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Advanced Diagnostic Imaging
(ADI)
July 2015
1
Introduction
2
• 2011 Contract award - The Agency for Health
Care Administration (AHCA) awarded
eQHealth Solutions the contract to provide
Comprehensive Medicaid Utilization
Management Services (CMUMP) for the state
of Florida
• Local office / operations in Tampa Bay area
5802 Benjamin Center Drive, Suite 105
Tampa, FL 33634
Partnership: Agency for Health Care
Administration and eQHealth
3
http://fl.eqhs.org
eQHealth Provider Manuals
eQSuite® User Guide
Links to AHCA Handbooks
Forms and Downloads
FAQs
Training Schedules & Registration
Training PowerPoints
Resources
4
Effective August 1, 2015, all Fee-For-Service
(FFS) outpatient advanced diagnostic imaging
(ADI) procedures, including magnetic resonance
imaging (MRI), computerized axial tomography
(CAT or CT), and positron emission tomography
(PET) scans, will require authorization through
eQHealth.
Advanced Diagnostic Imaging
5
AUGUST 1, 2015
MedSolutions will process ADI requests received prior to 8/1/15.
eQHealth begins accepting requests 8/1/15.
Start Date
6
Recipient Requirements
7
Recipients must be:
Enrolled in a Medicaid benefit program that covers the services:
Fee-for-Service;
Dually eligible recipients
Medicare/Medicaid
Commercial/Medicaid
Eligible at the time services are rendered*
*Medically Needy recipients must have active eligibility on the date of service. The date of service and the dates on the PA must be included in the eligibility span.
Requests Not Reviewed by eQHealth
8
Recipients who are:
Members of a Medicaid Managed Medical
Assistance (MMA)
Recipients enrolled in MMA must have
authorization from their managed care plan.
Not Medicaid eligible, but have other coverage for
radiology services through a third party liability
source such as:
Medicare
Commercial insurance
Services provided in the following locations require
authorization:
Outpatient Hospital Departments
Physician Offices
Ambulatory Surgery Centers
Independent Laboratories
Place of Service
9
ADI services do not require authorization if provided
during:
Hospital inpatient stays
23 hour observation
Emergency Department
Place of Service
10
Medical Necessity Criteria
11
Chapter 59G-1.010 (166), Florida Administrative Code:
“Medically necessary” or “medical necessity” means that the medical or allied care, goods, or services furnished or ordered must meet the following conditions:
1. Be necessary to protect life, to prevent significant illness or significant
disability, or to alleviate severe pain;
2. Be individualized, specific, and consistent with symptoms or confirmed
diagnosis of the illness or injury under treatment, and not in excess of
the patient’s needs;
3. Be consistent with generally accepted professional medical standards
as determined by the Medicaid program, and not experimental or
investigational;
4. Be reflective of the level of service that can be safely furnished, and
for which no equally effective and more conservative or less costly
treatment is available statewide; and
5. Be furnished in a manner not primarily intended for the convenience of
the recipient, the recipient's caretaker, or the provider.
Medical Necessity
12
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
13
Codes Requiring Authorization
14
A full list of the ADI codes requiring authorization is posted
on:
http://fl.eqhs.org
Multi-Specialty tab
Forms and Downloads folder
Direct link: http://fl.eqhs.org/LinkClick.aspx?fileticket=lT0AtwYQh0g%3d&tabid=333&mid=942
Review Requests
15
Prior Authorization:
Ordering Provider
M.D./D.O
PA
ARNP
Dentist
Podiatrist
Chiropractor
Retrospective;
Rendering provider
Hospital
ASC
Physician Office
Independent Lab
Reading Radiologist
Review Request Submission
16
Requests may be submitted via fax, using the posted review request form until 10/1/15.
http://fl.eqhs.org, Multi-Specialty/ADI, Forms and Downloads.
Note: There are separate forms for Ultrasound/Bio-Physical Profile (BPP). It is important to use the correct form.
All requests submitted on or after 10/1/15 MUST be submitted via eQSuite®, the online utilization management system.
Exception: Ultrasound/BPP requests continue to be submitted via fax.
Review Requests
17
Initial Request Submission Review Completion Timeframes
Routine requests Prior authorization Timeframe begins upon receipt of all required
documentation
Approved at 1st level/nurse review - within 1
business day
Referral to second level review- within 3
business days
Retrospective Reviews Within one year of the
retroactive eligibility
determination
Within 20 business days
Reconsideration review Within 10 business days of
the denial notice
Within 3 business days of receipt of the request
for reconsideration.
Request Submission & Review
Completion Timeframes
18
Type Method Timeframe
Extension of
authorization time
frame
Providers can extend for an additional
30 days, using the eQSuite® utility.
Only one 30 day extension may be
submitted.
N/A
Change of facility Submit on-line helpline ticket
Call Customer Service
Within 2 business days
Upcoding/downcoding
Modifications to an Existing Review
19
When the prior authorized code
requires….
The following process is followed
Upcoding: e.g. the code for “no contrast” was
originally approved and contrast was used
A new review determination IS required.
The provider will:
o Contact eQHealth’s Customer Service
line or submit an online helpline request
to cancel the existing authorization.
o Enter a new review request with
documentation to substantiate the
medical necessity for the study that was
performed
Downcoding: e.g. the code for “with contrast” was
originally approved and contrast was not used
A new review determination is NOT required.
The provider will:
o Contact eQHealth’s Customer Service
line or submit an online helpline request
to change in the code.
Upcoding/Downcoding
20
Verification that there are no review exclusions:
• Recipient is not eligible for part of the
requested timeframe;
• Duplication of service;
• Requested service is not covered;
• Assessment of the submitted supporting
documentation to ensure it is complete,
legible and conforms to all AHCA policy
requirements.
First Level Review
Screening
21
The clinical reviewer performs the review by applying:
• Definition of medical necessity as stated in Chapter 59G-1.010
(166), Florida Administrative Code (F.A.C.)
• McKesson InterQual
• Agency-approved clinical criteria or guidelines
Resources:
• American College of Radiology: http://www.acr.org/
• ACR Appropriateness Criteria®
• American College of Radiology Practice Parameters
SmartReview algorithms will be loaded in eQSuite® on September 1, 2015
First Level Review
Clinical
22
First Level Reviewers may:
• Approve the services as requested;
• Pend the request for additional information from the provider;
• Refer the request to a physician peer reviewer for review and
determination; or
• Cancel or issue a technical denial of the request if appropriate,
e.g.:
• Duplicative service;
• Noncompliance with AHCA policy.
First Level Review Determinations
23
• Physician peer reviewers base their determination
on generally accepted professional standards of
care, on their clinical experience and judgment and
peer to peer consultation with the ordering
physician.
• Physician reviewers may render an approval or an
adverse determination.
• An adverse determination may be a full denial of
the requested services or a reduction in services.
Second Level Review
24
Determination notifications are issued within one business day of the determination.
• An electronic advisory message is immediately issued for the requesting provider.
• A written notification of the determination is posted on eQSuite®.
• Determination specifies the approved code(s) and the duration (from and through dates).
• Notifications may be downloaded and printed.
• The recipient or legal guardian receives written, mailed notification.
Review Determination Notification
25
Notifications include:
• Service(s) approved or denied;
• Dates of service(s) approved;
• Reason for an adverse decision;
• 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
26
Any party may request a reconsideration of an
adverse determination by:
• eQSuite® (electronic)
• Phone
• Fax
Reconsiderations
27
A physician reviewer not involved in the original
adverse determination will render one of the following: • Uphold the original adverse determination;
• Modify the original determination, approving a portion
of the service requested; or
• Reverse the original determination, approving
services requested.
Reconsideration reviews are completed within three
business days of receipt of a complete and valid
request.
Please Note: When requesting a reconsideration, new and/or additional clinical information should be submitted.
Reconsiderations
28
Recipients, or their legal representatives, may appeal an
adverse decision by requesting a fair hearing.
The appeal must be submitted:
• By written statement to AHCA Medicaid Area Office;
and
• Within 90 calendar days of the date of the adverse
determination notification mailing.
Fair Hearings
29
Supporting documentation is determined by
AHCA policy and is required to substantiate the
necessity of services.
The ordering physician prescription is required
when the request is submitted by the facility or
the reading radiologist.
If additional supporting documentation is
required, the requesting provider will be notified
via an eQSuite® pend.
Required Supporting Documentation
30
Options for submitting documentation:
1. Upload and directly link the information to the
eQSuite® review record.
2. Download eQHealth bar coded fax covered
sheet(s) from http://fl.eqhs.org and submit the
information using our 24/7 toll free fax line
855-440-3747.
3. Attach documentation to the faxed request
form (for requests submitted prior to 10/1/15)
Submitting Supporting
Documentation
31
Each fax cover sheet includes a bar code that is specific to the particular recipient and the type of required information.
The review-specific fax cover sheets are available for downloading and printing as soon as the review request is completed and entered into eQSuite®.
You must use only the assigned fax cover sheet for the specific type of supporting documentation.
Do not copy or reuse fax cover sheets!
Submitting Supporting
Documentation
32
eQSuite®
33
Proprietary eQHealth web-based software:
• Secure HIPAA-compliant technology allows
providers to record and transmit information
necessary to obtain authorizations.
eQSuite®
34
Minimal Computer System Requirements:
• Intel Pentium 4 or higher CPU and monitor
• Windows XP SP2 or higher
• 1 GB free hard drive space
• 512 MB memory
• Internet Explorer 9 or higher, Mozilla Firefox
35 or higher, or Safari 6 or higher
• Broadband internet connection
eQSuite ®
35
• Create new reviews
• Respond to requests for additional information
• Submit documentation
• Respond to adverse determinations
• Search for authorization requests/reviews
• View and download reports and letters
• Online Helpline
• Control system access
• Update user profiles
eQSuite® Functions
36
Live Demonstration
eQSuite®
37
1. Complete the Provider Contact Form;
2. Assign logons to staff.
Getting Started
38
Provider Outreach, Education
and Technical Assistance
39
• Provider Outreach and Education
• Customer Service Representatives
1-855-444-3747
8 a.m. – 5 p.m. Eastern Time
Monday – Friday
(except recognized Florida state holidays)
Provider Education & Outreach Team
40
Dedicated Florida Provider Website
http://fl.eqhs.org
Blast email distribution list
Send request to [email protected]
Include email address and “ADI” in the
body of the email.
Provider Communications
41
Transition
42
MedSolutions is responsible for all Fair
Hearings for adverse determinations
made by MedSolutions.
eQHealth is responsible for all revisions,
corrections and modifications to
MedSolutions’ reviews.
For reconsideration of MedSolutions’
adverse determinations, submit a new
authorization request to eQHealth.
Questions and Answers
43