prior authorization process for incontinence supplies...used for managing incontinence in...

Prior Authorization Process

for Incontinence Supplies

July 24, 2019

Objectives

1

Promote understanding of the HUSKY Health program’s

Prior Authorization (PA) process for incontinence

supplies

Describe the use of the Department of Social Services

(DSS) Fee Schedule

Explain documentation requirements

Reduce the administrative burden associated with the

PA process

Prior Authorization Overview

All HUSKY Health members are eligible to receive healthcare goods

or services from Connecticut Medical Assistance Program (CMAP)

enrolled providers

Only CMAP enrolled providers will be reimbursed for goods or

services provided to HUSKY Health members

All ordering, prescribing, or referring providers must be enrolled as

either an ordering/prescribing/referring (OPR) or CMAP provider

Medical necessity determinations are made on a case-by-case,

person-centered assessment of members needs

Payment is based on the member having active coverage, benefits,

and policies in effect at the time of service

All determinations are made on the basis of medical necessity and

must be in compliance with the Definition of Medical Necessity,

Connecticut General Statutes§17b-259b(a)

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Definition of Medical Necessity

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Section 17b-259b(a)

“Medical Necessity” (or “Medically Necessary”) means those health

services required to prevent, identify, diagnose, treat, rehabilitate, or

ameliorate an individual’s medical condition; including mental illness, or

its effects, in order to attain or maintain the individual’s achievable

health and independent functioning provided such services are:

(1) Consistent with generally-accepted standards of medical

practice that are defined as standards based on:

(A) Credible scientific evidence published in peer-reviewed

medical literature that is generally recognized by the

relevant medical community

(B) Recommendations of a physician-specialty society

(C) The views of physicians practicing in relevant clinical

areas

(D) Any other relevant factors

Definition of Medical Necessity (cont.)

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(2) Clinically appropriate in terms of type, frequency, timing,

site, extent and duration, and considered effective for the

individual’s illness, injury, or disease

(3) Not primarily for the convenience of the individual, the

individual’s healthcare provider, or other healthcare providers

(4) Not more costly than an alternative service or sequence of

services at least as likely to produce equivalent therapeutic or

diagnostic results as to the diagnosis or treatment of the

individual’s illness, injury, or disease

(5) Based on an assessment of the individual and his/her

medical condition

All final determinations of medical necessity must

be based upon this statutory definition

DSS Fee Schedule

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Locating the DSS Fee Schedule

Go to www.ctdssmap.com

Click on “Provider”

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Locating the DSS Fee Schedule (cont.)

Click on “Provider Fee Schedule Download”

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Locating the DSS Fee Schedule (cont.)

Click on the “I Accept” button at the bottom of the

License Agreement

Choose the desired Provider Fee Schedule

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Fee Schedule Special Instructions

The top and the bottom of every fee schedule includes

special instructions

Manual pricing instructions:

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Fee Schedule Special Instructions

(cont.)

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Fee Schedule Special Instructions

(cont.)

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Submitting a PA

Request

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Outpatient PA Request Form

Visit www.ct.gov/husky,

click “For Providers,”

“Prior Authorization,”

“Prior Authorization

Forms & Manuals,” then

“Outpatient Prior

Authorization Request

Form”

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Outpatient PA Request Form Completion

You will need to complete all sections of the PA form

including start date, end date, procedure code, modifiers

(if applicable), and number of units

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Outpatient PA Request Form

Completion (cont.)

Dates

Start date is the anticipated date of delivery

Date span may be up to one year for HUSKY A, C, and D

Date span may be up to six months for HUSKY B/HUSKY Plus

Procedure Code

Verify the DSS Fee Schedule to determine the appropriate code

Code needs to match the description/code on the MD

prescription

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Outpatient PA Request Form

Completion (cont.) Units

If the code requires prior authorization, then the number of units should

equal what the member requires for the entire span of the authorization

Units

If the code does not require prior authorization on the fee schedule, but

you are requesting an overage, then the number of units will equal only

the overage for the span of the authorization

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Submitting a PA Request

Providers may submit a prior authorization request by:

Fax: 203.265.3994 or

Medical Authorization Portal

For assistance: ClearCoverageHelpdesk@chnct.org

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Clinical Documentation

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Documentation Requirements

PA form

Prescription

Clinical Documentation

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Prescription

Per Section 17b-262-721(f) of the Regulations of

Connecticut State Agencies, all orders for medical and

surgical supplies shall at a minimum include the

following:

Member’s name, address, and date of birth

Diagnosis for which the medical and surgical supplies are

required

Detailed description of the medical and surgical supplies,

including quantities and directions for usage, when appropriate

Length of need for the medical and surgical supplies prescribed

Prescribing practitioner’s name, address, signature, and

signature date and

NPI number of the ordering, prescribing, referring practitioner

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Medical Policies

Medical policies can be located on the HUSKY Health website.

Visit www.ct.gov/husky, click “For Providers,” “Medical

Management,” then “Policies, Procedures & Guidelines.”

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Medical Policies (cont.)

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Medical Policies (cont.)

The primary purpose of medical policies are to assist

providers with the information needed to support a

medical necessity determination

Medical policies are guidelines only

Coverage decisions are based on an assessment of the

individual and their unique clinical needs

All final determinations of medical necessity must be

based upon the legal definition of medical necessity

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Coverage Guidelines

Coverage guidelines for diapers and absorbent products

used for managing incontinence in individuals covered

under the HUSKY A, C, and D (Medicaid) and HUSKY

Plus (part of CHIP) programs, ages three years and

older, are made in accordance with the DSS definition of

medical necessity

Coverage determinations are based on an assessment

of the individual and his or her unique clinical needs. If

the guidelines conflict with the definition of medical

necessity, the definition of medical necessity shall

prevail

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Coverage Guidelines (cont.)

Diapers and absorbent products may be considered

medically necessary in the management of incontinence

associated with a broad range of medical conditions

including, but not limited to, neurological conditions,

congenital anomalies, injuries to the pelvic region,

injuries to the spinal cord, fistula, bowel prolapse and

infections

Consideration is always given to the unique needs of a

given individual

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Procedure for HUSKY A, C, & D

Prior authorization of diapers and absorbent products is

required for individuals ages 3 to 12

Prior authorization for individuals ages 13 and older is

required when the request for these supplies exceeds

the quantity limits as outlined in this policy and on the

DSS MEDS – Medical Surgical Supplies Fee Schedule

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Documentation for HUSKY A, C, & D

Signed prescription from the ordering physician (for re-

authorization requests a physician signature on the refill

order sheet will fulfill this requirement) identifying

specific type, and quantity of items needed;

Fully completed State of Connecticut, DSS Outpatient

Prior Authorization Request Form to include the primary

diagnosis, a secondary diagnosis of incontinence, and

signed clinical statement; and

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Documentation for HUSKY A, C, & D

(cont.)

Additional pertinent clinical information to support the

medical necessity of requested items:

Office visit note

Separate letter of medical necessity

Box 25 of the PA form:

Must be written by the ordering physician and box 26 must be

signed by the ordering physician

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Claims Submission

Claims for diapers and absorbent products should be

submitted, following the provider’s usual claims

submission protocol to DXC Technology

When requesting diapers and absorbent products in

excess of the amounts identified below:

All items must be delivered within the authorized timeframe

Supplies up to the quantity limit must be delivered and billed on

one of date of service

Supplies above the quantity limit must be delivered and billed on

a different date of service

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Limitations

Diapers and absorbent products are not covered for

individuals ages 0 to 2 for HUSKY A, B, C, or D

Diapers and absorbent products are not covered for

individuals enrolled in HUSKY B but are covered under

its supplement, HUSKY Plus program for members ages

3 and over

HUSKY Plus provides supplemental coverage of children with

intensive physical health needs for services not covered under

the HUSKY B program

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HUSKY Plus

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HUSKY Plus Benefit Categories

For more information about which medical benefits are

covered under HUSKY Plus, go to www.ct.gov/husky, click

“For Providers,” “Medical Management,” “Benefit Grids,”

then “DME Grid”

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http://www.huskyhealthct.org/providers/provider_postings/benefits_grids/Home_Health_Grid.pdf

Initial Requests

First time requests for goods and services will be

reviewed under HUSKY B

Goods or services that are excluded/exhausted under HUSKY B

will be referred for evaluation under HUSKY Plus automatically

Upon determination of HUSKY B exhaustion or non-coverage, a

person-centered medical necessity review will be completed under

HUSKY Plus

Providers will not be required to submit a new request for

consideration under HUSKY Plus

Authorizations can be requested for up to a six month period of

time

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Reauthorization Requests

Requests for ongoing goods will require PA under

HUSKY Plus:

Box 16 must reflect HUSKY Plus

Authorizations can be requested for up to six months

Requests must include:

Valid prescription

Updated clinical notes

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HUSKY Plus Covered Services

Effective March 15, 2018

Children over the age of three and

Combined 180 diapers and pull-ups and/or

Combined 180 disposable liners/shields/underpads

Reference: Provider Bulletin 2018-05

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Modification Requests

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Modification Requests: Size

Requests can be submitted to modify an existing

authorization due to change in size of supply

Request an end date to the existing authorization

Date of last shipment

New authorization request that includes:

Updated prescription indicating new size and quantity per month

Updated medical documentation as previously outlined

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Modification Requests: Quantity

Requests can be submitted to modify an existing

authorization due to change in quantity

Modification request to include:

Updated prescription indicating new quantity per month

Updated medical documentation that outlines the change in medical

condition that warrants an increase in quantity

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Urgent Requests

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Definition of an Urgent Request

Illnesses or injuries of a less serious nature than those

constituting emergencies but for which treatment is

required to prevent a serious deterioration in the

individual’s health, and for which treatment cannot be

delayed without imposing undue risk to the individual’s

well-being until the individual is able to secure services

from his/her regular physician(s).

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Urgent Process

Urgent requests will be reviewed within one business

day

Requests that do not meet the definition of urgent will be

changed to expedited and will be reviewed within the 14

day turnaround time

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Review Timeframe

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Review Timeframe

Once a request is submitted, a pending authorization number

is generated

If more information is needed, the clinical reviewer will

contact the provider via fax, phone and/or email, or through

their Clear Coverage™ account; if additional information is

required, the provider is given additional time to submit the

requested information

All requests for DME are reviewed within 14 calendar days

from the date of receipt

A decision must be made by the 20th business day from the

date of receipt

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Request Approvals

Approval letters are generated after the request

approval has been given

The approval letter is mailed to the member and faxed to

the DME provider

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Request Denials

Denial letters are mailed to the member and faxed to the

ordering physician and DME provider within three

business days of the determination

A member or their provider can appeal a denial

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Questions/Comments

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