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

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

2. Zenovia Vaughn • Program Manager • Office of Health Improvement (803) 898-2682

3. 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

4. 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 Hospital • DME (wheelchairs) • OOS Transplant Requests • Surgical Justifications • Therapy (PT/OT/ST) for Adults • Mental Health Counseling

5. August 1, 2012 • All DME Services • Botox ( Injections) • October 1, 2012 • Hospice • Home Health • Childrens PT/OT/ST- After frequency limits

6. 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

7. 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.

8. 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.

9. 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 from • Alliant – send claim to PO Box 1415 with the cover letter • and 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.

10. 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.

11. 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)

12. 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

13. SCDHHS Addresses • Prior Authorizations (KePro) • (855) 326-5219 Customer Services • (855) 300-0082 Fax • Atrezzoissues@kepro.com