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Nursing Facility Services
Presented byNew Mexico Medicaid Utilization ReviewBlue Cross Blue Shield of New Mexico
2009
Prior Authorization Requests
US MailP.O. Box 27950Albuquerque NM 87125-7950
Delivery services (e.g., FedEx)4373 Alexander Boulevard NEAlbuquerque NM 87107
Hand-Carried and Drop Box Submissions4373 Alexander Boulevard NEAlbuquerque NM 87107
Nursing Facility Eligibility
NF General Eligibility- the recipient’s functional level is such that two or more ADLs cannot be accomplished without consistent, ongoing, daily assistance in some or all of the following levels of service; skilled, intermediate and/or assistance level. The functional limitations of the individual must be secondary to a condition for which general treatment plan oversight by a physician is medically necessary.
Nursing Facility Eligibility
NF Medical Eligibility- a recipient must meet the criteria for either low or high nursing facility level of care. Medical Eligibility Criteria (approved 11/25/02 by MAD)
http://www.hsd.state.nm.us/mad/policymanual.html
General Documentation Requirements
Review decisions are based solely on the documentation provided:
The Long Term Care abstract ISD 379**The clinical record or appropriate portions of the record (may contain related hospital records or similar) which justify the clients medical necessity**•
Nurses Notes, MD notes, Physician orders (LOC order**), Therapy documentation, ADL flow sheets, etc.
The current Minimum Data Set (MDS)Other supportive documentation or facility-written responses to requests for additional information.
**required
INITIAL Review Documentation Requirements
1)
Current abstract (ISD-379).2)
Valid level of care (LOC) order for Medicaid LNF or HNF.
3)
Current History and Physical (H&P) (physically signed and dated within 6 months of initial LOC order date). *If the ISD-379 is signed and dated by the MD or CNP, an electronic signature is acceptable on the H&P.
INITIAL Review Documentation Requirements
5)
Clinical documentation to support general eligibility/ LNF/ HNF for nursing facility placement.
6)
PASRR Level 1 screen form( all questions completed) or PASRR waiver letter
7)
When requesting HNF, please send documentation supporting the daily skilled need of the resident for he timeframe requested.
Continued Stay (C/S) Documentation Requirements1)
New, completed ISD-379.
2)
Level of care (LOC) order valid within 60 days of (prior to) the effective date of continued stay.
3)
Current physician progress notes within 6 months of the continued stay date.
4)
Current documentation to support the LOC requested, documentation must be current for time frame requested,
(the closer to the Continued Stay date the better)
Valid Physician Orders
The level of care order (LOC) order must have 4 components1)
Physician signature and date (both hand written)
2)
Specific level of care (LNF or HNF), not both 3)
If the LOC order is a verbal order or a telephone order, the licensed individual taking the order must also sign and date the order and include who is giving the order (MD, CNP)
4)
Resident identification information (name, DOB, identification #, etc.)
Valid Physician Orders
Orders are valid for 60 days 60 day time frame begins the date that the physician order was signed, or the date in which the verbal/ telephone order was received by the nurse.
All orders are valid from the date they are written.
Back dated orders are not valid and will be processed from the date of the order.
Valid Physician Orders
All orders with a stamped signature and /or stamped date next to MD/CNP/ PA signature will not be accepted; the signature by the healthcare provider MUST be both,hand signed and hand dated
High NF Eligibility
The recipient’s functional level MUST FIRSTmeet the general eligibility requirements for Low NF In addition to meeting LNF, the recipient must have at least one condition or limitation that it is medically necessary to receive:
daily skilled monitoring and/or daily skilled interventions to maximize medical stability or achieve restoration of function
Medicaid-Pending Documentation
Mark “pending” on top of abstractDo not fill in Medicaid number (# 7)Do provide the same required documentation for Initial and Continued Stay PA requests
Documentation to support general/LOC eligibilityValid LOC order ( LNF or HNF)Current History and PhysicalPASRR Level 1 screen form or waiver letterNo difference between pending/ not pending in terms of documentation requirements
Medicaid-Pending Documentation
If approved, your facility and the ISD office will receive a copy of the MAD 385 (pending certification form). A certification information sheet is attached to the MAD 385 to alert you to the pending approval time frames associated with the valid LOC order and the documentation contained in the submission.The MAD 385 identifies only the level of care. Billable days are not approved until the ISD office issues an effective date.The MAD 385 is valid up to 90 days depending on the LOC and type of submission.
Medicaid-Pending Documentation
When the resident becomes effective per the ISD office, the facility is responsible for calling MUR and providing the effective-date information to allow us to issue billable days to the pending abstracts.Provided that all the correct documentation for the period requested is present, MUR will review the original abstract(s) and certify timeframes associated with the pending approvals.
Discharge Status Requirements
If a resident does not meet the general eligibility requirements, they may be considered for “discharge status” if there is a demonstrated need for placement required, i.e. Assisted living or other lower level care
The first authorization at the discharge status level may be approved for a maximum of 90 daysSubsequent requests may be considered for a minimum of six monthsOnly the Peer Consultant can issue a determination of Discharge Status.
Discharge Status Requirements
While the resident is in Discharge Status, it is the facilities responsibility to demonstrate and document** ongoing efforts, and/or failures of, attempts at trying to find the resident an appropriate alternative lower level of care placement (e.g., assisted living)**documentation is required to be submittedThe facility must continue to submit the ISD-379 and the appropriate required documentation
Discharge Status – Financial Impact
Facility – NO impact on payment rate to the facility as long as documented efforts at attempted placement continue
The facility will continue to be paid at the LNF payment level
Resident – NO impact to the residentResident can become eligible for LNF at a later date
The Ideal Submission
Valid LOC order signed & datedSigned H&P or progress notes within 6 months of initial or c/s datePASRR Screen or waived form (initial)Current documentation supporting the requested level of care (MDS, MD or RN progress notes, CNA flow sheets, etc)Only submit the necessary documentation to meet the LOC requested
Scenarios
Scenario 1
LNF vs. HNF?86 year old residentHeavy ADL assist Multiple medications Resident for 3 years Developed a stage II ulcer on the coccyx Requires continuous oxygen
Scenario 1-
Results
Resident meets LNF criteria requirementsResident does not meet HNF criteria
In order to meet HNF, the resident must have one stage III or IV decubitus requiring skilled nursing intervention and monitoring
Scenario 2
LNF or HNF?77 year old residentHistory of a right hip replacement 2 years ago, and has ongoing CHFContinuous oxygen Multiple medications, no changesRequires assistance with ADLsNew Physical Therapy order, therapy is provided 4 times per week for 1 hour each session
Scenario 2 -
Results
Probably LNF, as client does not meet required minimum therapy requirements of 5 hours per weekThe facility must send billing logs or other form of documentation which clearly shows the units or minutes of therapy provided each day/ session in order to determine HNF eligibility
Scenario 3
Level of Care?55 yr old residentRequires some assistance with ADLsIndependent with bathingNo behaviors notedMedications stableNo changes notedPlacement after hospitalizationHistory of Schizophrenia
Scenario 3 -
Results
Questionable LNFNursing Facility must initially refer to PASRR for review If review is sent to MUR, we will send to PASRR for reviewIf the review is waived by PASRR and returned to MUR, it will be referred to Peer Consultant for reviewPossible outcome is discharge status or denial
Scenario 4
Level of Care? 66 year old residentModerate assistance required with ADLs.Re-admitted from hospital, feeding tube placedDiagnosis: dehydrationRequires I&O Medication changes Protime lab draws every 2 weeks
Scenario 4 -
Results
Probably HNFDocumentation of new feeding tubeMedication changesOn-going physician intervention with skilled monitoring and intervention
Residents on Coumadin with lab draws for protime every 2 weeks does not qualify as HNFHNF is appropriate to stabilize a resident and re-establish a baseline.
Tips for LOC Orders
If your facility has pre-printed, standing orders, include options for LNF or HNFHave the physician circle the LOC being requested, and sign and date the orderIf the LOC is changed on the pre-printed orders, the person making the change must provide their initials, date and title
The change must take place before the physician has signed the final order
MUR Review Process
All Prior Authorization requests (Abstracts) are reviewed by the Utilization Review Department. The clinical reviewers involved with Nursing Facility reviews are:
Nurses Peer consultants (physician)
Clinical Reviewers
Nurse reviewers can approve prior authorization requests; however, all potential denials must be referred to and determined by a peer consultant
Peer consultants include physicians and other clinical professionals, depending on the type of review involved
Review Decisions and Due Process Letters
Denial Process
If a nursing facility review is denied by the Peer Consultant, your facility will receive a Due Process letter.This letter will detail;
level of care requestedlevel of care approved time frame associated with the decision, if approved, and the reason for the determination. Information is included specifying the hearing process; Re-Review, Reconsideration and Fair Hearing.
The Appeal Process
The Appeal Process consists of several possible steps:
Re-reviewReconsideration Fair Hearing
Re-Review Process
Based on MAD regulations, the written request must be received within 10 calendar days from the date of the denial letter
Valid requests will be processed within 15 calendar days of receiptThe abstract should be marked “RE-REVIEW” at the top
Re-Review Process
The re-review request must include a new ISD 379, additional medical/clinical information (in addition to the initial information submitted) to meet the requirements for the re-review process
Reconsideration Process
The request for reconsideration must be received within 30 calendar days from the date of the initial or re-review denial.This request must include a new ISD 379 and additional medical/clinical information (in addition to the initial and re-review information submitted) in order to meet the requirements for the reconsideration process
Reconsideration Process
If a re-review is unable to be requested within the mandated 10-days, a request may be made for a reconsideration (without benefit of a re-review) The request must be received within 30 days of the date of the initial denial letter or review determination letter“Reconsideration” should be indicated on the top of the ISD 379
The Fair Hearing Process
Requests for Fair Hearings are administered through the Administrative Hearings Bureau A Fair Hearing request can be initiated by either the recipient or provider. (Sections 8.352.2 and 8.353.2 of the Program Manual)All Fair Hearing requests must be submitted to the Administrative Hearings Bureau. MUR is not involved in the requesting of a fair hearing.
Customer Service
800-392-9019 (number is valid both in- and out-of-state)Customer Service hours are 8:00 a.m. to 5:00 p.m., Monday-Friday.ACD (Automatic Call Distribution) allows calls to be handled in the order received.MUR may be contacted via the Internet at
Help Us Help You!
Have this information ready:Recipient numberRecipient nameRecipient date of birthProvider numberProvider nameDate request was sent to MURItem(s) or service(s) requested
Help Us Help You! cont
Recipient calls regarding denial/ reduction/modification letters
Recipients are encouraged to contact their providersProviders are encouraged to assist their clients by discussing the availability of re-reviews and reconsideration requests
Following up on Submissions
Please allow time for review to reach MUR before calling to ask if it has been completed
MUR has 8 business days to complete reviews (per the HSD/MAD contract)
MUR’s imaging system allows the Customer Service representatives to view where the review is in the process (and when it was received)
Forms
ALL forms can be downloaded from the Web site from a PDF file or as a Microsoft Word document
Save to your desktop and print off copiesForms are no longer available through customer service or at our drop-off location
Program Policy Manual Online
http://www.hsd.state.nm.us/mad/policymanual.html
8.312.2UR Long Term Care Utilization Review for Nursing Facilities
Medicaid UR WebsiteThe Medicaid UR website is located
at:http://bcbsnm.com
Questions??Questions about the NF process??
Questions about documentation??
Questions about policy/ procedures??
THANK YOU!for your time and attention
