INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT South Carolina KEPRO- Requirements for Requesting Prior Authorizations (PA) New 1/15/2015

INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT

South Carolina KEPRO- Requirements for Requesting Prior

Authorizations (PA)

New 1/15/2015

TOPICS

• Retroactive Eligibility

• Service Types

• Submission Requirements by Service Type

• KEPRO SCDHHS Website

• Contact Information

RETROACTIVE

ELIGIBILITY

RETRO CASES

A case may be submitted as a “retro” when retroactive eligibility occurs.

• Member not eligible for coverage at the time services were provided.

• Member gains eligibility that is made retroactive to the date of service.

• A “retro” case is NOT one that is submitted late for any reason.

SERVICE TYPES

• Botox

• Transplants

• Therapies (PT, OT, ST)

• Home Health

• Mental Health Counseling

• PRTF/Freestanding Psych

• DME

• Hospice

• Surgical Procedures

• Inpatient

SERVICE TYPE

BOTOX

BOTOX

• Procedure Codes:– J0585 Botox (onabotulinumtoxin A)

– J0586 Dysport (abobotulinumtoxin A)

– J0587 Myobloc (rimabotulinumtoxin B)

– J0588 Xeomin (botulinum toxin type A)

BOTOX

J0585 Botox (onabotulinumtoxin A)• Strabismus• Blepharospasms• Severe primary axillary hyperhidrosis• Upper limb spasticity in adults• Cervical dystonia in adults• Chronic migraines• Spasticity related to CP in children

BOTOX

J0585 Botox – NEW INDICATION

Urinary incontinence due to detrusor overactivity in neurologic conditions (spinal cord injury or MS).

Must document inadequate response to or being

intolerant of an anticholinergic medication.

BOTOX

J0586 Dysport (abobotulinumtoxin A)• Cervical dystonia in adults

J0587 Myobloc (rimabotulinumtoxin B)• Cervical dystonia in adults

J0588 Xeomin (botulinum toxin type A)• Cervical dystonia in adults who failed treatment

with Botox• Blepharospasm in adults who failed treatment with

Botox

BOTOX

Clinicals Required– Diagnosis

– Specific muscle groups to be injected

– Amount to be injected in each muscle group

– Planned Frequency of injections

SERVICE TYPE

ORGAN

TRANSPLANTS

ORGAN TRANSPLANTS

• Transplants MUST have a current PA before the event occurs

• Types of transplants requiring a PA:– Heart Transplant– Liver Transplant– Lung Transplant– Mismatched Bone Marrow– Multi-organ Transplants

• Liver/Small Bowel• Liver/Pancreas, • Liver/Kidney,• Kidney/Pancreas • Heart/Lung• Multivisceral

– Small Bowel– Pancreatic Transplant

ORGAN TRANSPLANTS

• No prior authorization is required for – Corneal Transplant– Kidney Transplant– Matched Bone Marrow (autologous inpatient and outpatient, allogeneic related

and unrelated, and cord). Includes Stem Cell Transplants

• Pre-transplant admission for chemotherapy and/or cell harvest may require inpatient prior authorization (follow policy of primary insurance carrier for inpatient admission).

ORGAN TRANSPLANTS

• Organ transplants must be performed at CMS approved Transplant Center: www.cms.hhs.gov/ApprovedtransplantCenters

• Servicing Provider: Referring Physician NPI number

• Timely submission: at least 10 days advance notice, excluding emergent cases

• Transplant authorization:

- Transplant authorization approved for 365 days from date of PA request

- Authorization covers 75 hours prior to transplant event and up to 90 days after transplant event.

http://www.cms.hhs.gov/ApprovedtransplantCenters

ORGAN TRANSPLANTS

• Eligibility: - Medicare Primary, Medicaid MCO, Private Insurance: KEPRO will review and

authorize for the transplant event only

- Transplant evaluation / workup is done outpatient, KEPRO does not review for evaluation; follow Primary Insurance carrier policy for prior authorization

• Out-of-State Transplant: - Transplant services must not be available in SC

- Evaluation is outpatient. KEPRO does not review / authorize

• Required Documentation: – Transplant Prior Authorization request Form (must be completely filled out).– Letter of Medical Necessity, signed by physician – Fax Submissions require KEPRO Prior Authorization Fax Form – Transplant

and Surgical justification

Transplant Prior Authorization Request Form

THERAPY SERVICES

Physical Therapy (PT)

Occupational Therapy (OT)

Speech Therapy (ST)

PT, OT , and ST

21 Years and Older - OP Hospital and Private Setting Prior Authorization is required. Provider Manual - Hospital Services and Physician provider manual for

over 21.

Under 21–OP Hospital and Private setting Prior authorization is required ONLY when therapies exceed

105 hours or 420 units per fiscal year. Information on remaining units may be found on SC Web Portal.

Provider Manual – Physician Manual and Private Rehab Manual

EVALUATIONS

• Allowed 1 Evaluation per service per year.

• Approval given for “1” unit.

• Approval given for a 30-day time span.

INITIAL REQUESTS

• Approval period for 4 weeks.

• 1 unit of approval = 15 minutes.

• Clinical submission should include:

– Individual Plan of Care (IPOC)

– Short-term and long-term goals

– Home Exercise Program

CONCURRENT REQUESTS

• Approval period is for 8 weeks.

• 1 unit of approval = 15 minutes

• Clinical submission should include:

– Individual Plan of Care (IPOC)

– Short-term and long-term goals – have they been met?

– Home Exercise Program (HEP)

– Compliance with HEP

HELPFUL CLINICAL INFORMATION

• Medical history – why is therapy required?

• Current functional status:

– Are assistive devices required?

– Are they willing/able to participate in therapy?

SERVICE TYPE

HOME HEALTH

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, ST

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

• 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.

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 requests for additional information. – 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

HOME HEALTH

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).

SERVICE TYPE

MENTAL HEALTH

COUNSELING

MENTAL HEALTH COUNSELING

• All services must be prior authorized unless retroactive eligibility exists.

• All submissions must include a valid DSM-IV or CPT diagnosis code. – This excludes irreversible dementias, intellectual disabilities, or

developmental disorders unless they co-occur with a serious mental disorder.


• For Licensed Independent Practitioners (LIP) providers, KEPRO reviews for the following codes:

– 96101 – Psychiatric Evaluation (MUST include referral source)

– 90832/90834/90837 – Individual Psychotherapy

– 90853 – Group Psychotherapy

– 90846/90847 – Family Psychotherapy


Submission Requirements For LIP Providers

– LIP Authorization Fax Form

– Pediatric and Adult Initial Requests must also include Comprehensive Assessment

• Demographic Information• Presenting Complaint (Behaviors, Symptoms) • Medical History • Family History• Psychological/psychiatric treatment history• Substance Use History• Mental Status Exam • Current Diagnosis• Functional Assessment• Individual/Family Strengths and Support System• Any history of abuse


• Pediatric and Adult Concurrent Requests require submission of:

• Individual Plan of Care

• Progress Notes to include clinical information to meet McKesson InterQual Requirements

– What symptoms is the member experiencing? – How does the illness affect the member’s functioning, in school, job or

relationships? – For adolescents and adults, how many visits has the patient attended out

of the last 5 scheduled visits?


• Submission Requirements for Physicians

– Physician’s Mental Health Form.

– Clinical documentation as to why services are required.

– For Concurrent Reviews for Adolescents and Adults, include number of visits attended out of the last 5 scheduled visits.


• Submission Requirements for FQHCs

– Clearly document that request is from an FQHC. – Use NPI of facility when submitting. – All services will be reviewed under CPT code T1015 with HE modifier.– Maximum of 12 units may be approved per review. – Submission must include:

• FQHC Required Mental Health Form • Individual Plan of Care (IPOC) • Clinical Summary • For Concurrent Reviews for Adolescents and Adults, include number of

visits attended out of the last 5 scheduled visits.

SERVICE TYPE

PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY

(PRTF)

PRTF

Psychiatric Residential Treatment Facilities (PRTFs) are

facilities, other than a hospital, that provide psychiatric

Services to recipients under age 21.

PRTFs provide inpatient Psychiatric Services to recipients who do not need acute inpatient psychiatric care, but

need a structured environment with intensive treatment services.

PRTF

Submission Requirements

• 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 (unless emergency)

• Respond to request for additional information within the 2 business days specified

PRTF – INITIAL REQUEST

• Initial approval period may be for a maximum of 21 days.

• Required documentation includes CALOCUS and Certificate of Need (CON). – Clinical should include: Current symptoms, treatment history, support

system.

• Clinical will be used to meet criteria in McKesson InterQual.

• Stays may not overlap between facilities.

PRTF – CONCURRENT REQUEST

• Approval period may be for a maximum of 30 days.

• Submission should be by day #14 of current stay so as to not have lapse in coverage.

• Required documentation includes IPOC, progress summary, and documentation/attestation that required services are occurring: – Individual Psychotherapy at least 90 minutes per week.– Group Psychotherapy sessions at least 3 times a week. – Family Psychotherapy at least once per month. – Face-to-face meeting with facility physician/psychiatrist at least once a

month. – Psychiatric evaluation within 60 hours of admission– Psychological evaluation within 30 days of admission.

PRTF – CONCURRENT REQUEST

• If services are required for more than a year’s time:

– A new case will need to be set up (a case may not span more than 365 days).

– An updated CALOCUS will need to be submitted.

– Submission is required of narrative explaining why continued PRTF services are needed.

FREE-STANDING PSYCHIATRIC

FREESTANDING

PSYCHIATRIC INPATIENT

(UNDER 21 and 65 and older)


Inpatient admissions must be prior authorized by KEPRO (unless emergent). Services need to be medically prescribed treatment, which is documented in an active written treatment plan.

KEPRO will review requests for the medical necessity of the initial admission, and will approve for “1” day.


• Required Documentation:

– Certificate of Need (CON) – or attestation to same on Fax Form.

– Freestanding Psychiatric Inpatient Fax form.

– Additional clinical to substantiate inpatient request.


Criteria• Identify Medication compliance/adherence

• Current presenting symptoms

• Impairments on functioning

Durable Medical Equipment

DURABLE MEDICAL

EQUIPMENT (DME)


• KEPRO reviews for a specific list of CPT codes, as listed in the Procedure Codes section of the DME Manuals.

• Do not require authorization for recipients with the following coverage types: 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


• Equipment may be approved that covered under the SC State Plan. It must be medically necessary and appropriate for use in the beneficiary’s home.

• Convenience and prevention items are not covered.


• Submission of Medicaid Certificate of Medical Necessity (MCMN) is required.

• There are 6 versions: – Equipment/Supplies (DME 001)– Power/Manual wheelchair and/or Accessories (DME 003)– Orthotics/prosthetics/diabetic shoes (DME 004)– Enteral nutrition (DME 005) – Parenteral nutrition (DME 006) – Oxygen (DME 007)

• MCMN is valid for 12 months.


• Modifiers required--- NU LL UE RR• DME Manual, Section 4, lists modifiers required for all

codes reviewed by KEPRO.

– NU – New item – LL – Capped rental item. – UE – Used item – RR – Rental.


• LL Modifiers – Capped rental item. Items cannot be initially purchased. Is considered purchased when it has been rented for 10 months.

– E0250 – Manual hospital bed– E0470/E0471 Respiratory assist devices– E0601 CPAP Device– E0784 Insulin pump – E0791 Parenteral infusion pump– E0940 Trapeze free stand – E2000 Gastric suction pump– K0001 Standard manual wheelchair– K0195 Elevating leg rest


• RR Modifiers– Rentals. • Note that 6 CPT codes have a limited rental period; initial approval

may be for 4 months. If required, providers may submit for an additional 4 months, and then 2 months. Equipment may not be rented for over 10 months.

• E0372 Powered air overlay mattress • E0277 Power pressure-reducing air mattress• E0193 Powered air flotation bed• E0194 Air fluidized bed • E2402 Negative pressure wound therapy electrical pump• E0747 Osteogenesis stimulator


• Fax request to KEPRO using DME Fax Form

• Clinical will be used to meet McKesson Interqual criteria.

• SCDHHS DME Manual lists specific criteria required for some equipment – – Beds– Wheelchairs– Wound VAC– MICKey buttons

Prior Authorization Checklist

SERVICE TYPE

HOSPICE

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

HOSPICE

• General Inpatient Services– Documentation required for a new admission into

hospice and the request is GIP:• KePRO Fax Form• SCDHHS Election Form (DHHS 149)• 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

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

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

HOSPICE

DHHS 149 Form

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 is 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

HOSPICEDHHS Form 151- Medicaid Hospice Physician Certification and Recertification

HOSPICE

Required Clinical Documentation:

• Plan of Care– Goals/Interventions

• Lab results, Diagnostic Tests, any clinical to substantiate request for hospice services

HOSPICE

Other Required Documentation

• DHHS Form 153 (Revocation Form)

• DHHS 154 (Discharge Form)

• DHHS 152 (Change Request Form)

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

HOSPICEDHHS Form 153- Medicaid Hospice Revocation

HOSPICEDHHS Form 154- Medicaid Hospice Discharge

HOSPICEDHHS Form 152- Medicaid Hospice Provider Change Request Form

SERVICE TYPE

SURGICAL JUSTIFICATIONS

SURGICAL JUSTIFICATION

• Only pertains to Outpatient Surgical procedures– Hospital Provider manual for complete listing of Codes (Beginning section 4-63)– Physician Provider Manual for complete listing of Codes (Beginning Section 4-18)

• 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

http://scdhhs.kepro.com/


• Hysterectomies

• Must include Consent for Sterilization signed 30 days prior to the procedure. – Exceptions are:

• If urgent/emergent surgery required (with bypassing of waiting period), submission of doctor’s note with explanation is required.

• If retroactive eligibility was obtained, must include documentation showing recipient was informed of future sterility prior to surgery.

• All submissions must include “Surgical Justification for Hysterectomy.”

• Clinical information will be used to meet McKesson InterQual criteria.

Consent for Sterilization Form

Surgical Justification-Hysterectomy


• Gastric Bypass

- Two questions that must be answered

1) 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.

SERVICE TYPE

INPATIENT ADMISSIONS

INPATIENT

• Includes: Inpatient Acute, Inpatient Psych and Inpatient Rehab and LTAC

– NO PA required for Birth/Delivery– No concurrent reviews (DRG)

• Review of Admission Only - NOT Length of Stay

• Servicing Provider- Must display Facility NPI number – Allscripts Case Management Fax is sufficient as long as NPI number is

recorded

• KEPRO Inpatient Prior Authorization Fax form (Fax submissions only)

INPATIENT

• All non-urgent admissions must be preauthorized (submitted on or before date of admission). This includes planned surgical procedures and admissions for routine chemotherapy.

• Urgent/emergent admissions must be submitted within 5 business days of the admission.

• KEPRO will complete review (including requests for additional information) within 5 business days.

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 request within the 2 business days specified.

- Clinical information will be used to meet criteria specified in McKesson Interqual.

INPATIENT

• Medicare/Medicaid (Dually Eligible)- All services rendered to dually eligible Medicare/Medicaid patients

should be filed to Medicare first.

• Commercial Insurance

- All services rendered to recipients with commercial insurance should be submitted to the primary payor first.

INPATIENT

• Managed Care Organization

- PA request for beneficiaries enrolled in a managed care organization (MCO) must be handled by the MCO.

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.

INPATIENT

• Hints re: McKesson InterQual 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.)

INPATIENT

• Hints re: McKesson InterQual Criteria

• Note any failed outpatient treatment related to this admission.

• If nurse reviewer is unable to meet criteria with supplied clinical information, case will be forwarded for physician review.

MEDICAL NECESSITY DENIALS

• Medical necessity denials are denials where clinical information that has been submitted has been reviewed by a Physician who has determined that the request is not medically necessary (based on the clinical submitted).

• If you disagree with denial decision, please follow instructions as outlined in your denial letter.

• Reconsideration request- Submit to KEPRO within 60 days from receipt of denial letter.

• Appeals request- Submit to state within 30 days of receipt of denial letter. Appeals should be submitted after a reconsideration review has been completed.

ADMINISTRATIVE DENIALS

• Administrative denials are denials in which the request for services was submitted untimely or required DHHS forms were not submitted

• Administrative denials are administered by the Clinical Nurse Reviewer.

• Administrative denials do not allow for reconsiderations, only appeals directly to SCDHHS

• Appeals request- Submit to state within 30 days of receipt of denial letter.

Response Time for Decisions from the QIO

• For all service types excluding DME and PRTF/Freestanding Psych, KEPRO must render a decision within 5 business days.

• KEPRO has 15 days to process DME requests and 2 business days to process PRTF/Freestanding Psych

Note***this is excluding time for pending for additional information, physician review

SOUTH CAROLINA WEBSITE

FORMS

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

OUTPATIENT FAX FORM

OUTPATIENT FAX FORMS cont.

INPATIENT FAX FORMS

Registration for Atrezzo Connect Provider Portal

INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT

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

https://dmas.kepro.org/

Atrezzo Connect

Atrezzo Connect allows for:

–Secure access to Atrezzo Connect (Provider Portal)

–Provider will be able to access letters by Case/Request, Respond/Send messages To/From KEPRO

Required Information for Security Verification

• The provider must enter information to verify authenticity for security reasons

• Registration Code:

– SCDHHS Legacy ID

Simple -5 Step Registration Process

• Start by clicking the Atrezzo Login button on the SCDHHS-KEPRO website

Login Page

• You will be brought to this login page

Step 2 – Enter NPI and Legacy ID

• Enter your organization’s NPI number and Legacy Provider ID = Provider Registration Code

• Click NEXT

Step 3 – Terms of Agreement

• Review Terms of Agreement. Upon acceptance, you will be taken to setup for User information.

Step 4 – Verify Address

• Click on the correct address(s) for the new account (this associates your user information with these locations)

• If all apply, check all of them

• Click SELECT

Step 5 – Enter Account Information

• Enter user account information

• User Name, Password, First/Last Name, E-mail and Fax Number are required fields!

• Click NEXT-This will take you to the Password setup and security question Slide)

• Passwords do not expire. Minimum 8 characters required.

Successful Completion

• Successful Completion of setup, takes you to the Home Page

View all request and Create new request

• Click Member to search using Member id or Last name/DOB• Click Request/Case to search using Case id, Member info or Request info

Create Preferences, Manage User accounts and New Provider Registration

Use this tab to change your password or update your contact information

View Atrezzo User Guide and View FAQs

Account Administrator

• All information submitted for registration under Provider/Facility Information will represent as the Provider Portal Administrator (Group Admin).

• The Group Admin is responsible for managing and creating all Submitting User accounts for your NPI #

– Create other Group Admins’ & Admin Users

– Set Preferences, i.e. Diagnosis and Procedure codes, etc

KePRO Contacts

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Thank You!