INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT

1. INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT South Carolina KePRO QIO Request Submission Requirements New 6/14/2012

2. Topics • Service Type(s) • KePRO SCDHHS Website • Service Type Requirements • Contact Information

3. Prior Authorization Service Types • Therapies – (PT, OT, SP) • Home Health • Hospice • Inpatient • Surgical Justification • Organ Transplants • Durable Medical Equipment • Mental Health Counseling • Botox

4. Therapies – PT, OT , and SP 21 years and Older - OP Hospital • Provider Manual - Hospital Services and Physician provider manual, for over 21 Under 21–OP Hospital and Private setting • Prior authorization is required when Therpaies exceed 105 hours or 350 units • Provider Manual – Physician Manual and Private Rehab Manual, for under 21 • Evaluation = 1 • Follow up session(s) - 1 unit = 15minutes

5. Home Health • Home Health visits are limited to a total of 50 visits per state fiscal year that begins July 1 and ends June 30. • Prior authorization from KePRO is required to exceed the 50 visit limitation. • Home Health covered services: • Nursing services • Home health aide • PT, OT, SP

6. Home Health • Requests to exceed the 50 visit limitation must include: • KePRO Outpatient prior authorization request form • Executive summary describing in detail the extenuating circumstances which make additional visits medically necessary • Supporting medical documentation that justifies the medical necessity • Supporting medical documentation can include the plan of care and clinical service notes per Home Health service being requested

7. Home Health • Home Health providers are required to track and request additional Home Health visits prior to the expiration of the 50 visit limitation by utilizing the SC Medicaid Web-based Claims Submission Tool (Web Tool) • Authorization requests are for a 60 day plan of care period.

8. Home Health • Authorization requests for extended service beyond the initial authorization period must be submitted to KePRO prior to the last authorized day in the certification period • Providers have two business days to respond to additional information pend notices. • If no response received to pend, the request will be forwarded for Higher level review or administratively denied • Providers have two business days to respond to Insufficient information requests • If no response received to pend, the request will be closed requiring re-submission for prior authorization

9. Home Health • KePRO will issue a PA number for approved authorization requests. The Home Health agency will then be able to bill for the additional visits. • Claim submission above the 50 visit limitation without a KePRO PA number will generate an edit 837 (service requires QIO PA) and an edit 850 (home health visit frequency exceeded).

10. Hospice Hospice Procedure codes • T1015- GIP General Inpatient Care • S9126- Routine home Care • S9123- Continuous home Care • S9125- Inpatient Respite Care • NOTE: T2046 – Hospice Room and Board Services do not require prior approval

11. Hospice • General Inpatient Services • Documentation required for a new admission into hospice and the request is GIP: • KePRO Fax Form • SCDHHS Election Form • Admission Assessment or Initial Care Plan • Verbal Order • Supporting Documentation • Written Certification must be obtain prior to the submission of the other hospice procedure codes within15 days or • If the other codes will not be requested, written certification must be obtained prior to submitting hospice claims

12. Hospice • Note: Required Documentation: • For Prior Authorizations completed by KePRO (Effective 10/1/12) , the forms below can be faxed to KeRPO • For Prior Authorizations completed by SCDHHS (Prior To 10/1/12) , the forms below can be mailed to SCDHHS • DHHS Form 153 (Revocation Form) • DHHS 154 (Discharge Form) • DHHS 152 (Change Request Form

13. Hospice • KePRO Outpatient Fax Form • Please make sure that all necessary information has been filled out on the KePRO fax form • Include all 3 procedure codes (GIP should also be included if that is the status of the client upon submission) • Requests for GIP should be submitted at the time of inpatient admission, and if approved, will be approved for a 30 day time span

14. Hospice DHHS 149 Form (Medicaid Hospice Election): • Designate an effective date for the election period to begin • The request must be submitted to KePRO within 15 business days of election of benefits • If not received within 15 business days, the request will be approved effective the date the request was received by KePRO • The days are subdivided into election periods • Two 90-day periods each • An unlimited number of subsequent periods of 60 days each

15. Hospice DHHS 149 Form

16. Hospice DHHS Form 151- Medicaid Hospice Physician Certification and Recertification • Written certification statements must be obtained within 2 calendar days after hospice care has been initiated • Signed by the Medical Director of the Hospice or the physician member of the Hospice interdisciplinary group • Signed by the person’s attending physician (if the individual has an attending physician) • If written certification if not obtained within 2 days after the initiation of Hospice care: • A verbal certification may be obtained within these 2 days • A written certification must be obtained prior to submission of a request for prior authorization

17. Hospice DHHS Form 151- Medicaid Hospice Physician Certification and Recertification

18. Hospice • DHHS Form 153- Medicaid Hospice Revocation • Complete DHHS form 153 • Designate an effective date to revoke Hospice • Submit Form 153 to KePRO within 5 business days of revocation of benefits • Mail a copy of the form to the nursing facility or ICF/MR • DHHS Form 154- Medicaid Hospice Discharge • Designate an effective date to discontinue Hospice • Submit form to KePRO within 5 working days of the effective date of discharge • DHHS Form 152- Medicaid Hospice Provider Change Request • Complete all appropriate portions of Form 152 • Submit a copy of Form 152 to KePRO within 5 business days • Send a copy to the receiving Hospice Provider within 2 days

19. Hospice DHHS Form 153- Medicaid Hospice Revocation

20. Hospice DHHS Form 154- Medicaid Hospice Discharge

21. Hospice DHHS Form 152- Medicaid Hospice Provider Change Request Form

22. Inpatient • NO PA required for Birth/Delivery • No concurrent reviews (DRG) • Includes the following services- Inpatient Acute, Inpatient Psych and Inpatient Rehab. • Review of Admission Date Only NOT Length of Stay • Servicing Provider- Must display Facility NPI number • All scripts Case Management Fax is sufficient as long as NPI number is recorded • KePRO Inpatient Prior Authorization Fax form (Fax submissions only)

23. Inpatient • Admission From an Observation Unit • When a patient is admitted to the hospital from an observation stay, bill the date the beneficiary was switched to inpatient status as the first day of the inpatient admission. • Only if the observation stay is unrelated to the inpatient admission, excluding the day of admission, can the observation days be billed as outpatient services. • Observation stays related to and within 72 hours of the inpatient admission are considered inpatient services and are included in the DRG payment.

24. Inpatient • Kepro is only reviewing for the 1st 24 hours of admission. Supporting clinical should address this period of care. • Documentation must be legible • Respond to request for additional information within the 2 business days specified • Consider McKesson Interqual 2012 Criteria when submitting supporting clinical documentation

25. Inpatient Hints re: MckessonInterqual Criteria • When additional information is requested, please address the specific questions  • When requesting inpatient surgical procedure, be concise as to what procedure is being performed and specify the date of service • Specific IVFs (i.e. volume expanders) administered and the rate. • Diet status (NPO, advancing, etc.) • Note any failed outpatient treatment related to this admission • IV: Drips note if continuous or the titration frequency • Route and frequency for all medications and treatments (i.e. po meds, nebulizers, etc.)

26. Inpatient • All Inpatient Surgical Admissions,  including Hysterectomy (excluding Organ Transplants) require Prior Authorization as Inpatient • Hysterectomy – Required Documentation: • Navigate to Forms tab on website (see slide #4) •  Consent for Sterilization Slide 10 (Form- DHHS 1723) • Replaces- Hysterectomy Acknowledgement Form • Surgical Justification for Hysterectomy Slide 11(Revised 6/1/2012) • Non- Emergency requires 30 day wait from Member signature • Emergent Hysterectomy requires Physician explanation in order to waive 30 day notification requirement

27. Surgical Justification • Only pertains to Outpatient Surgical procedures • Hospital Provider manual for complete listing of Codes (Beginning section 4-65) • Physician Provider Manual for complete listing of Codes (Beginning Section 4-11) • Refer to KePRO website at http://SCDHHS.KePRO.com or SCDHHS Bulletin “Services Performed by KePRO - Attachment A • Servicing provider: Physician NPI number • Fax Submissions utilize KePRO  Prior Authorization Fax Form – Transplant and Surgical justification

28. Consent for Sterilization Form

29. Surgical Justification-Hysterectomy

30. Surgical Justification • Gastric Bypass - Two questions that must be answered • Is it medically necessary for the individual to have such surgery.  2) Is the surgery to correct an illness that caused the obesity  or was aggravated by obesity  .   If No, to the above questions please submit additional information  regarding why procedure is needed.   

31. Organ Transplant • Medicare Primary, no authorization required unless  Medicare denies or benefits exhausted • Required  Documentation: • Transplant Prior Authorization request Form • Fax Submissions utilize KePRO  Prior Authorization Fax Form – Transplant and Surgical justification • Timely submission at least 10 days advance notice, excluding emergent cases • Servicing Provider: Referring Physician NPI number • Organ transplant must be performed at CMS Approved transplant Center: www.cms.hhs.gov/ApprovedtransplantCenters

32. Transplant Prior Authorization Request Form

33. Durable Medical Equipment • When extended utilization or unusual amounts or types of equipment or supplies are required, the Provider must request Prior Auth.  Prior authorization is required for items identified in Appendix “A”. If the item does not require preauthorization or does not exceed the established limits, the provider may provide and bill for these items up to the established limit without Prior Auth. If Prior Auth is required, Prior Auth must be obtained, except for MCHM, HOAD, HOAP, MCSC or Medicare . • For timely submission, providers must submit on or before requested start of care or the request will be approved the date it was received by KePRO • For DME requests, KePRO has 15 days to review requests for prior authorization

34. Durable Medical Equipment • Modifiers required--- NU-New; UE- Used; RR-Rental • NOTE: When requesting a rental, please indicate the number of units to be billed for the entire duration of time requesting. • MCMN Valid 12 months • Fax request utilize Prior Authorization Fax Form- DME, MH Counseling, and Therapies  (PT, OT, SP) • Criteria: • InterQual (CERMe) Durable Medical Equipment • SCDHSS Manuals for Specific criteria rules regarding Approved DME Procedure Codes (Appendix “A”) specific criteria rules

35. Mental Health Counseling • Medical Necessity Statement (MNS) – Valid 12 months, unless following occurs: • Physician • If no Behavioral Health Service 90 consecutive days, then Medical Necessity needs to be re-established • LIP • If no Behavioral Health Services for 45 consecutive days, then Medical Necessity needs to be re-established. • Required Documentation • Physician • MNS • LIP • LIP Referral • LIP Referral Authorization

36. Medical Necessity Statement Physician Referrals for Rehab Services

37. DHHS LIP Referral Form

38. LIP Referral Authorization Request Form

39. H2017- Rehabilitative Psycho Social Rehab • Required Documentation • Rehabilitative Psychosocial Services Fax Form • IPOC • Clinical Presentation • Required Clinical – Documentation should support the members Clinical presentation Timely submission prior to or before requested start of care date. (Excluding procedure codes listed on LIP Referral Form)

40. Retroactive Eligibility Retro Eligibility - Providers MUST submit a SCDHHS Notice of Eligibility Form 945 or any official SCDHHS form showing retro eligibility to include the date the facility was notified pt was deemed eligible and eligibility start and end date.

41. Medical Necessity Denials If you disagree with denial decision, please follow instructions as outlined in your denial letter. • Reconsideration request- within 60 days from receipt of denial letter. • Appeals request- within 30 days of receipt of denial letter. Appeals should be submitted after a reconsideration review has been completed

42. Administrative Denials If you disagree with denial decision, please follow instructions as outlined in your denial letter. • Appeals request- within 30 days of receipt of denial letter. Appeals should be submitted after a reconsideration review has been completed • There is no reconsideration for an administrative denial

43. South Carolina Web Site

44. Forms Navigate to Form Tab to obtain Documents such as: Fax and Justification forms

45. Outpatient Fax Form

46. KePRO Outpatient Fax Form cont.

47. Inpatient Fax Form

48. INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT Registration for Atrezzo Connect Provider Portal

49. How To Register For Atrezzo Connect • Website Address: https://scdhhs.kepro.com • Select “ Registration For Atrezzo Connect” (Slide 3) • Enter your 10 digit National Provider Identifier (NPI) number and Legacy South Carolina Medicaid provider ID • Select a unique user name and password & complete required user information