Transcript Prior Authorization Service Types

INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT
South Carolina KePRO
QIO Request Submission
Requirements
New 6/14/2012
Topics
• Service Type(s)
• KePRO SCDHHS Website
• Service Type
Requirements
• Contact Information
Prior Authorization Service
Types
• Therapies – (PT, OT, SP)
• Home Health
• Hospice
South Carolina Web Site
Forms
Navigate to Form Tab
to obtain Documents
such as: Fax and
Justification forms
Therapies – PT, OT , and SP
• 21 years and Older - OP Hospital
• Under 21–OP Hospital and Private setting
• Medicare Primary – Medicare claim denied or benefits
exhausted – Then Medicaid PA could be obtained
• Medicare Hospice- Therapy is not related to the illness.
• Provider Manual - Hospital Services provider manual,
not the Private Rehab provider manual
• Evaluation = 1
• Follow up session(s) - 1 unit = 15minutes
– See Hospital Provider Manual - Section 4-74 to 76 for Codes requiring PA and
appropriate Unit designation
Therapies-PT,OT,SP
• Therapy codes:
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92506
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92607
92608
92609
92610
97001
97002
97003
97004
97012
97016
97018
97022
97024
97026
97028
97032
97033
97034
97035
97036
• Therapy codes:
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97110
97112
97113
97116
97124
97140
97150
97530
97532
97533
97535
97537
97542
97597
97598
97605
97606
97750
97755
97760
97761
97762
Home Health
Home Health covered services:
• Nursing services
• Home health aide
• PT, OT, SP
Home Health
KePRO will review for the following
procedure codes:
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T1030- Nursing care in home by Registered nurse
T1031- Nursing care by a Licensed Practical nurse
T1021- Home Health Aide Visit
T1028- Assessment Visit DME Evaluation
A9900- Supplies
S9127- Social Work visit, in the home
S9128- Speech Therapy
S9129- Occupational Therapy
S9131-Physical Therapy
Home Health
• Recipients may receive up to 50 home
health skilled nursing, PT, OT, SP visits
per fiscal year without prior authorization.
• Prior authorization is required for services
beyond the first 50 visits
• 1 unit = 1 visit
Home Health
• Request for extended service beyond the initial authorization period
must be submitted to KePRO prior to the last authorized day in the
certification period
• Provider has two business days to respond to additional information
pend notices.
– If no response received to pend, the request will be forwarded
for Higher level review or administratively denied
• Providers have two business days to respond to Insufficient
information request
– If no response received to pend, the request will be closed
requiring re-submission for Prior authorization
Hospice
• Effective October 1, 2012, all requests for Hospice
Services for Medicaid-only Recipients will need to be
submitted to KePRO for Prior Authorization
Hospice
Hospice Procedure codes
• T1015- GIP General Inpatient Care
• S9126- Routine home Care
• S9123- Continuous home Care
• S9125- Inpatient Respite Care
Hospice
•
Required Documentation:
– KePRO Outpatient Fax Form
– DHHS 149 (Election Form)
– DHHS 151 (Physician Certification Form)
– Plan of Care (POC)
– DHHS 153 (Revocation Form)- If applicable
– DHHS 154 (Discharge Form)- If applicable
– DHHS 152 (Change Request Form)- If applicable
• Clinical documentation to support request
Hospice
• KePRO Outpatient Fax Form
– Please make sure that all necessary information has
been filled out on the KePRO fax form
– Include all 3 procedure codes (GIP should also be
included if that is the status of the client upon
submission)
– Requests for GIP should be submitted at the time of
inpatient admission, and if approved, will be
approved for a 30 day time span
Hospice
• DHHS 149 Form (Medicaid Hospice
Election):
– To be eligible to elect Hospice under Medicaid:
• Person must be certified as being terminally ill.
– Person is considered terminally ill if he or she has a medical
prognosis that his or her life expectancy is 6 months or less, if
the disease runs its normal course
– Hospice coverage is available for an unspecified
number of days.
– The days are subdivided into election periods
• Two 90-day periods each
• An unlimited number of subsequent periods of 60 days each
Hospice
• DHHS 149 Form (Medicaid Hospice
Election):
– Designate an effective date for the election
period to begin
– The request must be submitted to KePRO within
15 business days of election of benefits
– If not received within 15 business days, the
request will be approved effective the date the
request was received by KePRO
Hospice
DHHS 149 Form
Hospice
• DHHS Form 151- Medicare Hospice
Physician Certification and Recertification
– Hospice must ensure the following conditions
are met:
• Written certification statements must be obtained
within 2 calendar days after hospice care has
been initiated
– Signed by the Medical Director of the Hospice or the
physician member of the Hospice interdisciplinary group
– Signed by the person’s attending physician (if the
individual has an attending physician)
Hospice
• DHHS Form 151- Medicare Hospice
Physician Certification and Recertification
– Hospice must ensure the following conditions
are met:
• If written certification if not obtained within 2 days
after the initiation of Hospice care:
– A verbal certification may be obtained within these 2
days
– A written certification must be obtained prior to
submission of a request for prior authorization
Hospice
• DHHS Form 151- Medicare Hospice
Physician Certification and Recertification
– Hospice must ensure the following conditions
are met for recertification:
• The Hospice must obtain (no later than 2 calendar
days after the beginning of that period):
– A written certification statement completed by the
medical director of the hospice or the physician member
of the Hospice’s interdisciplinary group
– Must include the physician’s signature
– A statement that the individual’s medical prognosis is of
a life expectancy of 6 months or less, if the terminal
illness runs its normal course
Hospice
DHHS Form 151- Medicare Hospice Physician Certification and Recertification
Hospice
• Revocation
– A beneficiary may revoke the election of
Hospice care at any time
– The individual loses any remaining days in the
Hospice benefit period and regular Medicaid
benefits are reinstated effective the date of the
revocation
– The individual may at any time elect to receive
Hospice coverage for any other Hospice election
period for which he or she is eligible.
Hospice
• DHHS Form 153- Medicaid Hospice
Revocation
– To revoke Hospice, the individual must:
• Complete DHHS form 153
• Designate an effective date to revoke Hospice
• Submit Form 153 to KePRO within 5 business
days of revocation of benefits
• Mail a copy of the form to the nursing facility or
ICF/MR
Hospice
DHHS Form 153- Medicaid Hospice Revocation
Hospice
• Discharge:
– Discharge of an individual may occur for the
following reasons:
• The individual expires
• The individual is noncompliant
• The individual is determined to have a prognosis greater
than 6 months
• The individual moves out of the Hospice’s geographically
defined service area
• If discharging for reasons other than death, the Hospice
provider must send a copy of the Medicaid Hospice
Discharge Statement to the beneficiary or responsible party
upon discharge
Hospice
• DHHS Form 154- Medicaid Hospice
Discharge:
– Form 154 must be completed
– Designate an effective date to discontinue
Hospice
– Submit form to KePRO within 5 working days
of the effective date of discharge
Hospice
DHHS Form 154- Medicaid Hospice Discharge
Hospice
• DHHS Form 152- Medicaid Hospice
Provider Change Request Form
– Form 152 is to be used when an individual
chooses to change the designation of the
particular Hospice from which he or she
elects to receive Hospice Care in each
election period
– To change the designation of Hospice
providers, the individual must notify their
current Hospice provider that they which to
change Hospices
Hospice
• DHHS Form 152- Medicaid Hospice
Provider Change Request Form
– The Hospice provider that is releasing the
beneficiary must:
• Complete all appropriate portions of Form 152
• Submit a copy of Form 152 to KePRO within 5
business days
• Send a copy to the receiving Hospice Provider
Hospice
– The receiving Hospice Provider must:
• Receive a copy of Form 152 within 2 business
days of the effective date of change
• Forward a completed copy to the SCDHHS
Hospice Program Manager within 5 business days
of the effective date of receiving Hospice’s first
day of service to be included for billing
• Mail a copy of the form to the nursing facility or
ICF/MR
• For Medicaid only beneficiaries, Form 152 can be
faxed to KePRO
Hospice
DHHS Form 152- Medicaid Hospice Provider Change Request Form
DME
Effective October 1,2012 the following two
codes will require prior authorization
request from KePRO:
• S8189- Tracheostomy Supply, not otherwise classified
• L0638- Lumbar-sacral orthotic (SLO)
• Providers must attach pricing information on claims for
procedure codes that are manually priced
Outpatient Fax Form
KePRO Outpatient Fax Form cont.
KePRO Contacts
Thank You!
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