MDwise – You have been authorized – a guide for prior authorization for claim submission

IHCP Annual Workshop October 2010

APP0044 (09/10)

Purpose for today’s presentation

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Role of MDwise medical management 2.

New universal prior authorization form 3.

You have been authorized…. now what? 4.

You received a denial … now what? 5.

Quick tips for claims adjudication (audience participation) 6.

Tools and resources 2

Who is MDwise

 MDwise is a local, not-for-profit company serving Hoosier Healthwise, Care Select and Healthy Indiana Plan (HIP) members. We have been giving the best possible health care to our neighbors since 1994. In fact, we only take care of families living in Indiana. Our services are provided to more than 280,000 members in partnership with over 1,400 primary medical providers.

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Role of Medical Management

  MDwise delegates medical management functions to the MDwise delivery systems (see quick contact sheet). Medical Management focuses on the outcome of treatment with an emphasis on:  Appropriate screening activities.

  Reasonableness and Medical necessity of all services.

Quality of care reflected by the choice of services provided, type of provider involved, and the setting in which the care was delivered.

  Evaluation of standards of care/guidelines for provision of care Best practice monitors.

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Role of Medical Management

  Medical Management service authorization activities conducted by the Medical Management staff include: Preauthorization of inpatient and selected outpatient services, management concurrent review and retrospective review on selected inpatient and outpatient services authorization and denial notification.

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Contacting Medical Management

 Contact member’s Medical Management Department for services that require authorization (see quick contact sheet) Hoosier Healthwise 6

Universal Prior Authorization Form

 A standardized Prior Authorization form will be utilized by all health coverage program providers.

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New prior authorization form

Indiana Health Coverage Programs Prior Authorization Request Form Click HERE to view form.

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Out-of- Network Authorizations

 Members of MDwise networks that require covered services not available within the network must have prior authorization from the Delivery System’s Medical Management Department (before services are rendered).

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Referral to Specialist

   A prior authorization number may not be required when referring to an in-network provider. Please refer to the delivery system medical management department or provider directory for assistance in locating an in-network provider.

Retroactive authorizations for referrals is not guaranteed (contact members medical management department).

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Prior authorization for DME

  Contact the member’s Delivery System Medical Management Department for approved providers and DME (Durable Medical Equipment) prior authorization requirements.

Universal prior authorization form available online at www.MDwise.org/providers Hoosier Healthwise 11

Behavioral Health Authorizations

      Standardized forms for Behavioral Health: BH/Primary Medical Provider Coordination Form Therapy/Outpatient Treatment Form (OTR) Form Psychological Testing Form Neuropsychological Testing Form These forms can be found on our website: www.MDwise.org/providers/forms/behavioralhealth Hoosier Healthwise 12

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Claims submission

Providers are encouraged to submit their claims electronically In-MDwise Network Providers must submit their claims to the delivery system claims department where the member is assigned.

Providers should contact the applicable delivery system for specific instruction on electronic claims submission Please note that all electronic claims must be submitted using the HIPPA compliant transaction and codes sets Providers may submit paper claims to the applicable delivery system address (see quick contact sheet ) 13

Claims Filing Limit

   In-Network Providers have a filing limit that ranges from 90 to 180 days, depending on their contract with the Delivery System.

Claims filing limit for 2011 will change to 90 days for all MCEs.

Out-of-Network Providers have 365 days from the date of service to file a claim.

 It is the responsibility of ALL providers to check eligibility at the time of each visit.

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Claims Dispute

  Claims dispute 

In and out of network- Call Delivery System to inquire about claim

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Delivery System must respond within 30 calendar days of inquiry Claim disputes must be submitted in writing. Include reason for dispute, claim and MDwise EOB or remittance advice.

Provider has 60 calendar days

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From receiving remittance advice denial or

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After delivery system fails to make determination or In-network appeals should be forward to members delivery system for resolution

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Out-of-network appeals should be forward to MDwise Corporate at P.O. Box 441423, Indianapolis, IN 46244-1423 Attention: Appeal Manager

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Member Appeals

 Effective 7-1-2010 the member appeals process was revised to ensure consistency across plans and compliance with Federal and NCQA guidelines. A member appeal is for a denied service request that has NOT been provided. A provider may appeal the denied service request on behalf of a member within 30 days of their denial. Appeals should be sent to MDwise Appeal Manager , P.O. Box 441423, Indianapolis, IN. 46244. Please include any information that may be helpful in resolving the appeal.

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Pharmacy Authorizations

 The pharmacy benefit for Hoosier Healthwise and HIP is being administered through HP. Please refer to bulletin bt200929.

 The PDL is updated on a regular basis. The PDL can is available hard copy and online @ www.indianapbm.com

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You have been authorized now what?

 Submit your claim !!!!

 Audience participation 18

You have been authorized now… what?? Audience participation

   Question # 1.

MDwise St. Francis member receives a tubaligation from an approved provider. The claim was submitted but denied. What was the reason for the denial? 19

You have been authorized now… what?? Audience participation    Question # 2 MDwise Methodist member receives hysterectomy at an in network facility. Prior authorization was obtained, but the claim denied. What was the reason for the denial?

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You have been authorized now… what?? Audience participation Question #3  Durable medical company, Safety Wheels, orders a custom wheelchair for a MDwise Hoosier Alliance member. Delivers the wheelchair to the patient and submits the claim to MDwise Hoosier Alliance, but the claim is denied.  Why did the claim deny?

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You have been authorized now… what?? Audience participation Question # 4  MDwise Select Health member receives prior authorization for physical therapy by an in network provider. When member presents for therapy, occupational therapy was also rendered. Provider submits claims with PT and OT services on claim and a portion of the claim of denied.

 What portion of the claim denied and why?

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You have been authorized now… what?? Audience participation Question # 5  MDwise St. Vincent member presents in St.Vincent’s ED (emergency department) for severe leg pain. After several hours in the ED, the patient is admitted as inpatient. After 20 days in the hospital the patient is finally discharged. The claim is submitted with the correct coding elements. The claim denied.  What did the claim deny? 23

You have been authorized now… what?? Audience participation Question #6  MDwise ProHealth member is seen by an ears, nose and throat specialist (otolaryngologist). The provider who rendered the service is contracted with MDwise Wishard. The claim was submitted to MDwise ProHealth and was denied.  Why did the claim deny?

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Thank You and Questions

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