Prior Authorization, Adjustments, Appeals and DME

1. Prior Authorization, Adjustments, Appeals and DME

2. UTILIZATION MANAGEMENT

3. Utilization Management PRIOR AUTHORIZATION Prior Authorization is an approval from MHS to provide services designated as needing approval prior to treatment and/or payment. REFERRAL A referral is a request (verbal, written, or telephonic communication) by a PMP for specialty care services.

4. Utilization Management • ALL referrals to participating specialists for office visits require communication between the PMP and the specialist. • ALL referrals to non-participating specialists and/or for procedures that require authorization must be obtained by contacting MHS.

5. Utilization Management Self Referrals • Podiatrist • Chiropractic • Family Planning • Routine Vision Care • Routine Dental Care • Mental Health by Type and Specialty • HIV/AIDS Case Management • Diabetes Self Management • Immunizations

6. Utilization Management Services that require a prior authorization regardless of contract status: • Assistant Surgeon • Blepharoplasty • Nuclear Cardiology/SPECT scans, PET, MRI, MRA • Circumcision • Transplant evaluation and request • Dental Surgery for members >5 years old and/or general anesthesia is requested • Dialysis • Experimental or investigational treatment/services • Genetic testing or counseling

7. Utilization Management Services that require a prior authorization regardless of contract status: • Hysteroscopy, infertility services • Implantable devices including cochlear implants • Mammoplasty • Nutritional counseling (non-diabetics only) • OB ultrasounds (2 per pregnancy without authorization) • Pain Management Programs including epidural, facet and trigger point injections • Scar revision; cosmetic or plastic surgery; septoplasty; rhinoplasty; spider and/or varicose vein treatment

8. Utilization Management HOSPITAL SERVICES • All elective inpatient/outpatient services must be prior authorized with MHS at least 2 business days prior to the date of service. • All urgent and emergent services must be called to MHS within 2 business days after the admit. Failure to prior authorize services will result in claim denials.

9. Utilization Management TRANSFERS • MHS requires notification and approval for all non-emergent transfers, at a minimum two (2) business days advance notice. • MHS requires notification within two (2) business days following all emergent transfers. Transfers are inclusive of, but not limited to the following: • Facility to facility • Level of care changes

10. Utilization Management To initiate an authorization, referral staff will require the following information: • Place of service: outpatient, observation or inpatient • Service type: elective, emergent or transfer • Service date • Name of admitting physician • CPT code for proposed services • Primary and any secondary diagnosis • Contact name and number to obtain clinical information

11. Utilization Management • Prior Authorization (PA) should be initiated through the MHS referral line at 1-877-MHS-4U4U (647-4848). • The PA process begins at MHS by speaking with the MHS non-clinical referral staff. • PAs can also be submitted online via our website at www.managedhealthservices.com. Additional documentation may be required to be sent via fax for approval of authorization.

12. Utilization Management MHS will: • Provide a PA number at the time of the call unless clinical information is required. • Provide the caller with the name and phone/fax number of the Case Manager (CM) assigned to the case if clinical information is required. • The CM will correspond with the provider via the provider’s preferred method: phone or fax.

13. Utilization Management • The MHS CM will review all available clinical documentation; apply Milliman Care Guidelines, and seek Medical Director input as needed. • PA for Observation Level of Care (up to 72 hours) is not required in contracted facilities. • If the provider requests an inpatient level of care for a covered/eligible condition/procedure and documentation supports an outpatient/observation level of care, the case will be sent for a Medical Director review.

14. Utilization Management • If the provider requests inpatient level of care for a covered/eligible condition and documentation supports an inpatient level of care, the request will be approved. • The CM may send any requests to a Medical Director for review/decision if he/she determines the individual clinical elements require the skills/knowledge of a physician or for which complete clinical information cannot be obtained.

15. Utilization Management Examples of diagnoses potentially appropriate for Observation Level of Care Ambulatory Diagnoses Allergic Reaction (Generalized) Asthma Bronchitis Enteritis (Diarrhea) Epistaxis (Nose Bleed) Failure to Thrive Fracture (Simple) Hypertension Pre-term Labor Renal Colic / Calculus (Kidney Stone) Sinusitis Sprains Urinary Tract Infection (UTI) Other not specifically listed

16. Utilization Management Examples of diagnoses potentially appropriate for Observation Level of Care Symptomatic Diagnoses Abdominal Pain Altered Mental Status (Confusion) Back Pain Chest Pain Dehydration Delayed Recovery following Anesthesia/ Procedure Dizziness / Weakness Electrolyte Imbalance Epigastric Pain Fever Flank Pain / Tenderness Headache Nausea / Vomiting Shortness of Breath (SOB) Uncontrollable Vomiting/Pain after OutptSurg/Chemo Any “Rule Out” Diagnosis Other not specifically listed

17. Utilization Management Denial of Request and Appeal Process If MHS denies the requested service: • The MHS CM will notify the provider verbally within one business day of the denial, provide the clinical rationale, and explain appeal rights. • A formal letter of denial explaining denial rationale and appeals rights will be mailed within the next business day. • If denial is based on Milliman Care Guidelines, provider has right to obtain a copy of the guidelines in which denial is based.

18. Utilization Management Denial of Request and Appeal Process If MHS denies the requested service: • If member is still receiving services the provider has the right to an expedited appeal which must be requested by the attending physician. • If the member has already discharged, an appeal must be submitted in writing from the attending physician within 60 days of the denial. • The attending physician has the right to a peer-to-peer discussion. • Peer-to-peer discussions and expedited appeals are initiated by calling MHS at 1-877-MHS-4U4U (647-4848) and asking for the Appeals Coordinator.

19. Utilization Management MEDICAL NECESSITY GRIEVANCE AND APPEALS Managed Health Services Attn: Appeals Coordinator 1099 North Meridian Street, Suite 400 Indianapolis, IN 46204 Determination will be communicated to the provider within 20 business days of receipt.

20. DURABLE MEDICAL EQUIPMENT

21. DME Policy • Before an item can be considered to be durable medical equipment: • It must be able to withstand repeated use. • It must be primarily and customarily used to serve a medical purpose. • It is generally not useful to a person in the absence of an illness or injury. • It is appropriate for use in the home.

22. DME Policy Items including, but not limited to, the following are examples of DME: Hospital beds Wheelchairs Canes Walkers Raised toilet seat Oxygen systems Ventilators Nebulizers Neuromuscular Stimulators Bone growth Stimulators Infusion Pump CPAP/BIPAP Wound Vacs

23. DME Policy • DME with a purchase price of more than $500.00 require prior authorization. • Manually Priced DME – must be submitted with invoice. • DME authorization requested by treating PMP or specialist.

24. DME Policy • All DME authorizations must be obtained prior to dispensing. • Orthotics and prosthetics items with a purchase price above $250.00 require an MHS authorization.

25. DME Policy • All DME items, regardless of purchase price, must be medically necessary as defined by: 405 IAC 5-2-17 “Medically reasonable and necessary service”.

26. DME Policy If the DME requires authorization, the authorization must be completed prior to dispensing the items, with the following exceptions: • DME item necessary as part of discharge planning from the hospital. • DME item necessary as part of the treatment plan for an urgent / emergent medical condition. • DME item previously authorized by another MCO as a component of continuity of care during the 1st 30 days of transition.

27. DME Policy • DME authorization decisions by MHS are based on medical necessity. • The MHS Prior Authorization form should accompany all clinical information submitted as part of the prior-authorization request. • Authorization duration is based on medical necessity, anticipated outcomes, compliance with utilization, benefit limitations, and alternative treatment options available to meet the medical need of the member. • Authorization requests to extend an existing authorization are required to be submitted prior to the expiration date of the current authorization. • Authorization numbers and units are provided for approved DME items.

28. Claims Adjustment and Appeals

29. Resubmitted Claims • Clearly mark RESUBMISSION or CORRECTED CLAIM at the top of the claim. • Must attach EOP, documentation, and explanation of the resubmission reason. • May use the Provider Claims Adjustment Request Form. • Providers have 60 calendar days from the date they receive their EOP to file a resubmission.

30. Adjusted Claims • If you need to make an adjustment to a paid claim, you can do so by calling Provider Inquiry or you may submit on paper with the adjustment request form. • Attach a Provider Adjustment Form along with documentation, including EOP (if available) explaining reason for resubmission. • Claim adjustments must be submitted within 60 days of the date of the MHS EOP.

31. Dispute Resolution PROVIDERS HAVE 60 CALENDAR DAYS FROM THE DATE OF RECEIPT OF THE EOP TO FILE AN OFFICIAL DISPUTE OR APPEAL WITH MHS. • Verbal inquiries can be made by calling the MHS Provider Inquiry Line at 1-877-MHS-4U4U (647-4848). A verbal inquiry is not considered a dispute or appeal and does not stop the 60 calendar days from the date of receipt of the EOP to file a dispute or appeal. • Informal Claim Dispute - Level One Appeal • Formal Claim Dispute/Objection – Level Two Appeal (Administrative)

32. MHS – Need to know www.managedhealthservices.com & 1-877-MHS-4U4U (647-4848)

33. Provider Inquiry Services Call us at 1-877-647-4848. We are ready to help you! • Knowledgeable, friendly staff available 8:00-6:00 EST • Focused commitment to professional service • Claims address P.O. Box 3002 Farmington, MO 63640 • Dispute & appeal processes (60 days from receipt of EOP) • Appeal address P.O. Box 3000 Farmington, MO 63640 • Filing limits dependent upon contract status • Follow IHCP requirements

34. MHS WEBSITE • www.managedhealthservices.com • Enhanced website – Access for both contracted/non-contracted groups • On-line Registration – Multiple Users • Provider Directory Search Functionality • Enhanced Claim Detail • Direct Claim Submission (Professional Claims only) • Prior Authorization • Claim Auditing Software Tool • Downloadable Eligibility Listing • Printable, Current Forms and Manual

35. Questions and Answers