PRIOR AUTHORIZATION Assistive & Adaptive Equipment Trina Hazley, RN; Manager James Glier, RN Clinical Operations Prior Authorization Unit

Prior Authorization All Prior Authorization (PA) Requests Are Submitted Electronically Into The Medicaid Information Technology System By The Provider Expecting Reimbursement For the Requested Service. Providers Upload Supporting Documents (e.g., Prescriptions, CMN’s, Assessment Reports, etc.) That Attach To The Request. 9/18/2018

Prior Authorization MITS Runs A Series Of Edits & Audits To Assist In Streamlining The Process Based On: Eligibility – Recipient Eligibility – Service Provider Service Coverage Duplicate Request Presence Of Attachment(s) 9/18/2018

Prior Authorization If A Recipient Is Not Medicaid Eligible On Date Request Entered – Rejected If Requested Service (HCPCS) Code Is Not Covered – Cannot Be Entered If No Attachment – 30 Business Days In “Awaiting Documents” Then Auto Deny (251) 9/18/2018

Prior Authorization Appendix DD OAC § 5101:3-1-60 “Fee Schedule” Shows If An Item Is Covered And Reimbursement Rate, If Established. NC = Not Covered Exception: Age 20 & Under (Early and Periodic Screening, Diagnosis, and Treatment) EPSDT = Anything Is Coverable If Medically Necessary 9/18/2018

Prior Authorization OAC § 5101:3-1-01 Medicaid: Medical Necessity “...“Medically necessary services" are defined as services that are necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort....” 9/18/2018

Prior Authorization A medically necessary service must: Meet generally accepted standards of medical practice; Be appropriate to the illness or injury for which it is performed as to type of service and expected outcome; Be appropriate to the intensity of service and level of setting; 9/18/2018

Prior Authorization A medically necessary service must: Provide unique, essential, and appropriate information when used for diagnostic purposes; Be the lowest cost alternative that effectively addresses and treats the medical problem; and Meet general principles regarding reimbursement for Medicaid covered services found in rule 5101:3-1-02 of the Administrative Code. 9/18/2018

Prior Authorization Reviews Are Conducted By AN MTA or RN. Can APPROVE Can DENY Can “PEND FOR ADDITIONAL INFORMATION” 9/18/2018

Prior Authorization When “Pended” The Service Provider Has 30 Business Days To Respond To The Reviewer’s Request For Additional Information. If No Response Received In MITS An Auto Denial Is Generated (010) After 30 Business Days 9/18/2018

Prior Authorization Navigating Coding & Coverages Uses Of “Miscellaneous” Codes: To Request A Service Which Has Been Classified As Miscellaneous. To Attempt To Receive Reimbursement For A Non-Covered Service Under The State Plan. To Attempt To Receive Greater Reimbursement Than The Established Medicaid Maximum. To Approve A Non-Covered Service Under EPSDT. 9/18/2018

Prior Authorization Double Check Fee Schedule To See If Item Is Covered Under Its Own HCPCS Code. Double Check Fee Schedule To See If Item Is Not Covered Under Its Own HCPCS Code. Codes Based On Function Not Materials Or Cost 9/18/2018

Prior Authorization “Red Flag” Denial Reasons 146 – Look Up Correct Code For This Service 172 – Resubmit Request Using Correct Code 251 – Supporting Documents Not Received 010 – Additional Information Not Received 9/18/2018

Prior Authorization “Red Flag” Denial Reasons 224 – Requested Documentation Not Supplied 225 – Service Not Covered Under Correct Code 102 – Not Medically Necessary 080 – Medical Necessity Not Established 9/18/2018

Prior Authorization “Red Flag” Denial Reasons 159 – Item Not Considered Medical In Nature 214 – Unable To Approve W/O Documentation 334 – Equip Intended As Restraint Not Covered 9/18/2018

Prior Authorization Hearing Process Recipients May Request Hearing At Any Time For Any Reason. To Appeal Denial Of PA The Request Must Be Received In BSH Within 90 Days Of The Date On The Denial Letter. 9/18/2018

Prior Authorization Hearing Process Agency Responsible For Showing Denial Is/Was In Conformance With The Applicable OAC Rule(s) 9/18/2018

Prior Authorization QUESTIONS? 9/18/2018

Prior Authorization Contact Us: 614-466-6734 9/18/2018

Prior Authorization THANK YOU 9/18/2018