KePRO’s Service Authorization Process for Durable Medical Equipment

1. INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT KePRO’s Service Authorization Process for Durable Medical Equipment

2. WY DOH/KePRO Service Authorization Process Durable Medical Equipment • Overview of Service Authorization Process • Information needed for a Request 2

3. Verifying Eligibility • Eligibility verification avoids unnecessary Service Authorization delays associated with Service Authorization submission (due to incorrect payer source). Eligibility should be checked for each date of service. • Providers must submit Service Authorization requests for member eligible dates under the Wyoming DOH Medicaid Fee For Service Plan. 3

4. Submitting Service Authorization Requests Requests may be submitted via: • Atrezzo Provider Portal Connect • KePRO Fax: 855-294-1197 • WY Call CenterTelephone: 855-294-1196 • Mail: KePRO 2810 North Parham Rd., Suite 305, Henrico Va. 23294 4

5. Information Needed for DME Request From CMN/ DMAS 352 Certificate of Medical Necessity • The CMN must be completed (signed & dated by the physician, nurse practitioner, or physician assistant) PRIOR to the PA Request and prior to the member receiving DME Medical Supplies and equipment. • The only exception to this is a member who is Retroactive eligible or who has had Medicare Part B denial or HCPCS Code is non covered by Medicare Part B 5

6. Information Needed for a Request (cont.) Please include the following clinical information : • Mobility Impairments • Endurance Impairments • Restricted Activity • Skin Breakdown if Applicable (Site, Size, Depth and Drainage) 6

7. Information Needed for a Request (cont.) • Impaired Respiration if Applicable with Most Recent PO2 Level. • Does the member require Assistance with ADL’s. • Speech Impairments • Required Nutritional Supplements 7

8. Information Needed for a Request (cont.) • Is the Item Suitable for Use In Home • Does the Patient/Caregiver demonstrate Willingness / Ability to Use the Equipment • Date Patient Last Examined By MD • List ICD-9 Code, Diagnosis Description and Date of Onset 8

9. Information Needed for a PA Request (cont.) For Each Item Requested: • Begin Service Date • HCPCS Code • Item Description • Length of Time Needed • Quantity Ordered per Month • Quantity/Frequency of Use • Physician Signature and Date (References to “Physician” also include Physician Assistant and/or Nurse Practitioner • Please note if equipment is a rental or purchase • CMN form, PA request form, and DME Fax request forms can be accessed at http://wydoh.kepro.com 9

10. Information Needed for a Request (cont.) • Please also include a brief description of the patient condition including: –Current Symptoms –Reason the Equipment is Needed This information assists the reviewers in further assessing the patient’s condition. 10

11. Tips For Submitting Requests • When requesting a wheelchair, please include the wheelchair evaluation results and the correct wheelchair code • If member has Medicare Part B and benefits were denied or exhausted please note that on the fax or in your clinical notes if you use DDE • If your member is retroactive eligible for medicaid please note that on the fax or in your clinical notes if you use DDE 11

12. Reference Materials • Criteria that is used for review consists of the McKesson InterQual® Durable Medical Equipment, and for HCPCS Codes not covered under McKesson InterQual® theWyoming Medicaid Rules, Chapter 11, Medical Supplies and Equipment are used. • The Wyoming/KePRO website includes a list of HCPCS Codes which require PA. This can be accessed by going to the KePRO/Wyoming DOH website @: http://wydoh.kepro.com . 12

13. Retroactive Reviews • Service Authorization requests for retroactively eligible members or “retro-reviews” are only for cases that the member has Medicaid retroactive eligibility. • Requested start of care date should be entered as the first day hands-on service was provided to the individual once Medicaid eligibility was effective. • On the fax form –Please mark Retro Eligibility and indicate if review is due to Medicare B denial 13

14. WY DOH/KePRO DME Process • The “ Wyoming Medicaid DME Medical Supplies and Equipment requiring PA is based on the Health Care Financing Administration Common Procedure Coding System (HCPCS)To access the HCPCS codes requiring PA go to: http://wydoh.kepro.com and you will be able to access this file. • The Procedure Code file identifies and describes HCPCS Codes which require Service Authorization. It also includes the age requirements, maximum units of service, notates if Medicare Coverage for the item and indicates if item is a rental. Please note that all rentals will require the rr modifier when direct Portal access is used to submit your request. • For Information on how to access the Wyoming DOH Fee File Information for HCPCS Codes go to : http://wyequalitycare.acs-inc.com/manuals/Manual_DME.pdf 14

15. WY DOH/KePRO DME Process • Service Authorization is requested by the enrolled DME provider • PA Approval letters are sent to the requesting Provider • Notice of Adverse Decision is sent to the Member and to the requesting Provider 15

16. Resources Check the Wyoming DOH Medicaid Memos and Manuals online at: http://wyequalitycare.acs-inc.com/manuals/Manual_DME.pdf DME Medical Supplies & Equipment Manual http://wydoh.kepro.com 16

17. Resources (cont) • KePRO Website http://wydoh.kepro.com • For any questions regarding the submission of Service Authorization Auth requests, please contact KePRO at the WY Call Center 855-294-1196  OR  855-294-1197 – WY Fax 17

18. WYDOH KePRO Service Authorization Process Durable Medical Equipment Thank you 18