Transcript Slide 1

INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT
Service Authorization for Surgical
Procedures (Service Type 0302)
Presented to Virginia Medicaid Providers
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Methods of Submission of Service Authorization
(Srv Auth) Requests to KePRO
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KePRO accepts service authorization (Srv Auth) requests through direct
data entry (DDE), fax and phone.
Submitting through DDE puts the request in the worker queue
immediately; faxes are entered by the administrative staff in the order
received.
For direct data entry requests, providers must use Atrezzo Connect
Provider Portal.
For DDE submissions, service authorization checklists may be accessed
on KePRO’s website to assist the provider in assuring specific information
is included with each request.
To access Atrezzo Connect on KePRO’s website, go to
http://dmas.kepro.com.
10/15/12
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Methods of Submission of Srv Auth Requests to
KePRO
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Provider registration is required to use Atrezzo Connect.
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The registration process for providers happens
immediately on-line.
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From http://dmas.kepro.com, providers not already
registered with Atrezzo Connect may click on “Register” to
be prompted through the registration process. Newly
registering providers will need their 10-digit National
Provider Identification (NPI) number and their most recent
remittance advice date for YTD 1099 amount.
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The Atrezzo Connect User Guide is available at
http://dmas.kepro.com : Click on the Training tab, then the
General tab.
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Srv Auth Requests: Contact Information for KePRO/
DMAS Provider Information
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Providers with questions about KePRO’s Atrezzo Connect Provider Portal
may contact KePRO by email at [email protected].
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For service authorization questions, providers may contact KePRO at
[email protected].
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KePRO may also be reached by phone at 1-888-827-2884, or via fax at 1877-OKBYFAX or 1-877-652-9329.
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Provider Manual Copies Available
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COPIES OF MANUALS
DMAS publishes electronic and printable copies of its Provider Manuals
and Medicaid Memoranda on the DMAS Web Portal at
https://www.virginiamedicaid.dmas.virginia.gov/wps/portal.
This link opens up a page that contains all of the various communications
to providers, including Provider Manuals and Medicaid Memoranda.
The Internet is the most efficient means to receive and review current
provider information.
If you do not have access to the Internet or would like a paper copy of a
manual, you can order it by contacting:
Commonwealth-Martin at 1-804-780-0076. A fee will be charged for the
printing and mailing of the manual updates that are requested.
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VIRGINIA MEDICAID WEB PORTAL
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DMAS offers a web-based Internet option to access information regarding
Medicaid or FAMIS member eligibility, claims status, check status, service
limits, service authorizations, and electronic copies of remittance advices.
Providers must register through the Virginia Medicaid Web Portal in order
to access this information. The Virginia Medicaid Web Portal can be
accessed by going to: www.virginiamedicaid.dmas.virginia.gov. If you
have any questions regarding the Virginia Medicaid Web Portal, please
contact the Xerox State Healthcare Web Portal Support Helpdesk, toll free,
at 1-866-352-0496 from 8:00 a.m. to 5:00 p.m. Monday through Friday,
except holidays.
The MediCall audio response system provides similar information and can
be accessed by calling 1-800-884-9730 or 1-800-772-9996. Both options
are available at no cost to the provider. Providers may also access service
authorization information including status via KePRO’s Provider Portal at
http://dmas.kepro.com.
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Srv Auth Information: Member Eligibility
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Decisions made by KePRO apply only to individuals enrolled in Medicaid
fee-for-service on dates of service requested.
KePRO’s decision does not guarantee Medicaid eligibility or fee-for-service
enrollment.
It is the provider's responsibility to verify member eligibility and to check for
managed care organization (MCO) enrollment.
For MCO enrolled members, the provider must follow the MCO's Srv Auth
policy and billing guidelines.
Because the individual may transition between fee-for-service and the
Medicaid managed care programs, KePRO will honor the Medicaid MCO
service authorization if the member has been disenrolled from the MCO.
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ELIGIBILITY VENDORS: How to check for Member
Eligibility
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DMAS has contracts with the following eligibility verification vendors
offering internet real-time, batch and/or integrated platforms. Eligibility
details such as eligibility status, third party liability, and service limits for
many service types and procedures are available. Contact information for
each of the vendors is listed below:
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Passport Health Communications, Inc.
www.passporthealth.com
[email protected]
Telephone: 1 (888) 661-5657
SIEMENS Medical Solutions – Health Services
Foundation Enterprise Systems/HDX
www.hdx.com Telephone: 1 (610) 219-2322
Emdeon
www.emdeon.com Telephone 1 (877) 363-3666
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Surgical Procedures: Procedure/Service Codes that
Require Srv Auth-How to Determine if Srv Auth is
Needed.
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In order to determine if services need to be service authorized, providers
should go to the DMAS website: http://dmasva.dmas.virginia.gov and look
to the right of the page and click on the section that says Procedure Fee
Files which will then bring you to this: http://www.dmas.virginia.gov/prfee_files.htm.
You will now see a page entitled DMAS Procedure Fee Files. The
information provided there will help to determine if a procedure code needs
service authorization or if a procedure code is not covered by DMAS.
To determine if a service needs Service Authorization determine whether
you wish to use the CSV or the TXT format.
Click on either the CSV or the TXT version of the file. Scroll until you find
the code you are looking for.
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Surgical Procedures: Procedure/Service Codes that
Require Srv Auth-How to Determine if Srv Auth is
Needed (continued).
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The Procedure Fee File will tell you if a code needs to be prior authorized
as it will contain a numeric value for the PA Type, such as one of the
following:
00 – No PA is required
01 – Always need PA
02 – Only needs PA if service limits are exceeded
03 – Always need PA, with per frequency.
To determine whether a service is covered by DMAS you need to access
the Procedure Rate File Layouts page from the DMAS Procedure Fee
Files.
Flag codes are the section which provides you special coverage and/or
payment information. A Procedure Flag of “999” indicates that a service is
non-covered by DMAS.
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Srv Auth Information Specific to Surgical
Procedures (0302)
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Service requests must be submitted by the provider prior to the service being
performed, since this is a planned service ; per DMAS Memo dated 3/9/12
and Physician/Practitioner Manual Appendix D.)
Inpatient hospitalization services must be authorized separately by KePRO
should the procedure or service requires an inpatient hospital level of care.
The provider is responsible for submitting this request.
For those CPT/HCPCS codes that utilize SIMplus criteria, providers must
submit a request within two (2) business days following the procedure to be
considered timely
Service authorization decisions are rendered for 1 unit and 90 days or as
requested by provider but not to exceed a six month timeframe.
Administrative denials would occur if the provider did not respond to a
pended request for initial clinical information or submitted a request after the
request for service has been performed and the member is not retro-eligible
Established timeframes listed above are also applicable to out of state
providers.
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Srv Auth Information Specific to Surgical
Procedures (0302)
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McKesson InterQual®, CMS or DMAS Specific Criteria is utilized to review
Srv Auth request.
If the Clinical or Nurse Reviewer is unable to approve the request based on
established criteria the request is automatically referred for Physician
Reconsideration Review.
Application of EPSDT Criteria for members under the age of 21, are
performed at a Physician Review level or as directed by the Contractor’s
Medical Director. .
KePRO will apply SIMplus® criteria to certain procedure codes (see
Provider Memo dated 3/9/2012 and Physician Manual Ch IV and V.
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These services will be reviewed retrospectively since SIMplus® is not designed for
prospective review of surgeries or for any type of prior authorization
Providers must submit their request timely, within 2 business days following the procedure.
If there is additional information required, the Contractor will pend the request for 20
business days. If the provider does not submit the additional information within the 20
business days specified, then the request will move forward in the review process and a
final determination made with the information that has been submitted.
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Srv Auth Information Specific to Surgical
Procedures (0302)
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For all Gastric Bypass/Bariatric surgical services, KePRO must verify that
the treating facility is a CMS certified center of excellence. The link below
has an updated site for all CMS certified facilities. If the treating facility is
not CMS certified, the request can be administratively denied. This is
supported by 12VAC30-50-580, facility selection standards for good
surgery outcomes.
http://www.cms.gov/MedicareApprovedFacilitie/BSF/list.asp#TopOfPage
DMAS also requires KePRO to apply two levels of Physician Reviews for
all gastric bypass/bariatric procedure requests as noted under Physician
Reconsideration Review section.
For all Septoplasty surgeries, the DMAS Medical Director has modified
McKesson InterQual® criteria to require a CT scan to confirm septal
deviation. For requests that do not have a completed CT scan, the
reviewer will reject the case until the provider obtains a CT scan, thus
completing the required work up. The provider can then re-submit their
request once a CT scan is obtained.
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Srv Auth Information Specific to Surgical
Procedures (0302)
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Cosmetic surgery is not covered when provided solely for the purpose of
improving appearance.
The exclusion of cosmetic surgery does not apply to congenital deformities or to
deformities due to recent injury. When surgery also restores or improves a
physiological function, it is not considered cosmetic surgery. (Provider Manual
and 14VAC5-140-60)
Abnormal congenital malformations and deformities, in children under the age of
21 years, are not considered cosmetic.
Medical necessity, for approval, in adults 21 years of age and older must be
clearly documented.
Treatment of trauma related deformity, especially in the acute stages, is not
considered cosmetic. In chronic stages, medical necessity is required.
Implantable devices for the sole purpose of Substance Abuse treatment is not
covered for members 21 years of age and older (12VAC30-50-140). there needs
to be documented evidence of an organic cause of pain in order to meet pain
management services, including implantable drug infusion therapy.
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Srv Auth Information Specific to Surgical
Procedures (0302) Requests
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Should the date of service request change KePRO will update the service
authorization while considering any untimely issues.
Retrospective review will be performed when a provider is notified of a
member’s retroactive eligibility for Virginia Medicaid coverage.
Retrospective review will also apply when Medicaid dually eligible
members exhaust their Medicare coverage.
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Faxing Requests to KePRO
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Providers must use the specific fax form listed below when requesting
Surgical Procedures
If the fax form is not accompanied by the request, KePRO will reject the
request and the provider must resubmit the entire request with the correct
fax form.
The DMAS 351 (Procedures/Devices Service Authorization Request Form)
is the appropriate form to use for Surgical Procedures)
Forms are available on KePRO’s website at http://dmas.kepro.com.
Providers may click on the “Forms” tab to view a listing of all KePRO
fax forms, labeled by form number and service type.
Service authorization checklists may be accessed on KePRO’s website to
assist the provider in assuring specific information is included with each
request for Surgical Procedures.
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Out of State Provider Requests
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Out of state providers must be enrolled with Virginia Medicaid in order to
submit a request for out of state services to KePRO.
If the provider is not enrolled as a participating provider with Virginia
Medicaid, the provider is still encouraged to submit the request to the
Contractor, as timeliness of the request will be considered in the review
process.
Out of state providers may enroll with Virginia Medicaid by going to:
https://www.virginiamedicaid.dmas.virginia.gov/wps/myportal/ProviderEnrol
lment.
(At the toolbar at the top of the page, click on Provider Services and then
Provider Enrollment in the drop down box. It may take up to 10 business
days to become a Virginia participating provider.)
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Out of State Providers Not Enrolled in Virginia
Medicaid
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KePRO will pend the request back to the provider for 12 business days to
allow the provider to become successfully enrolled.
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If the provider responds with the necessary information within the 12
business days, the request will then continue through the review process
and a final determination will be made on the service request.
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If KePRO does not receive the information to complete the processing of
the request within the 12 business days, the request will be rejected, as the
service authorization cannot be entered into MMIS without the providers
National Provider Identification (NPI).
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Once the provider is successfully enrolled, the provider must resubmit the
entire request.
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Review Process for Out of State Providers
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Procedures may be performed out of state only when the service cannot
be performed in Virginia and/or meet any of the circumstances below.
Services provided out of state for circumstances other than these specified
reasons shall not be covered.
For out-of–state facilities request, the Contractor will need to apply item
number 3 and 4.
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1. The medical services must be needed because of a medical emergency;
2. Medical services must be needed and the recipient's health would be endangered if he
were required to travel to his state of residence;
3. The state determines, on the basis of medical advice, that the needed medical services,
or necessary supplementary resources, are more readily available in the other state;
4. It is the general practice for recipients in a particular locality to use medical resources in
another state.
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Review Process for Out of State Providers
(continued)
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For out-of–state facilities request, the Contractor will need to apply item
number 3 and 4 on the previous slide. If the provider is unable to establish
item 3 and 4, the Contractor will:
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If surgery requested is Gastric Bypass/Bariatric Surgery then supply the provider with a list
of CMS Certified Hospitals in Virginia for Gastric Bypass/Bariatric Surgery
Pend the request for 20 days
Have the provider research and confirm items 3 or 4 and submit back to the Contractor their
findings
Should the provider not respond or not be able to establish items 3 or 4 the
request can be administratively denied. This decision is supported by
12VAC30-10-120 and 42 CFR 431.52.
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DMAS Helpline Information
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The “HELPLINE” is available to answer questions Monday through Friday
from 8:00 a.m. to 5:00 p.m., except on holidays. The “HELPLINE”
numbers are:
1-804-786-6273
1-800-552-8627
Richmond area and out-of-state long distance
All other areas (in-state, toll-free long distance)
Please remember that the “HELPLINE” is for provider use only. Please
have your Medicaid Provider Identification Number available when you call.
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Questions and Answers
Thank you for your Participation!
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