Innovative Resource Group, Inc. d/b/a
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Transcript Innovative Resource Group, Inc. d/b/a
Innovative Resource Group d/b/a
Innovative Resource Group, Inc. d/b/a
“Improving the health of those we serve.”
We are a specialty health
services company that
focuses on
communication and
technology to develop a
more effective and
efficient system of care
for West Virginia.
The APS-West Virginia Office is located in
Charleston, West Virginia,
with field staff working throughout the state.
CONTRACT HISTORY
August 2000 – 2009
December 2009 - Present
APS Healthcare
Administrative Services
for Medicaid Behavioral
Health O/P, MR/DD Waiver,
BCF Socially Necessary
Services & BHHF Charity
Care & Federal Block
Grant Reporting
WVMI
Utilization Management
of Medicaid Medical Services
Behavioral Health Inpatient,
Aged & Disabled Waiver, and
Nursing Home Admission
& Re-Evaluation
Screenings
APS Healthcare
DHHR combined the APS & WVMI
Contracts into one inclusive Contract,
which was awarded to APS in late 2009:
Medicaid Medical & Dental Services
Medicaid Behavioral Health In/Outpatient
Medicaid MR/DD Waiver Program
Medicaid Aged & Disabled Waiver Program
Medicaid & Non-Medicaid Nursing Home
Bureau for Children & Families: Socially
Necessary Services & Out of State Services
BHHF Charity Care, Block Grant Reporting
and Select Administrative Services
All programs are fee-for-service,
not risk based.
OVERVIEW OF PROGRAM
• APS Healthcare is implementing a Direct
Data Entry system (DDE) for all areas of
medical necessity review.
• Prior Authorization Requests will be
submitted through the DDE system
Medical Care Connection® or by faxing
updated UMC forms that “mimic” the DDE
requirements.
AUTHORIZATION RULES
• Requirements include all data elements for
submission of Prior Authorizations by review area
per specifications approved by BMS.
• Requirements are derived from the BMS Manual
Chapters/UMC forms and review criteria.
• Medical CareConnection® data elements include
required fields and criteria specific fields to
improve accuracy and completeness of
submissions.
NOTE: Utilizing existing clinical review protocols, criteria,
and manual requirements to prevent disruption to the service delivery system.
These will be updated as criteria, manual chapters and guidelines are updated.
Areas of Medical Review
Medical Necessity Reviews will be conducted by the UMC in the following areas:
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Inpatient Services
Inpatient Medical Rehabilitation <21
Cardiac Rehab
Pulmonary Rehab
Chiropractic
Dental and Orthodontic Services
Durable Medical Equipment (DME)
Home Health
Hospice
Private Duty Nursing
Lab
Radiology
Imaging
Occupational Therapy
Physical Therapy
Speech Therapy
Audiology
Outpatient Surgery
Podiatry
Vision
Out-of-Network Services
Orthotics/Prosthetics
Medical Utilization
Management
Provider wants to request a medical
service for a WV Medicaid Member
O-O-N work flow is
initiated
Provider goes to the APS
WV CC System provider
portal or fax is entered
Not enrolled
Referred to APS to
register
N
Enrollment
&
Registration
Once Id’ed
as O-O-N
Referring
Provider to enrolled
and registered
N
Not registered
Y
Provider logs on
and initiates
request
N
Closed with
message or sent
to eligibility file
Closed
Eligibility
Check
N
N
Once Registered
Service
provider
eligibility is
checked
Member
eligibility is
checked
Not enrolled
O-O-N work flow is
initiated
Not registered
Referred to APS to
register
No
No
Y
Eligibility Specialist
sends to clinical
Y
Y
Y
APS Nurse Reviewer can
view eligibility issues
Clinical
Review
Inpatient
Hospital Services
Organ Transplants
Bariatric
Inpt under 21
Request is sent to clinical
queue after applicable
clinical rules are applied
Outpatient
OP Surgery – Bariatric
Physician Services
Podiatry
Vision
Dental
Orthodontic
Rehab
OT
PT
Speech
Audiology
Chiropractic
Cardiac Rehab
Pulmonary Rehab
DME
Orthotics/Prosthetics
APS Nurse Reviewer can
view “Pend” reasons
Diagnostic
Services
Lab
Imaging
Radiology
Enteral Nutrition
Inpt Rehab <21
Hospice
Organ Transplants
Bariatric Surgery
PDN
Cardiac Rehab
Pulmonary Rehab
Home Care
Home Health
PDN
Hospice
NOTES:
Provider is enrolled by Unisys and
this is reflected in the eligibility file.
Medical CM
Medical
CM
Auth is issued if
provider enrolls
and med
necessity is met
Provider is registered with APS by
completing registration log-on and
user terms with APS.
High Cost outliers
per BMS report
*When member is <21 referral – is
request related to EPSDT referral
*For DME/Orthotics/Prosthetics –
TPL check is yes, list Third Party
WV Medical CareConnection®Provider Portal
• Provider Portal is the mechanism by which DDE requests for
prior authorization are made
• The system allows the provider logging in to perform actions
based on their user role and provider type (e.g. DME provider
can make DME requests only but Hospital may be able to
make many types of requests based on the services they
provide)
• Business rules prompt the appropriate workflows based on
the provider type and the services requested
• Validation rules ensure mandatory information is complete
before submission
• Requests submitted via DDE go directly to the appropriate
WVMI work queue and are reviewed on a “first in/first out”
basis (requests are date and time stamped upon submission)
Eligibility Check
• It is responsibility of provider to verify
Medicaid eligibility and type of Medicaid
coverage ( e.g. MCO/PAAS/Traditional)
• APS will check member eligibility for the
requested service start date and provider
eligibility per a file from Molina
Benefits of DDE
• Efficiencies in process, provider input time
and future submissions for same member
• Decreased physician time and denials
• Faster receipt of prior authorization
resolutions
• Makes tracking much easier
Log-in Screen
Home Screen- Welcome Page
Search Member Screen
Create New Request
Demographic Screen
Provider Screen
Administrative Screen
Service Selection Screen
Diagnostics Screen
Diagnosis Screen
Evaluation Screen
Treatment
Submit to APS
Means of Submission
Division
Direct Data
Entry
Fax
Phone
Cardiac & Pulmonary Services
Y
Y
N
Chiropractic
Y
Y
N
*
Dental & Orthodontics
Y
Y
N
*
Durable Medical Equipment
Y
Y
N
Except Apnea and Nebulizers for
Age 3 and under
Home Health/Hospice/PDN
Y
Y
N
Inpatient Rehab <21
Y
Y
N
Inpatient Services
Y
Y
N
Except Urgent
Lab/Imaging/Radiology
Y
Y
N
Medical Case Management
N/A
N/A
N/A
Orthotics & Prosthetics
Y
Y
N
Out-of-Network
Y
Y
N
Outpatient Surgery
Y
Y
N
Physical/Occupational Therapy
Y
Y
N
Podiatry
Y
Y
N
Speech & Audiology
Y
Y
N
Vision
Y
Y
N
*NOTE When materials for the prior authorization request cannot be sent by other means (e.g. x-rays, dental molds, etc.)
Postal
*
**
WVMI Medical Necessity Review
• Reviews are submitted via DDE or fax
• DDE will validate the information for
submission
• Request forms submitted via fax must be
legible & complete or will be returned
• Only medically urgent reviews will be
accepted via phone
Definition of “Medically
Urgent” Case Review
• 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.
Provider Registration
• First groups to
register are: Inpatient
Acute Services,
Inpatient Rehab <21,
PT, OT, Speech &
Audiology
• Registration is
necessary to receive
and view prior
authorizations
Provider Type
Acute Inpatient
Inpatient
Rehabilitation<21
Occupational
Therapy
Physical Therapy
Speech
Audiology
Registration
All referring and
Service ProvidersAugust/September
2011
All referring and
Service ProvidersAugust/September
2011
All referring and
Service ProvidersSeptember 2011
All referring and
Service ProvidersAugust/September
2011
All referring and
Service ProvidersAugust/September
2011
All referring and
Service ProvidersAugust/September
2011
Testing
Implementation/
“Go-Live”
Maintenance
September
2011
October 2011
Post-go-live
September
2011
October 2011
Post-go-live
October 2011
November 2011
Post-go-live
October 2011
November 2011
Post-go-live
November
2011
December 2011
Post-go-live
November
2011
December 2011
Post-go-live
WHAT TYPES OF USER ROLES
CAN I ELECT TO HAVE FOR MY ORGANIZATION?
• Organization Manager: at least one individual with this role must be
designated. This user type can add and delete users for the
organization, and can perform administrative functions within the
application for the organization as well as perform all of the functions
of other user roles.
• UM Manager: This user role can perform oversight functions for
provider users who only have read, write privileges and can submit
requests to APS. This user role can also provide oversight functions
related to management and tracking of UM requests for those areas
of the organization to which they have been given access.
• Provider: Can create, submit (if designated), request modification (if
so designated) and search requests they have submitted. This user
only has access to those records that they have created or that are
assigned to them by a UM Manager.
• Other Users: Nurse/consultant Reviewer, Physician Reviewer, BMS
User
PA Notification Files
A flexible method of informing providers of
the prior authorization resolution that can
be utilized by billing departments to import
authorizations into existing systems.
– Providers are notified electronically: either by
individual search or daily uploaded batch file
– Faxed resolutions will no longer exist
– Process is easy
Notification of Denial,
Reconsideration
• Members/Consumers: US Mail
• Referring Providers: DDE, Fax or US Mail
• Servicing Provider: DDE, Fax or US Mail
Denials
• Different Types:
• -Medical Necessity Denials
– No medical necessity per criteria and/or physician
review
• -Policy Denials
– Not a covered service or age parameters not met
– Retrospective PA request not within policy
parameters
– Invalid or incomplete information on faxed prior
authorization request
Notification Letters
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Specific Manual Citations
What Members need to do
What Providers need to do
Updated and better organized based on
feedback
Timeframes of Reviews
• Urgent- 24 hours ( 1 business day)-for requests that meet the
definition of urgent.
• Non-Urgent- 48 hours (2 business days) from the request
submission to completion of review.
• Physician Review- 24 additional hours (1 business day)-reviews
that do not meet medical necessity criteria upon review by nurse.
• Retrospective Review- 72 hours if request meets policy.
• Reconsiderations- 14 calendar days. Must be requested and
submitted with all pertinent documentation within 60 calendar days
from member/provider notification of the service denial.
• NOTE: Requests submitted after 3PM will be addressed the next
business day. These requests will be processed as submitted and
addressed sooner if practicable.
Criteria by Provider Type
Review Area
BMS Manual
Chapter
InterQual Criteria
Smart Sheet
Guidelines
Inpatient/Acute Care
510
Adult, Child, and
Procedures
Y
State Criteria: Botox
Inpatient Medical
Rehab <21
510
N/A
N
Medicare: Rehabilitation
Care
Laboratory
529
N/A
N
State Criteria: BRAC 1 & 2
Imaging/Radiology
528
UMC Imaging Criteria
Y
State Criteria: Portable Xray
510
Adult, Child,
Pediatric, and
Procedures:
Specialty Referral
Y
State Criteria: Dorsal
Column Stimulators and
Botox
Cardiac/Pulmonary
Rehab
527
Rehabilitation Criteria
N
Rehabilitation and State
Criteria
DME
506
DME
Y
State Criteria: Oxygen and
Incontinence
Medicare: Wheelchairs
Orthotics/Prosthetics
516
DME
N
Dental and
Orthodontic
505
N/A
N
Outpatient Surgery
American Academy of
Dentistry and American
Academy of Pediatric
Dentistry
Criteria, cont…
Review Area
BMS Manual
Chapter
InterQual Criteria
Smart Sheet
Chiropractic
504
Outpatient and
Rehabilitation Criteria
N
Podiatry
520
Specialty Referral
N
Speech/Audiology
530
Home Care: Speech and
Language Pathology
Adult & Child
N
Vision
525
N/A
N
Physical/Occupational
Therapies
515
Home Care: Physical &
Occupational Therapies
N
Home Health
508
Home Care
N
Hospice
509
Home Care, Acute: Adult
& Child
N
Home Care: Skilled
Nursing
N
Private Duty Nursing
Guidelines
Medicaid Program
Instruction MA-01-21;
Medicare OASIS
InterQual Criteria/SmartSheets
• WVMI will utilize InterQual criteria, where
available, for review of medical necessity
• SmartSheets, are available to physicians
and DME vendors
• Providers must visit WVMI website to enroll
https://secure.wvmi.org/wvproviders/
For further assistance contact……..
Melissa Nichols, 304-346-9864 ext. 3233
General/Targeted Policy Updates
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Program policies are located in the BMS manual chapters. BMS will update manuals with new,
revised, or clarified information, as applicable and the UMC will perform required updates to the
DDE system as applicable.
Changes and updates will be noted on the APS and WVMI websites. We will update providers as
soon as practicable to give as much advance notice of an upcoming change or addition as
possible.
CPT code changes are reflected in the Master code List based on 2011 updates. Covered
services requiring prior authorization coincide with current manual requirements for each area of
review. Master code List will be updated if updated manuals in any program area add or delete
codes requiring prior authorization.
Please reference Chapter 100, topic "Manual Updates“ for these updates.
Specific workflows and data demands have been developed to accommodate EPSDT and Out-ofNetwork requirements.
For the purpose of the initial DDE implementation the following is a summary of changes
by review area:
Dental: Updated Manual Chapter 505 was implemented November 1, 2010 – all relevant
requirements, codes and UM forms are incorporated in the DDE system. Retrospective review
policy was modified to allow 10 days to request retrospective reviews for urgent dental situations.
Speech: Manual Chapter 530-in the process of being updated- it is proposed that therapists must
bill under individual NPI number rather than under facility
Updates continued
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Occupational and Physical Therapies: Manual Chapter 515- in the process of being updatedproposed changes will require an initial authorization for the first 6 visits requiring a minimal
amount of patient information. Subsequent authorizations will require the full clinical information
required to apply criteria. Occupational and Physical therapists must enroll and bill using individual
NPI numbers.
Chiropractic: there are no changes to this manual- DDE system for PA requests reflects the
current manuals and codes requiring PA. Enhancements to request screens highlight data
required per criteria.
Radiology/Imaging: there are no changes to this manual- DDE system for PA requests reflects the
current manuals and codes requiring PA. Enhancements to request screens highlight data
required per criteria.
Laboratory: there are no changes to this manual- DDE system for PA requests reflects the current
manuals and codes requiring PA. Limited genetic screening labs require prior authorization.
Podiatry: there are no changes to this manual- DDE system for PA requests reflects the current
manuals and codes requiring PA have been updated to mirror requirements in the Molina system.
Vision: Manual Chapter 525- in the process of being updated- possible changes to PA
requirement for some codes, addition to codes available to adults and changes in requirements for
prior authorization after service limits.
Outpatient Surgery: there are no changes to this manual- DDE system for PA requests reflects the
current manuals and codes requiring PA. There are some services that are now covered in an
outpatient setting that were previously only covered inpatient. There are some codes deleted from
the PA requirement. The Master Code List reflects these changes. Enhancements to request
screens highlight data required per criteria.
Updates continued
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Durable Medical Equipment (DME): there are no changes to this manual- DDE system for PA
requests reflects the current manuals and codes requiring PA. Enhancements to request screens
highlight data required per criteria.
Orthotics & Prosthetics: there are no changes to this manual- DDE system for PA requests
reflects the current manuals and codes requiring PA. Enhancements to request screens highlight
data required per criteria.
Cardiac & Pulmonary Rehabilitation: There are no changes in coverage for the traditional
Medicaid population. Review criteria are the same as required for this service in Chapter 527Mountain Health Choices. Request screens highlight data required per criteria.
Inpatient Services/Inpatient Medical Rehabilitation <21: there are no changes to this manual- DDE
system for PA requests reflects the current manuals and codes requiring PA. Enhancements to
request screens highlight data required per criteria.
Home Health: Manual Chapter 508-Updated Manual effective July 1, 2010-Prior Authorization
required after 60 visits-requirement will not be implemented until DDE system is implementeddate to be announced. Home Health will require an initial authorization for the first 60 visits
requiring a minimal amount of patient information.
Hospice: Implementation of this area will coincide with the effective date of the updated Manual
Chapter 509: Hospice Services. The updated chapter requires prior authorization of these
services and the DDE workflow and data elements reflect the requirements of the updated manual
chapter.
Private Duty Nursing: DDE system for PA requests reflects the current policy and codes requiring
PA. Enhancements to request screens highlight data required per criteria.
Retrospective Review Policy
Retrospective review is available in the following instances:
1. Weekends or holidays, or at times when APS/WVMI is closed. Retrospective
reviews must be initiated on the first APS/WVMI business day following the
service
2. Member eligibility has been back-dated and must be within 12 months of the
date of service
3. A procedure/service denied by the member’s primary payer provided all
requirements for the primary payer have been followed including the appeals
process.
Note: Dental providers have been granted a provision to request prior
authorization within 10 days of the procedure, for procedures that in the
practitioner’s opinion are medically necessary and in the best interest of the
patient should be performed before prior authorization can be sought. This
provision is being considered for other areas of review as well (e.g. inpatient,
imaging).
Out of Network
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Any service provided to a West Virginia
Medicaid member by an out-of-network
provider must have a prior authorization in
order for payment to be processed
– unless its an ER service or a foster
child placed out of state or it is a policy
exception per the BMS Manual Chapter
Medical Necessity Review for requests for
out-of-network services follow all
requirements of the relevant manual chapter
AND the UMC evaluates whether the
service can be provided by an in-network
provider.
Referrals (Referring Providers): sent from
a WV Medicaid enrolled provider for a WV
Medicaid member to receive services from
an out-of network provider.
Providers (Servicing Providers): Facility
or provider to which the member is being
referred is confirmed as out-of-network. The
provider needs to enroll prior to receiving
authorization and instructed to contact Fiscal
Agent for enrollment.
Provider
Out of Network Referrals
Start
Referring provider
makes referral to
O-O-N Provider
Yes
Is Referring
Provider in
Network?
Yes
Is Member
Medicaid
Eligible?
No
Request Closed –
Referring provider
and member notified
(letter sent)
No
End
Conduct Medical
Necessity Review
per appropriate
criteria/workflow
Is Service
Available In
Network?
Yes
No
Deny request –
letter to member
and provider
No
Is Medical
necessity
criteria met?
Yes
Yes
Does provider have
an Out of Network
contract?
No
Issue call tracking ticket to Molina who sends enrollment
letter/APS holds PA – unless urgent * Molina process starts
Provider
enrolled within
30 days?
Yes
APS issues
Authorization and
close call tracking
End
Close call tracking
No
Medical Case Management
• Automatically triggered for Inpatient: Organ Transplant &
Bariatric Procedures, Private Duty Nursing & Inpatient
Medical Rehab <21 for coordinating and managing the
authorized service and outpatient services following
discharge.
• Medical Case Management is also provided for
members identified by the Bureau for Medical Services
to monitor progress during or following delivery of
intensive or high cost services.
• Members with active authorizations whose Medicaid
provider discontinues enrollment in WV Medicaid are
managed through transition.
• The member and the referring physician are informed
that the service is being provided.
Medical Case Management
Care Manager
(CM) referral is
received*
CM admin screens
for Medicaid
eligibility and
assigns case
Initial contact with
member and
physician and
member notified
No
Contact/
agreement est.
with physician
Yes
Care plan
reviewed and
documented
No
Alternate care plan
developed
Physician
Reviewer makes
changes &
suggestions
Is care plan
appropriate?
Yes
Case management
plan initiated
* Reassessment
Cycle
Go To
A
* Per BMS outlier report – or – prior authorization of a medical service requiring ongoing Case Management
Medical Case Management
A
Attending
physician
decision
No
Yes
Physician
Reviewer &
attending
physician reach a
consensus
Case management
plan initiated
Case management
plan initiated
* Reassessment
Cycle
* Reassessment
Cycle
* Reassessment Cycle
Start
No
Continued monitoring
Reassessment as
indicated for continued
services?
Case closed. Attending physician
& member/representative notified
Yes
Services &
periodic
reassessment
continue until
desired outcome is
achieved or other
condition for
closure exists
Materials Available to Providers
•
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Master Code List
UM Guidelines
Frequently Asked Questions
Policy Updates
Step by Step Instructions for requesting &
navigating Medical UM Review in CC
Master Code List
• Master Code List includes all services
requiring prior authorization (PA) by review
area
• This document will be located on the APS,
WVMI, BMS and Molina websites.
MASTER CODE LIST
UM Guidelines
Contains:
• Summaries of BMS Manual Chapters (with disclaimer
that the provider is responsible for complying with
requirements of relevant Medicaid chapters for the
service(s) being requested)
• Workflow
• Prior Authorization Requirements
• Authorization/Review Criteria
• Review timelines
• Helpful Tips
Frequently Asked Questions
• A listing of frequently asked questions
from training sessions will be posted on
the APS and WVMI websites.
• FAQ’s from the Molina Provider Training
Workshops have been posted on the APS
& WVMI websites.
• A listing of questions from these trainings
and subsequent training will also be
posted on our websites for your review.
Communications
• APS will communicate changes, updates
and training opportunities by way of trade
and professional publications, email
announcements and postings on the APS,
WVMI, Molina, and BMS websites.
• Please make sure we have your contact
information in order to best communicate
with you!
QUESTIONS ?
Contact Us.
APS Healthcare
Telephone:
1-800-461-0655
Medical Services: 1-800-346-8272 ext. 6954
Web Address:
www.apshealthcare.com/wv
General e-mail Medical Services:[email protected]
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Helen Snyder, Associate Director ~ [email protected]
Heather Thompson, UM Nurse Reviewer ~ [email protected]
Sherri Jackson, Office Manager~ [email protected]
Denise Burton, Administrative Assistant~ [email protected]
WVMI
Telephone: Management 1-800-642-8686
Web Address: www.wvmi.org click on the link under Medicaid Information
•
John Marks, Director of State Services, [email protected]
•
Stacy Holstine, RN, BA, CPUM, Project Manager, [email protected]
•
Melissa Nichols, Support Staff Supervisor, [email protected]
ext. 6911
ext. 6907
ext. 6902
ext. 6949
ext. 2271
ext. 3279
ext. 3233