Authorization Review Process Chiropractic, Hearing, Optometric, Visual and Physician Services
- Transition to eQHealth Solutions
December 2012
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Introduction to eQHealth
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Mission Statement:
“To Improve the Quality of Health and Health Care by Using Information and Collaborative Relationships to Enable Change”
Vision:
“To be an Effective Leader in Improving the Quality and Value of Health Care in Diverse and Global Markets”
Mission and Vision
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• eQHealth is the Agency for Health Care
Administration’s contracted quality
improvement organization (QIO), responsible
for the Comprehensive Medicaid Utilization
Management Program for the state of Florida
• Local office / operations in Tampa Bay area
5802 Benjamin Center Drive, Suite 105
Tampa, FL 33634
• Branch office in Miami/Dade area
Partnership: Agency for Health Care
Administration and eQHealth
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Scope of Services
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Service Requirements
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Recipients must be:
• Enrolled in a Medicaid benefit program that covers the service requested:
• Fee for service
• MediPass
• Medically Needy
• Dually eligible (Medicare/Medicaid & Commercial/Medicaid)
• CMS (exception: enrolled in a CMS/PSN in a Reform County)
• Waiver Recipients
• Eligible at the time services are rendered.
Not Subject to Prior Auth by
eQHealth
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Recipients who are:
• Members of a Medicaid HMO
• Members of a Medicaid Provider Service
Network (PSN)
• Members of Children’s Medical Services (CMS)
(enrolled in a PSN in a Reform County)
• Residents of ICF/DD: vision services
Retrospective Review Requests
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Retrospective authorization may only be requested if
the recipient is granted retroactive Medicaid eligibility
that covers the date(s) services were provided.
Exceptions:
•Hearing evaluation beyond the maximum service limits
• Certain Hearing Aid Fitting and dispensing
•Hearing aids that meet the requirement for immediate need
•Repair or replacement of cochlear implant internal parts outside
of the manufacturer’s warranty
•Emergency Outpatient Surgeries (evidence of “emergency”
required)
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
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Multi-Specialty Includes the following
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Physician Services (includes Ambulatory Surgery, Oral and Maxillofacial Surgery)
Chiropractic
Hearing Services
Optometric & Vision Services
Special Services
Intrathecal Baclofen Therapy (ITB) Pump
Authorization Requirements
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Prior Authorization is required for all services that have
a “PA” marked on the ACHA fee schedule or as
indicated by the applicable handbook.
Prior Authorization numbers are valid for 120 days.
If an extension is needed, contact eQHealth
Customer Service.
Authorization Requirements
Chiropractic
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Codes that ONLY require a PA if the maximum number of visits (24/year)
are exhausted
• 98940 - Chiropractic Manipulative Treatment (Cmt); Spinal, One To
Two Regions
• 98941 - Chiropractic Manipulative Treatment (Cmt); Spinal, Three To
Four Regions
• 98942 - Chiropractic Manipulative Treatment (Cmt); Spinal, Five
Regions
Authorization Requirements
Hearing Services
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Codes that ALWAYS require a PA: • L7510 - Repair Of Prosthetic Device, Repair Or Replace Minor Parts
• L8615 - Headset / Headpiece For Use With Cochlear Implant Device, Replacement
• L8616 - Microphone For Use With Cochlear Implant Device, Replacement
• L8617 - Transmitter Coil For Use With Cochlear Implant Device, Replacement
• L8618 - Transmitter Cable For Use With Cochlear Implant Device, Replacement
• L8619 - Cochlear Implant External Speech Processor And Controller, Integrated System, Replacement
• L8623 - Lithium Ion Battery For Use With Cochlear Implant Device Speech Processor, Other Than Ear
Level, Replacement, Each
• L8624 - Lithium Ion Battery For Use With Cochlear Implant Device Speech Processor, Ear Level,
Replacement, Each
• L8627 - Cochlear Implant, External Speech Processor, Component, Replacement
• L8628 - Cochlear Implant, External Controller Component, Replacement
• L8629 - Transmitting Coil And Cable, Integrated, For Use With Cochlear Implant Device, Replacement
• L8691 - Auditory Osseointegrated Device, External Sound Processor, Replacement
• L8692 - Auditory Osseointegrated Device, External Sound Processor, Used Without Osseointegration,
Body Worn, Includes Headband Or Other Means Of External Attachment
• V5299 - Hearing Service, Miscellaneous
Authorization Requirements
Hearing Services
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Codes that ONLY require a PA if the limits are exhausted
• V5014 - Repair/Modification Of A Hearing Aid (Use For Factory Repair)
• V5050 - Hearing Aid; (Use For Category 1 Hearing Aids)
• V5090 - Dispensing Fee, Unspecified Hearing Aid
• V5200 - Dispensing Fee, Cros
• V5240 - Dispensing Fee, Bicros
• V5264 - Earmold/Insert, Not Disposable, Any Type.
• V5267 - Hearing Aid Supplies / Accessories
• V5299 – Hearing Supplies – Miscellaneous
Authorization Requirements
Vision/Optometric Services
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Codes that ALWAYS require a PA
• S0590 - Integral Lens Service, Miscellaneous Services Reported Separately
• V2199 - Not Otherwise Classified, Single Vision Lens
• V2299 - Specialty Bifocal
• V2399 - Specialty Trifocal
• V2500 - Contact Lens, Pmma, Spherical, Per Lens
• V2501 - Contact Lens, Pmma, Toric Or Prism Ballast, Per Lens
• V2511 - Contact Lens, Gas Permeable, Toric Or Prism Ballast, Per Lens
• V2513 - Contact Lens, Gas Permeable, Extended Wear, Per Lens
• V2520 - Contact Lens Hydrophilic, Spherical, Per Lens
• V2521 - Contact Lens Hydrophilic, Toric Or Prism Ballast, Per Lens
• V2523 - Contact Lens Hydrophilic, Extended Wear, Per Lens
• V2599 - Contact Lens, Other Type
• V2730 - Special Base Curve, Glass Or Plastic, Per Lens
• V2799 - Vision Service, Miscellaneous
Authorization Requirements
Vision/Optometric Services
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Codes that ONLY require a PA when the maximum exceeded • 92340 - Fitting Of Spectacles, Except For Aphakia; Monofocal
• 92341 - Fitting Of Spectacles, Except For Aphakia; Bifocal
• 92342 - Fitting Of Spectacles, Except For Aphakia; Multifocal, Other Than Bifocal
• 92352 - Fitting Of Spectacle Prosthesis For Aphakia; Monofocal
• 92353 - Fitting Of Spectacle Prosthesis For Aphakia; Multifocal
• V2020 - Frames, Regular, Office Repair, Plastic
• V2025 - Deluxe Frame (New Or Replacement; Metal
• V2115 - Lenticular, (Myodisc), Per Lens, Single Vision
• V2121 - Lenticular Lens, Per Lens, Single
• V2315 - Lenticular, (Myodisc), Per Lens, Trifocal
• V2319 - Trifocal Seg Width Over 28 Mm
• V2320 - Trifocal Add Over 3.25D
• V2410 - Variable Asphericity Lens, Single Vision, Full Field, Glass Or Plastic, Per Lens
• V2430 - Variable Asphericity Lens, Bifocal, Full Field, Glass Or Plastic, Per Lens
• V2510 - Contact Lens, Gas Permeable, Spherical, Per Lens
• V2710 - Slab Off Prism, Glass Or Plastic. Per Lens
• V2715 - Prism, Per Lens
• V2745 - Addition To Lens; Tint, Any Color, Solid, Gradient Or Equal, Excludes Photochromatic, Any Lens
Material, Per Lens
• V2755 - U-V Lens, Per Lens
• V2780 - Oversize Lens, Per Lens
Authorization Requirements
Physician Services
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Codes that ALWAYS require a PA
• 15781 - Dermabrasion, chemical peel
• 15820 - Blepharoplasty and Brow Pitosis repair
• 15822 - Blepharoplasty of upper lids
• 15823 - Blepharoplasty
• 15847 – Abdominoplasty
• 19318 - Breast Reduction Surgery
• 19324 - Breast Repair and Reconstruction
• 19325 – Mammoplasty, augmentation
• 36468 - Single or multiple injections of sclerosing solutions
• 36470 - Sclerotherapy injection, single vein
• 49904 - Extra abdominal omental flap
• 56805 - Ligation or transaction of fallopian tubes
• 67901 - Repair of blepharoptosis; frontalis muscle technique with suture or other
• 67902 - Eyelid Reconstruction, pitosis surgery
• 67903 REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION
Authorization Requirements
Physician Services
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Codes that ALWAYS require a PA
• 67904 - bilateral levator resection for upper lid ptosis
• 67906 – Repair of blepharoptosis, superior rectus technique
• 67908 - Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator res
• 67909 - Reduction of overcorrect of pitosis
• 67911 - UPPER or LOWER eyelid retraction
• 69300 - Otoplasty – unilateral or bilateral
• 69710 - Implantation or replacement of electromagnetic bone conduction anchored hearing aids
• 69711 – Remove/Repair Hearing Aid
• 69714 - Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to
external speech processor/cochlear without mastoidectomy
• 69715 - Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to
external speech processor/cochlear with mastoidectomy
• 69717 - Replacement (including removal of existing device), osseointegrated implant, temporal
bone, with percutaneous attachment to external speech processor/cochlear stimulator; without
mastoidectomy
• 69930 - Cochlear device implantation, with or without mastoidectomy
• S2411 - Fetoscopic Laser Therapy for treatment of Twin to Twin transfusion syndrome
Codes that ALWAYS require a PA
• E0783 - Infusion Pump System, Implantable,
Programmable
• E0786 - Implantable Programmable Infusion Pump,
Replacement
Note: Insertion of the pump does not require authorization.
Authorization Requirements
Intrathecal Baclofen Therapy (IBT)
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Authorization Requirements
Oral/Maxillofacial Surgery
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Codes that ALWAYS require a PA
• 21208 - Osteoplasty, facial bones augmentation
• 21230 - Graft; Rib Cartilage Autogenous to face
• 21235 - Graft, ear cartilage, autogenous to nose or ear
• 21248 – Reconstruction of mandible, mancilla
• 21249 - Reconstruction of mandible, mancilla, endosteel implant,
complete
• At this time, NO podiatry services require prior
authorization.
• For Chiropractic Services, prior authorization
should only be obtained for the 25th visit within
a specific calendar year.
Multi-Specialty Services – Specialty Exceptions
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Review Requests
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Please submit all review requests to :
eQHealth Solutions
Attn: Multi-Specialty Department
5802 Benjamin Center Drive, Suite 105
Tampa, FL 33634
Submission of Review Requests
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• Prior to submitting a review, verify:
• The recipient’s Medicaid eligibility
• The service is:
– -A covered Medicaid benefit
– -Required to be prior authorized by eQHealth
• The required supporting documentation is:
– -Complete
– -Legible
– The Multi Specialty Services Prior Authorization request form is complete and appropriately signed and dated
Review Requests
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Types of Review Requests:
• Initial Authorization
• Retrospective
– applicable only for recipients who are retroactively eligible for Medicaid
• Reconsideration review
– response to an adverse determination
Review Requests
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Prior authorization must be obtained prior to
providing services:
Exception
• Retrospective Medicaid eligibility:
– Authorization must be obtained prior to
billing.
– Claims must be billed within 12 months of
determination of eligibility.
Review Requests
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Service Type Submission Review Completion
Physician Services
At least 10 days prior
to initiation of services
1St Level – 3 business days
2nd Level – 2 additional business days
Vision / Optometry
Hearing Services
ITB Pump (Intrathecal
Baclofen Pump)
Special Services 21 business days
Request Submission & Response
Initial Request
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Service Type Submission Review Completion
Physician Services
–
As soon as the recipient
receives Medicaid
Eligibility.
Note: claims must be
submitted within 12
months of the date of
service
20 business days
Vision / Optometry
Hearing Services
ITB Pump
(Intrathecal
Baclofen Pump)
Request Submission & Response
Retrospective
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Service type Submission Review Completion
Physician Services –
Within 30 calendar days
of the notification date.
3 business days
receipt of request
Vision / Optometry
Hearing Services
ITB Pump (Intrathecal
Baclofen Pump)
Special Services
Request Submission & Response
Reconsideration Request
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Verification that there are no review exclusions:
• Recipient is not eligible for the service;
• Duplication of service;
• Request does not meet the replacement time
span requirement; (IBT/Cochlear Implant) or
• Requested service is not covered by Medicaid.*
*Exception: special services
First Level Review
Screening
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Review Determination Process
• 1st Level Clinician Review:
– Administrative Screening
– Clinical Screening
• 2nd Level Peer Review
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Review Determination Process
First Level Clinical Reviewers may:
• Approve the request
• Issue a technical denial of the request, if
appropriate, for example
– Duplicative service
– Noncompliant with Medicaid policy
• Pend the request back to the provider for:
– Additional or clarifying information
– Supporting documentation
• Refer the request to a second level Peer Reviewer
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Review Determination Process
Pended Requests (Administrative/Clinical)
• An advisory letter is mailed to the requesting
provider.
• The provider accesses the review record to
determine what additional information is needed.
• The information should be submitted within 5
business days.
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• Multi-Specialty Peer Reviewers base their determination on generally accepted professional standards of care, their clinical experience and judgment, Medicaid’s medical necessity criteria, and peer to peer consultation with the requesting provider when necessary.
• Peer Reviewers may render an approval or an adverse determination.
• An adverse determination may be a full denial of the requested services or a partial denial of the requested services.
Second Level Review
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Determination notifications are issued to providers, and
recipients within one (1) business day of the determination.
• The requesting provider will receive a written notification of
the determination via mail.
• The recipient, or legal guardian, also receives written,
mailed notification of the determination via mail.
Review Determination Notification
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Notifications include:
• Services approved or denied;
• Reason for an adverse determination;
• 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
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Any party involved in the case may request a
reconsideration of an adverse determination:
Requesting Provider/Recipient/Legal Guardian • Phone
• Fax
Reconsiderations
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A peer reviewer, not involved in the original adverse determination, will:
• Uphold the original adverse determination; • Modify the original determination, approving a
portion of the services requested; or • Reverse the original determination, approving all
the services requested.
Reconsideration reviews are completed within 3 business days of receipt of a complete and valid request.
Please Note: When requesting a reconsideration, new and/or additional clinical information must be submitted.
Reconsiderations
Recipients or their legal representatives, may appeal
an adverse determination by requesting a fair hearing.
The request must be submitted within 90 days from
the date of the adverse notification letter by calling or
writing:
• The local Medicaid area office; or
• Department of Children Families Office of Appeals
and Hearings
Fair Hearings
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Supporting documentation is determined by AHCA policy and is required to substantiate the necessity of items/services.
All supporting documentation must be submitted with the request for authorization for Multi-Specialty Services
ALL authorizations must be requested using the Multi-Specialty Services Prior Authorization Request form.
Required Supporting Documentation
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.
Additional Supporting Documentation Requirements
Physician Services
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SERVICE TYPE DOCUMENTATION
Physician Services – Includes
Ambulatory Surgery, Oral and
Maxillofacial Surgery
•Current medical records (within the past 6
months)
•Treating physician referral to specialty
provider
•Radiographs, MRI, laboratory results,
•Photographs
•Diagnostic studies
•Medical clearance letter
Oral and Maxillofacial Surgery
Additional to above
Prior dental records & treatment records as
applicable
.
Additional Supporting Documentation Requirements
Physician Services
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SERVICE TYPE DOCUMENTATION
Blepharoplasties • Current medical records ( last 6 months)
• Documentation of need for procedure
• Visual field study
• Eyelid photography with and without tape
• Optical exam.
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.
Additional Supporting Documentation Requirements
Optometric/Visual Services
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SERVICE TYPE DOCUMENTATION
Visual Services - Eyeglasses •Eyeglass Prescription
•Documentation of recipient’s condition that
meets the criteria for provision of specific
eyeglasses or lens types,
•Optical / refraction examination,
•Itemized invoice for eyeglasses provided.
Visual Services – Contact Lens •Recipient’s eligibility for contact lenses
•Eyeglass prescription
• All appropriate procedure codes
• Substantiation for special fitting
• Itemized invoice for lenses provided
• Documentation the type of lens to be provided
• Completed contact lens request form
.
Additional Supporting Documentation Requirements
Hearing Services
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SERVICE TYPE DOCUMENTATION
Hearing Services – Hearing
Aids and related items
•Current audiogram (last 6 months)
• Current medical records ( last 6 months)
• Physician’s order
• Medical clearance letter,
• All procedure codes and related fees.
Hearing Services – Cochlear
Implant Repair / Replacement
• Documentation of what failed and justification
of need for repair/replacement
• Itemized documentation of repair/replacement
cost
.
Additional Supporting Documentation Requirements
(Intrathecal Baclofen Therapy)
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SERVICE TYPE DOCUMENTATION
IBT •Current medical records ( last 12 months)
•Documentation of successful Baclofen trial
with intrathecal injection,
• Physical therapy assessment for the Baclofen
pump trial
• Referral letter from primary physician
• Documentation of trial of PO Baclofen
• Medical clearance letter
.
Additional Supporting Documentation Requirements
Special Services
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SERVICE TYPE DOCUMENTATION
Special Services • Attestation and documentation of need of
special service from treating provider
• Referral information from referring provider
• Current medical record (last 6 months)
• All procedure code information (if applicable)
eQHealth’s Peer Reviewers reserve the right to request additional information or clarifying information to substantiate the medical necessity for the service(s)requested.
Supporting Documentation
Additional Information
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1. Submit all supporting documentation along with
the Multi-Specialty Services Prior Authorization
Request form via mail for the initial request.
2. Additional supporting information requested after
the initial request may be submitted via mail or by
fax (855-677-3747.)
Submitting Supporting
Documentation
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• 11/22/12: Last date to submit authorization requests to AHCA
• 11/27/12: First date to submit requests to eQHealth
• 12/1/12: eQHealth begins reviewing authorization requests
Transition
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– Customer Service: 885-444-3747
Monday-Friday, from 8 a.m.–5 p.m.
Eastern Time
– Dedicated Florida Provider Website
http://fl.eqhs.org
– Blast emails
Provider Communications
and Resources
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