Medicaid QIO Training Sessions November 7th and 8th , 2012

Zenovia VaughnProgram Manager

Office of Health Improvement (803) 898-2682

Recent Changes Provider Services Center 1-888-289-0709

(Individual Programs, Provider Reps)No longer available

Claims inquiries; Assistance with edits; Eligibility; Enrollments, etc.

Online inquiry at http://www.scdhhs.gov/contact-us

Hard copy claims/ ECFs continue to be sent to the:P.O. Box 1415

Scope of Services• KePRO’s reviews are based on McKesson’s InterQual Criteria;

other nationally recognized standards of care; unless otherwise directed by DHHS.

• June 1, 2012- KePRO became operational• June 15, 2012- First Date of Service for claims

to edit with KePRO authorizations

Inpatient HospitalDME (wheelchairs)OOS Transplant RequestsSurgical JustificationsTherapy (PT/OT/ST) for AdultsMental Health Counseling

August 1, 2012

• All DME Services• Botox ( Injections)

October 1, 2012

• Hospice• Home Health• Childrens PT/OT/ST- After frequency limits

EDITS

Edit 837 - Service requires PA from KePRO - no PA on claim.

Edit 838 - Service requires PA from KePRO – PA is not valid.

Edit 839 - IP admission requires PA from KePRO

Frequently asked Questions

Medicare Primary - Is a PA required?Only if Medicaid is primary payor.

Retro Medicaid Benefits denied Part B only

If Alliant or DHHS approved a service does the provider request another PA.

If DOS is after June 1st, a KePRO authorization is required. Communicate with KePRO CS Rep. They will

assign a new number and fax this to you.

Frequently asked Questions

PT/OT/ST – Are the 3 criteria still required to be met. As of June 1, 2012 KePRO uses InterQual criteria for determining medical necessity.

DME – Repair and Replacement codes - for miscellaneous codes for wheelchair should be sent to DHHS if purchase was authorized by DHHS.

If admission is denied can we bill observation. Only if observation is ordered by the physician.

Frequently asked Questions

• How do we handle cases where patient received eligibility after the service.

DOS is prior to 6/1/2012 and service required a PA fromAlliant – send claim to PO Box 1415 with the cover letterand records.

DOS is after 6/1/2012 and it requires a PA from KePRO - Submit the request – indicate Retro eligibility, attach some official notification.

We are working with our IT to put an indication on the Web Tool.KePRO would see that indicator and know immediately it is Retro.

Also, KePRO is working to add an indication to their files.

Frequently asked Questions• Does a patient in SC Solutions require a PA.

SC Solutions is a Medical Home network. If claim is paid FFS – it require a PA. If paid by a capitated fee – does not require a PA unless it

is a Transplant.

• Should I send my Appeals to KePRO or to DHHS

Appeals are sent to DHHS at the time you wish to have an Administrative Hearing.

Things to Remember

Most of the PA requests are for members that are in FFS Medicaid.

MCO members require a PA for transplants and some Behavioral Health services.

MHN (Medical Home Network) members are considered FFS and need a PA.

If checking Eligibility on the WEBTOOL RSP Indicator MCHM = Managed Care (MCOs) MCCM = Medical Homes Networks (MHNs)

Things to Remember

Provider Manual updated each month. Change Log shows what’s changed.

Bulletins – Sign-up for E-Bulletins

http://www.scdhhs.gov

KePRO website: http://scdhhs.kePRO.com

SCDHHS Addresses

Prior Authorizations (KePro)

(855) 326-5219 Customer Services

(855) 300-0082 Fax

Atrezzoissues@kepro.com