necessity
Necessity
Meets Medical
Meets Medical
2048246064
ABC HOSPITAL
12345678910
Meets
Medical Approved
Meets Medical
Necessity
Necessity
ApprovedMeets Medical
2047245970 ABC HOSPITAL
Meets Medical
2047245970
ABC HOSPITAL
12345678910
Necessity Approved
Necessity
NecessityNecessity
Prior Reason
30
Pended
2012-02-16 2012-03-16
2/17/2012
533
30
Pended
Approved
2012-02-16 2012-03-16
2012-02-15 2012-03-15
2/17/20122/22/2012
WV001 206
2012-02-27 2012-03-27
2/24/2012
30
336
Pended
30
Pended
Pended
30
Pended
Approved
12345678910
12345678910
Reapproved
with Changes
WV001
30
Pended
Authorization Servicing Provider Servicing Provider
Number
Name
Medicaid ID
2/17/2012
161
30
Approved
Current Reason
2012-02-15 2012-03-15
2/21/2012
161
4
Approved
Approved
Current Status
2052245051
ABC HOSPITAL
12345678910
Reapproved
w ith
Approved
2052245051 ABC HOSPITAL
Meets Medical
Changes
Approved
2048246039
ABC HOSPITAL
12345678910
2012-02-24 2012-03-24
2/21/2012
30
4
Prior Reason
12345678910
Necessity
Meets Medical
Necessity
2048246080
ABC HOSPITAL
12345678910
Meets Medical
Approved
20532450612048246039
ABC HOSPITAL ABC12345678910
Approved
HOSPITAL
Necessity
Reapproved
Reapproved
with Changes
Approved
with Changes
2012-02-16 2012-03-16
2/17/2012
533
30
Pended
Approved
2012-02-16 2012-03-16
2/22/2012
206
30
Pended
Approved
2012-02-27 2012-03-27
2/24/2012
336
30
Pended
Approved
2055245006
ABC HOSPITAL
Meets Medical
2048246080
Necessity
Reapproved w ith
2053245061
Changes
Reapproved w ith
2055245006
Changes
12345678910
12345678910
ABC HOSPITAL
12345678910
ABC HOSPITAL
12345678910
ABC HOSPITAL
12345678910
WHEN IN DOUBT…
When things aren’t working correctly in C3,
there are a few things you can do to make
sure it’s not on your end:




1.) Are you registered with APS for C3?
2.) Has your Provider NPI been attached?
3.) Do you have the appropriate user role?
4.) Are you on the correct site?
For Requests as AUM Manager:
https://providerportal.apshealthcare.com
For Enrollment Maintenance as ORG Manager:
https://c3wv.apshealthcare.com



5.) Are you using Internet Explorer V.8?
6.) Have you cleared your cache/cookies?
7.) Have you checked your queue to see if it is
still in Saved mode?
If you have checked these items and are
still having difficulties contact APS for
technical assistance!
FOR CUSTOMER SERVICE CONTACT APS:
1-800-346-8272 ext. 6954
Medical Services email: [email protected]
Helen Snyder
Associate Director
[email protected]
ext. 6911
Heather Huffman
UM Coordinator
[email protected]
ext. 6907
Sherri Jackson
Office Manager
[email protected]
ext. 6902
Denise Burton
UM Coordinator
[email protected]
ext. 6949
Alicia Perry
Eligibility Specialist
[email protected]
ext. 6937
Jackie Harris
Eligibility Specialist
[email protected]
ext. 6928
GENERAL APS INFORMATION: WWW.APSHEALTHCARE.COM/WV
Fax: 1-866-209-9632 (For Registration and/or Technical Support Only)
ORG MANAGERS: HTTPS://C3WV.APSHEALTHCARE.COM
AUTHORIZATIONS: HTTPS://PROVIDERPORTAL.APSHEALTHCARE.COM
FOR CLINICAL SUPPORT CONTACT WVMI:
1.800.642.8686
WWW.WVMI.ORG