authorization review process - eqhealth solutionsfl.eqhs.org/portals/1/fianl multispecialty pp 9...

Authorization Review Process Chiropractic, Hearing, Optometric, Visual and Physician Services

- Transition to eQHealth Solutions

December 2012

1

Introduction to eQHealth

2

Mission Statement:

“To Improve the Quality of Health and Health Care by Using Information and Collaborative Relationships to Enable Change”

Vision:

“To be an Effective Leader in Improving the Quality and Value of Health Care in Diverse and Global Markets”

Mission and Vision

3

• eQHealth is the Agency for Health Care

Administration’s contracted quality

improvement organization (QIO), responsible

for the Comprehensive Medicaid Utilization

Management Program for the state of Florida

• Local office / operations in Tampa Bay area

5802 Benjamin Center Drive, Suite 105

Tampa, FL 33634

• Branch office in Miami/Dade area

Partnership: Agency for Health Care

Administration and eQHealth

4

http://fl.eqhs.org

Website demonstration

Dedicated Florida Website

5

http://fl.eqhs.org/

Scope of Services

6

Service Requirements

7

Recipients must be:

• Enrolled in a Medicaid benefit program that covers the service requested:

• Fee for service

• MediPass

• Medically Needy

• Dually eligible (Medicare/Medicaid & Commercial/Medicaid)

• CMS (exception: enrolled in a CMS/PSN in a Reform County)

• Waiver Recipients

• Eligible at the time services are rendered.

Not Subject to Prior Auth by

eQHealth

8

Recipients who are:

• Members of a Medicaid HMO

• Members of a Medicaid Provider Service

Network (PSN)

• Members of Children’s Medical Services (CMS)

(enrolled in a PSN in a Reform County)

• Residents of ICF/DD: vision services

Retrospective Review Requests

9

Retrospective authorization may only be requested if

the recipient is granted retroactive Medicaid eligibility

that covers the date(s) services were provided.

Exceptions:

•Hearing evaluation beyond the maximum service limits

• Certain Hearing Aid Fitting and dispensing

•Hearing aids that meet the requirement for immediate need

•Repair or replacement of cochlear implant internal parts outside

of the manufacturer’s warranty

•Emergency Outpatient Surgeries (evidence of “emergency”

required)

Medicaid reimburses services that do not duplicate another provider’s service and are medically necessary for the treatment of a specific documented medical disorder, disease or impairment.

The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, goods or services medically necessary or a medical necessity or a covered service.

Medical Necessity

10

Multi-Specialty Includes the following

11

Physician Services (includes Ambulatory Surgery, Oral and Maxillofacial Surgery)

Chiropractic

Hearing Services

Optometric & Vision Services

Special Services

Intrathecal Baclofen Therapy (ITB) Pump

Authorization Requirements

12

Prior Authorization is required for all services that have

a “PA” marked on the ACHA fee schedule or as

indicated by the applicable handbook.

Prior Authorization numbers are valid for 120 days.

If an extension is needed, contact eQHealth

Customer Service.


Chiropractic

13

Codes that ONLY require a PA if the maximum number of visits (24/year)

are exhausted

• 98940 - Chiropractic Manipulative Treatment (Cmt); Spinal, One To

Two Regions

• 98941 - Chiropractic Manipulative Treatment (Cmt); Spinal, Three To

Four Regions

• 98942 - Chiropractic Manipulative Treatment (Cmt); Spinal, Five

Regions


Hearing Services

14

Codes that ALWAYS require a PA: • L7510 - Repair Of Prosthetic Device, Repair Or Replace Minor Parts

• L8615 - Headset / Headpiece For Use With Cochlear Implant Device, Replacement

• L8616 - Microphone For Use With Cochlear Implant Device, Replacement

• L8617 - Transmitter Coil For Use With Cochlear Implant Device, Replacement

• L8618 - Transmitter Cable For Use With Cochlear Implant Device, Replacement

• L8619 - Cochlear Implant External Speech Processor And Controller, Integrated System, Replacement

• L8623 - Lithium Ion Battery For Use With Cochlear Implant Device Speech Processor, Other Than Ear

Level, Replacement, Each

• L8624 - Lithium Ion Battery For Use With Cochlear Implant Device Speech Processor, Ear Level,

Replacement, Each

• L8627 - Cochlear Implant, External Speech Processor, Component, Replacement

• L8628 - Cochlear Implant, External Controller Component, Replacement

• L8629 - Transmitting Coil And Cable, Integrated, For Use With Cochlear Implant Device, Replacement

• L8691 - Auditory Osseointegrated Device, External Sound Processor, Replacement

• L8692 - Auditory Osseointegrated Device, External Sound Processor, Used Without Osseointegration,

Body Worn, Includes Headband Or Other Means Of External Attachment

• V5299 - Hearing Service, Miscellaneous


Hearing Services

15

Codes that ONLY require a PA if the limits are exhausted

• V5014 - Repair/Modification Of A Hearing Aid (Use For Factory Repair)

• V5050 - Hearing Aid; (Use For Category 1 Hearing Aids)

• V5090 - Dispensing Fee, Unspecified Hearing Aid

• V5200 - Dispensing Fee, Cros

• V5240 - Dispensing Fee, Bicros

• V5264 - Earmold/Insert, Not Disposable, Any Type.

• V5267 - Hearing Aid Supplies / Accessories

• V5299 – Hearing Supplies – Miscellaneous


Vision/Optometric Services

16

Codes that ALWAYS require a PA

• S0590 - Integral Lens Service, Miscellaneous Services Reported Separately

• V2199 - Not Otherwise Classified, Single Vision Lens

• V2299 - Specialty Bifocal

• V2399 - Specialty Trifocal

• V2500 - Contact Lens, Pmma, Spherical, Per Lens

• V2501 - Contact Lens, Pmma, Toric Or Prism Ballast, Per Lens

• V2511 - Contact Lens, Gas Permeable, Toric Or Prism Ballast, Per Lens

• V2513 - Contact Lens, Gas Permeable, Extended Wear, Per Lens

• V2520 - Contact Lens Hydrophilic, Spherical, Per Lens

• V2521 - Contact Lens Hydrophilic, Toric Or Prism Ballast, Per Lens

• V2523 - Contact Lens Hydrophilic, Extended Wear, Per Lens

• V2599 - Contact Lens, Other Type

• V2730 - Special Base Curve, Glass Or Plastic, Per Lens

• V2799 - Vision Service, Miscellaneous


Vision/Optometric Services

17

Codes that ONLY require a PA when the maximum exceeded • 92340 - Fitting Of Spectacles, Except For Aphakia; Monofocal

• 92341 - Fitting Of Spectacles, Except For Aphakia; Bifocal

• 92342 - Fitting Of Spectacles, Except For Aphakia; Multifocal, Other Than Bifocal

• 92352 - Fitting Of Spectacle Prosthesis For Aphakia; Monofocal

• 92353 - Fitting Of Spectacle Prosthesis For Aphakia; Multifocal

• V2020 - Frames, Regular, Office Repair, Plastic

• V2025 - Deluxe Frame (New Or Replacement; Metal

• V2115 - Lenticular, (Myodisc), Per Lens, Single Vision

• V2121 - Lenticular Lens, Per Lens, Single

• V2315 - Lenticular, (Myodisc), Per Lens, Trifocal

• V2319 - Trifocal Seg Width Over 28 Mm

• V2320 - Trifocal Add Over 3.25D

• V2410 - Variable Asphericity Lens, Single Vision, Full Field, Glass Or Plastic, Per Lens

• V2430 - Variable Asphericity Lens, Bifocal, Full Field, Glass Or Plastic, Per Lens

• V2510 - Contact Lens, Gas Permeable, Spherical, Per Lens

• V2710 - Slab Off Prism, Glass Or Plastic. Per Lens

• V2715 - Prism, Per Lens

• V2745 - Addition To Lens; Tint, Any Color, Solid, Gradient Or Equal, Excludes Photochromatic, Any Lens

Material, Per Lens

• V2755 - U-V Lens, Per Lens

• V2780 - Oversize Lens, Per Lens


Physician Services

18


• 15781 - Dermabrasion, chemical peel

• 15820 - Blepharoplasty and Brow Pitosis repair

• 15822 - Blepharoplasty of upper lids

• 15823 - Blepharoplasty

• 15847 – Abdominoplasty

• 19318 - Breast Reduction Surgery

• 19324 - Breast Repair and Reconstruction

• 19325 – Mammoplasty, augmentation

• 36468 - Single or multiple injections of sclerosing solutions

• 36470 - Sclerotherapy injection, single vein

• 49904 - Extra abdominal omental flap

• 56805 – Clitoroplasty for intersex state

• 67901 - Repair of blepharoptosis; frontalis muscle technique with suture or other

• 67902 - Eyelid Reconstruction, pitosis surgery

• 67903 REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION


Physician Services

19


• 67904 - bilateral levator resection for upper lid ptosis

• 67906 – Repair of blepharoptosis, superior rectus technique

• 67908 - Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator res

• 67909 - Reduction of overcorrect of pitosis

• 67911 - UPPER or LOWER eyelid retraction

• 69300 - Otoplasty – unilateral or bilateral

• 69710 - Implantation or replacement of electromagnetic bone conduction anchored hearing aids

• 69711 – Remove/Repair Hearing Aid

• 69714 - Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to

external speech processor/cochlear without mastoidectomy

• 69715 - Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to

external speech processor/cochlear with mastoidectomy

• 69717 - Replacement (including removal of existing device), osseointegrated implant, temporal

bone, with percutaneous attachment to external speech processor/cochlear stimulator; without

mastoidectomy

• 69930 - Cochlear device implantation, with or without mastoidectomy

• S2411 - Fetoscopic Laser Therapy for treatment of Twin to Twin transfusion syndrome


• E0783 - Infusion Pump System, Implantable,

Programmable

• E0786 - Implantable Programmable Infusion Pump,

Replacement

Note: Insertion of the pump does not require authorization.


Intrathecal Baclofen Therapy (IBT)

20


Oral/Maxillofacial Surgery

21


• 21208 - Osteoplasty, facial bones augmentation

• 21230 - Graft; Rib Cartilage Autogenous to face

• 21235 - Graft, ear cartilage, autogenous to nose or ear

• 21248 – Reconstruction of mandible, mancilla

• 21249 - Reconstruction of mandible, mancilla, endosteel implant,

complete

• At this time, NO podiatry services require prior

authorization.

• For Chiropractic Services, prior authorization

should only be obtained for the 25th visit within

a specific calendar year.

Multi-Specialty Services – Specialty Exceptions

22

Review Requests

23

Please submit all review requests to :

eQHealth Solutions

Attn: Multi-Specialty Department

5802 Benjamin Center Drive, Suite 105

Tampa, FL 33634

Submission of Review Requests

24

• Prior to submitting a review, verify:

• The recipient’s Medicaid eligibility

• The service is:

– -A covered Medicaid benefit

– -Required to be prior authorized by eQHealth

• The required supporting documentation is:

– -Complete

– -Legible

– The Multi Specialty Services Prior Authorization request form is complete and appropriately signed and dated

Review Requests

25

Types of Review Requests:

• Initial Authorization

• Retrospective

– applicable only for recipients who are retroactively eligible for Medicaid

• Reconsideration review

– response to an adverse determination

Review Requests

26

Prior authorization must be obtained prior to

providing services:

Exception

• Retrospective Medicaid eligibility:

– Authorization must be obtained prior to

billing.

– Claims must be billed within 12 months of

determination of eligibility.

Review Requests

27

Service Type Submission Review Completion

Physician Services

At least 10 days prior

to initiation of services

1St Level – 3 business days

2nd Level – 2 additional business days

Vision / Optometry

Hearing Services

ITB Pump (Intrathecal

Baclofen Pump)

Special Services 21 business days

Request Submission & Response

Initial Request

28

Service Type Submission Review Completion

Physician Services

–

As soon as the recipient

receives Medicaid

Eligibility.

Note: claims must be

submitted within 12

months of the date of

service

20 business days

Vision / Optometry

Hearing Services

ITB Pump

(Intrathecal

Baclofen Pump)


Retrospective

29

Service type Submission Review Completion

Physician Services –

Within 30 calendar days

of the notification date.

3 business days

receipt of request

Vision / Optometry

Hearing Services

ITB Pump (Intrathecal

Baclofen Pump)

Special Services


Reconsideration Request

30

Verification that there are no review exclusions:

• Recipient is not eligible for the service;

• Duplication of service;

• Request does not meet the replacement time

span requirement; (IBT/Cochlear Implant) or

• Requested service is not covered by Medicaid.*

*Exception: special services

First Level Review

Screening

31

Review Determination Process

• 1st Level Clinician Review:

– Administrative Screening

– Clinical Screening

• 2nd Level Peer Review

32


First Level Clinical Reviewers may:

• Approve the request

• Issue a technical denial of the request, if

appropriate, for example

– Duplicative service

– Noncompliant with Medicaid policy

• Pend the request back to the provider for:

– Additional or clarifying information

– Supporting documentation

• Refer the request to a second level Peer Reviewer

33


Pended Requests (Administrative/Clinical)

• An advisory letter is mailed to the requesting

provider.

• The provider accesses the review record to

determine what additional information is needed.

• The information should be submitted within 5

business days.

34

• Multi-Specialty Peer Reviewers base their determination on generally accepted professional standards of care, their clinical experience and judgment, Medicaid’s medical necessity criteria, and peer to peer consultation with the requesting provider when necessary.

• Peer Reviewers may render an approval or an adverse determination.

• An adverse determination may be a full denial of the requested services or a partial denial of the requested services.

Second Level Review

35

Determination notifications are issued to providers, and

recipients within one (1) business day of the determination.

• The requesting provider will receive a written notification of

the determination via mail.

• The recipient, or legal guardian, also receives written,

mailed notification of the determination via mail.

Review Determination Notification

36

Notifications include:

• Services approved or denied;

• Reason for an adverse determination;

• Rights to a reconsideration and how to

request one; and

• Recipient’s right to a fair hearing and how

the recipient may request one.

Review Determination Notification

37

Any party involved in the case may request a

reconsideration of an adverse determination:

Requesting Provider/Recipient/Legal Guardian • Phone

• Mail

• Fax

Reconsiderations

38

A peer reviewer, not involved in the original adverse determination, will:

• Uphold the original adverse determination; • Modify the original determination, approving a

portion of the services requested; or • Reverse the original determination, approving all

the services requested.

Reconsideration reviews are completed within 3 business days of receipt of a complete and valid request.

Please Note: When requesting a reconsideration, new and/or additional clinical information must be submitted.

Reconsiderations

Recipients or their legal representatives, may appeal

an adverse determination by requesting a fair hearing.

The request must be submitted within 90 days from

the date of the adverse notification letter by calling or

writing:

• The local Medicaid area office; or

• Department of Children Families Office of Appeals

and Hearings

Fair Hearings

40

Supporting documentation is determined by AHCA policy and is required to substantiate the necessity of items/services.

All supporting documentation must be submitted with the request for authorization for Multi-Specialty Services

ALL authorizations must be requested using the Multi-Specialty Services Prior Authorization Request form.

Required Supporting Documentation

41

.

Additional Supporting Documentation Requirements

Physician Services

42

SERVICE TYPE DOCUMENTATION

Physician Services – Includes

Ambulatory Surgery, Oral and

Maxillofacial Surgery

•Current medical records (within the past 6

months)

•Treating physician referral to specialty

provider

•Radiographs, MRI, laboratory results,

•Photographs

•Diagnostic studies

•Medical clearance letter

Oral and Maxillofacial Surgery

Additional to above

Prior dental records & treatment records as

applicable

.


Physician Services

43


Blepharoplasties • Current medical records ( last 6 months)

• Documentation of need for procedure

• Visual field study

• Eyelid photography with and without tape

• Optical exam.

.


Optometric/Visual Services

45


Visual Services - Eyeglasses •Eyeglass Prescription

•Documentation of recipient’s condition that

meets the criteria for provision of specific

eyeglasses or lens types,

•Optical / refraction examination,

•Itemized invoice for eyeglasses provided.

Visual Services – Contact Lens •Recipient’s eligibility for contact lenses

•Eyeglass prescription

• All appropriate procedure codes

• Substantiation for special fitting

• Itemized invoice for lenses provided

• Documentation the type of lens to be provided

• Completed contact lens request form

.


Hearing Services

46


Hearing Services – Hearing

Aids and related items

•Current audiogram (last 6 months)

• Current medical records ( last 6 months)

• Physician’s order

• Medical clearance letter,

• All procedure codes and related fees.

Hearing Services – Cochlear

Implant Repair / Replacement

• Documentation of what failed and justification

of need for repair/replacement

• Itemized documentation of repair/replacement

cost

.


(Intrathecal Baclofen Therapy)

47


IBT •Current medical records ( last 12 months)

•Documentation of successful Baclofen trial

with intrathecal injection,

• Physical therapy assessment for the Baclofen

pump trial

• Referral letter from primary physician

• Documentation of trial of PO Baclofen

• Medical clearance letter

.


Special Services

48


Special Services • Attestation and documentation of need of

special service from treating provider

• Referral information from referring provider

• Current medical record (last 6 months)

• All procedure code information (if applicable)

eQHealth’s Peer Reviewers reserve the right to request additional information or clarifying information to substantiate the medical necessity for the service(s)requested.

Supporting Documentation

Additional Information

49

1. Submit all supporting documentation along with

the Multi-Specialty Services Prior Authorization

Request form via mail for the initial request.

2. Additional supporting information requested after

the initial request may be submitted via mail or by

fax (855-677-3747.)

Submitting Supporting

Documentation

50

• 11/22/12: Last date to submit authorization requests to AHCA

• 11/27/12: First date to submit requests to eQHealth

• 12/1/12: eQHealth begins reviewing authorization requests

Transition

51

– Customer Service: 885-444-3747

Monday-Friday, from 8 a.m.–5 p.m.

Eastern Time

– Dedicated Florida Provider Website

http://fl.eqhs.org

– Blast emails

*[email protected]

Provider Communications

and Resources

52

http://fl.eqhs.org/

Questions and Answers

Thank-you for attending

Your opinion is important to us.

Please complete the survey which will appear on your computer when

the webinar ends.

53

authorization review process - eqhealth solutionsfl.eqhs.org/portals/1/fianl multispecialty pp 9...

Documents