prior authorization process for incontinence supplies...used for managing incontinence in...
TRANSCRIPT
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)
2
Definition of Medical Necessity
3
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.)
4
(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 (cont.)
Click on “Provider Fee Schedule Download”
7
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
8
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.)
10
Fee Schedule Special Instructions
(cont.)
11
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”
13
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
16
Submitting a PA Request
Providers may submit a prior authorization request by:
Fax: 203.265.3994 or
Medical Authorization Portal
For assistance: [email protected]
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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
20
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.”
21
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
23
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
25
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
26
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
27
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
28
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
29
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
30
HUSKY Plus
31
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
33
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
34
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
35
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
37
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
38
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
41
Review Timeframe
42
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
43
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
44
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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