Service authorization for surgical procedures SERVICE TYPE 0302 **In order to play the audio, click the speaker icon on the bottom left of each slide or the slide show icon at the bottom right of the screen to have the presentation play automatically**

New health coverage for adults in Virginia Beginning January 1, 2019, more adults living in Virginia will have access to quality, low-cost health insurance. The new coverage includes hospital stays, doctors visits, preventive care, prescription drugs and much more! The rules have changed! So, if you applied for Medicaid in the past and were denied, you may soon be eligible. Eligibility is based on income, with a single (1) adult making up to $16,754. Or a family of three (3) making up to $28,677, qualifying for coverage. Interested in learning more? Check out the below resources or visit www.covera.org for more information and details on eligibility. Coverage for Adults Brochure (PDF) Coverage for Adults Flyer (PDF) FAQs – New Adult Eligibility for Health Coverages (PDF) Coverage for Adults Poster (PDF)

GAP (Governor’s access plan) As part of Medicaid Expansion, on January 1st, 2019, Virginia Medicaid will offer new health coverage for adults. Most Governor’s Access Plan (GAP) members will be enrolled automatically in this new program. Approximately 15,000 GAP members will automatically enroll into the Medicaid Expansion Program with an effective date of January 1st, 2019. GAP members with Immigration Status will remain in the Fee-For-Service population. If the member has any questions about the new health coverage for adults, or if they need to provide notification of a change in where they live, mailing address, phone number, change of income or health insurance coverage, please contact Cover Virginia GAP Processing Unit at 1-855-869-8190.

Methods of submission of service authorization (SRV auth) request to kepro KEPRO accepts SRV AUTH requests through direct data entry (DDE), fax and phone. Submitting through DDE puts the request in the worker queue immediately; faxes are entered by the administrative staff in order received. For DDE request, providers must use Atrezzo Provider Portal Connect. For DDE submissions, the SRV AUTH checklist may be accessed on KEPRO’s website to assist the provider in assuring specific information is included with each request. To access Atrezzo Provider Portal Connect on KEPRO’s website, go to http://dmas.kepro.com. KEPRO accepts SRV AUTH requests through direct data entry (DDE), fax and phone. Submitting through DDE puts the request in the worker queue immediately; faxes are entered by the administrative staff in order received. For DDE request, providers must use Atrezzo Provider Portal Connect. For DDE submissions, the SRV AUTH checklist may be accessed on KEPRO’s website to assist the provider in assuring specific information is included with each request. To access Atrezzo Provider Portal Connect on KEPRO’s website, go to http://dmas.kepro.com.

Methods of submission of srv auth request to kepro Provider registration is required to use Atrezzo Provider Portal Connect. The registration process for providers happens immediately on-line. From http://dmas.kepro.com, providers not registered with Atrezzo Provider Portal Connect may click on “Register” to be prompted through the registration process. Newly registering providers will need their ten (10) digit National Provider Identification (NPI) number and most recent remittance advice date for year-to-date (YTD) 1099 amount. The Atrezzo Provider Portal Connect User Guide is available at http://dmas.kepro.com: Click the “Training” tab, then the “General” tab. Provider registration is required to use Atrezzo Provider Portal Connect. The registration process for providers happens immediately on-line. From http://dmas.kepro.com, providers not registered with Atrezzo Provider Portal Connect may click on “Register” to be prompted through the registration process. Newly registering providers will need their ten (10) digit National Provider Identification (NPI) number and most recent remittance advice date for year-to-date (YTD) 1099 amount. The Atrezzo Provider Portal Connect User Guide is available at http://dmas.kepro.com: Click the “Training” tab, then the “General” tab.

Srv auth requests: contact information for kepro/dmas provider information Providers with questions about KEPRO’s Atrezzo Provider Portal Connect may contact KEPRO by email at atrezzoissues@kepro.com. For service authorization questions, providers may contact KEPRO at providerissues@kepro.com. KEPRO may also be reached by phone at 1-888-827-2884, or via fax at 1-877-OKBYFAX or 1-877-652-9329. Providers with questions about KEPRO’s Atrezzo Provider Portal Connect may contact KEPRO by email at atrezzoissues@kepro.com. For service authorization questions, providers may contact KEPRO at providerissues@kepro.com. KEPRO may also be reached by phone at 1-888-827-2884, or via fax at 1-877-OKBYFAX or 1-877-652-9329.

Provider manual copies available DMAS publishes electronic and printable copies of its Provider Manuals and Medicaid Memoranda on the DMAS Web Portal at, https://www.virginiamedicaid.dmas.Virginia.gov/wps/portal. The internet is the most efficient tool to receive and review current provider information. If you do not have access to the internet and/or would like a paper copy of a manual, you can order it by contacting: Commonwealth – Martin at 1-804-780-0076. A fee will be charged for the printing and mailing of the manual updates that are requested. DMAS publishes electronic and printable copies of its Provider Manuals and Medicaid Memoranda on the DMAS Web Portal at, https://www.virginiamedicaid.dmas.Virginia.gov/wps/portal. The internet is the most efficient tool to receive and review current provider information. If you do not have access to the internet and/or would like a paper copy of a manual, you can order it by contact : Commonwealth – Martin at 1-804-780-0076. A fee will be charged for the printing and mailing of the manual updates that are requested.

Srv auth information: member eligibility Decision made by KEPRO only apply to individuals enrolled in Medicaid fee-for-service on dates of service requested. KEPRO’s decision does not guarantee Medicaid eligibility or fee-for- service enrollment. It is the provider’s responsibility to verify member eligibility and to check for managed care organization (MCO) enrollment. For MCO enrolled members, the provider must follow the MCO’s SRV AUTH policy and billing guidelines. Because the individual may transition between fee-for-service and the Medicaid Managed Care Programs, KEPRO will honor the Medicaid MCO service authorization if the member has been dis- enrolled from the MCO. Decision made by KEPRO only apply to individuals enrolled in Medicaid fee-for- service on dates of service requested. KEPRO’s decision does not guarantee Medicaid eligibility or fee-for-service enrollment. It is the provider’s responsibility to verify member eligibility and to check for managed care organization (MCO) enrollment. For MCO enrolled members, the provider must follow the MCO’s SRV AUTH policy and billing guidelines. Because the individual may transition between fee-for-service and the Medicaid Managed Care Programs, KEPRO will honor the Medicaid MCO service authorization if the member has been disenrolled from the MCO.

Surgical procedures: procedure/service codes that require srv auth – how to determine if SRV AUTH is needed. In order to determine if services need to be service authorized, providers should go to the DMAS website: http://dmasva.dmas.Virginia.gov, look to the right of the page and click on the section “Procedure Fee Files” which will then bring you to: http://www.dmas.Virginia.gov/pr-fee_files.htm. You will then see a page entitled DMAS Procedure Fee Files. The information provided there will help determine if a procedure code needs service authorization or if a procedure code is not covered by DMAS. To determine if a service needs SRV AUTH, determine whether you wish to use the CSV or the TXT format. Click on either the CSV or TXT version of the file. Scroll until you find the code you are looking for. In order to determine if services need to be service authorized, providers should go to the DMAS website: http://dmasva.dmas.Virginia.gov, look to the right of the page and click on the section “Procedure Fee Files” which will then bring you to: http://www.dmas.Virginia.gov/pr-fee_files.htm. You will then see a page entitled DMAS Procedure Fee Files. The information provided there will help determine if a procedure code needs service authorization or if a procedure code is not covered by DMAS. To determine if a service needs SRV AUTH, determine whether you wish to use the CSV or the TXT format. Click on either the CSV or TXT version of the file. Scroll until you find the code you are looking for.

Surgical procedures: procedure/service codes that require srv auth – how to determine if SRV auth is needed (CONT’D) The Procedure Fee File will inform if a code needs to be prior authorized as it will contain a numeric value for the PA Type, such as one of the following: 00 – No PA required 01 – Always need PA 02 – Only needs PA if service limits are exceeded 03 – Always need PA, with per frequency To determine whether a service is covered by DMAS you need to access the Procedure Rate File Layouts page from the DMAS Procedure Fee Files. Flag codes are the section which provides you special coverage and/or payment information. A Procedure Flag of “999” indicates that a service is non-covered by DMAS. The Procedure Fee File will inform if a code needs to be prior authorized as it will contain a numeric value for the PA Type, such as one of the following: 00 – No PA required 01 – Always need PA 02 – Only needs PA if service limits are exceeded 03 – Always need PA, with per frequency To determine whether a service is covered by DMAS you need to access the Procedure Rate File Layouts page from the DMAS Procedure Fee Files. Flag codes are the section which provides you special coverage and/or payment information. A Procedure Flag of “999” indicates that a service is non-covered by DMAS.

Srv auth information specific to surgical procedures (0302) Service requests must be submitted by the provider prior to the service being performed, since this is a planned service. Per DMAS Memo – 03/09/2012 and Physician/Practitioner Manual Appendix D. Inpatient hospitalization services must be authorized separately by KEPRO, should the procedure or service require and Inpatient Hospital level of care. The provider is responsible for submitting this request. For those CPT/HCPCS codes that utilize SIMplus® criteria, providers must submit a request within two (2) business days following the procedure to be considered timely. Service authorization decision are rendered for one (1) unit and ninety (90) days or as requested by the provider, but not to exceed a six (6) month timeframe. Administrative denials occur if the provider did not respond to a pended request for initial clinical information or submitted a request after the request for service has been performed and the member is not retro-eligible. Established timeframes listed above are also applicable to out-of-state providers. Service requests must be submitted by the provider prior to the service being performed, since this is a planned service. Per DMAS Memo – 03/09/2012 and Physician/Practitioner Manual Appendix D. Inpatient hospitalization services must be authorized separately by KEPRO, should the procedure or service require and Inpatient Hospital level of care. The provider is responsible for submitting this request. For those CPT/HCPCS codes that utilize SIMplus® criteria, providers must submit a request within two (2) business days following the procedure to be considered timely. Service authorization decision are rendered for one (1) unit and ninety (90) days or as requested by the provider, but not to exceed a six (6) month timeframe. Administrative denials occur if the provider did not respond to a pended request for initial clinical information or submitted a request after the request for service has been performed and the member is not retro-eligible. Established timeframes listed above are also applicable to out-of-state providers.

Srv auth information specific to surgical procedures (0302) (CONT’D) McKesson InterQual®, CMS or DMAS Specific Criteria is utilized to review SRV AUTH request. If the Clinical Reviewer is unable to approve the request based on established criteria, the request is automatically referred for Physician Reconsideration Review. Application of EPSDT criteria for members under the age of twenty-one (21), are performed at a Physician Review level or as directed by the Contractor’s Medical Director. KEPRO will apply SIMplus® criteria to certain procedure codes (see Provider Memo dated 3/9/2012 and Physician Manual CH IV and V). These services will be reviewed retrospectively since SIMplus® is not designed for prospective review of surgeries or for any type of prior authorization. Providers must submit their request timely, within two (2) business days following the procedure. If there is additional information required, the Contractor will pend the request for twenty (20) business days. If the provider does not submit the additional information within the twenty (20) business days specified, the request will move forward in the review process and a final determination made with the information that has been submitted. McKesson InterQual®, CMS or DMAS Specific Criteria is utilized to review SRV AUTH request. If the Clinical or Nurse Reviewer is unable to approve the request based on established criteria, the request is automatically referred for Physician Reconsideration Review. Application of EPSDT criteria for members under the age of twenty-one (21), are performed at a Physician Review level or as directed by the Contractor’s Medical Director. KEPRO will apply SIMplus® criteria to certain procedure codes (see Provider Memo dated 3/9/2012 and Physician Manual Ch IV and V). These services will be reviewed retrospectively since SIMplus® is not designed for prospective review of surgeries or for any type of prior authorization. Providers must submit their request timely, within two (2) business days following the procedure. If there is additional information required, the Contractor will pend the request for twenty (20) business days. If the provider does not submit the additional information within the twenty (20) business days specified, the request will move forward in the review process and a final determination made with the information that has been submitted.

Srv auth information specific to surgical procedures (0302) (CONT’D) For all Gastric Bypass/Bariatric surgical services, KEPRO must verify the treating facility as a CMS certified Center of Excellence. The link below has an updated site for all CMS certified facilities. If the treating facility is not CMS certified, the request can be administratively denied. This is supported by 12VAC30-50-580, facility selection standards for good surgery outcomes. http://www.cms.gov/MedicareApprovedFacilities/BSF/list.asp#TopOfPage DMAS also requires KEPRO to apply two (2) levels of Physician Reviews for all gastric bypass/bariatric procedure requests, as noted under Physician Reconsideration Review section. For all Septoplasty surgeries, the DMAS Medical Director has modified McKesson InterQual® criteria to require a CT scan to confirm septal deviation. For requests that do not have a completed CT scan, the reviewer will reject the case until the provider obtains a CT scan, thus completing the required work-up. The provider can then re-submit their request once a CT scan is obtained. For all Gastric Bypass/Bariatric surgical services, KEPRO must verify the treating facility as a CMS certified center of excellence. The link below has an updated site for all CMS certified facilities. If the treating facility is not CMS certified, the request can be administratively denied. This is supported by 12VAC30-50-580, facility selection standards for good surgery outcomes. http://www.cms.gov/MedicareApprovedFacilities/BSF/list.asp#TopOfPage DMAS also requires KEPRO to apply two (2) levels of Physician Reviews for all gastric bypass/bariatric procedure requests, as noted under Physician Reconsideration Review section. For all Septoplasty surgeries, the DMAS Medical Director has modified McKesson InterQual® criteria to require a CT scan to confirm septal deviation. For requests that do not have a completed CT scan, the reviewer will reject the case until the provider obtains a CT scan, thus completing the required work-up. The provider can then re-submit their request once a CT scan is obtained.

Srv auth information specific to surgical procedures (0302) (CONT’D) Cosmetic surgery is not covered when provided solely for the purpose of improving appearance. The exclusion of cosmetic surgery does not apply to congenital deformities or deformities due to recent injury. When surgery restores or improves a physiological function, it is not considered cosmetic surgery (Provider Manual and 14VAC5-140-60). Abnormal congenital malformations and deformities, in children under the age of twenty-one (21) years, are not considered cosmetic. Medical necessity, for approval, in adults twenty-one (21) years of age and older must be clearly documented. Treatment of trauma related deformity, especially in the acute stages, is not considered cosmetic. In chronic stages, medical necessity is required. Implantable devices for the sole purpose of Substance Abuse Treatment is not covered for members twenty-one (21) years of age and older (12VAC30-50-140). There needs to be documented evidence of an organic cause of pain in order to meet pain management services, including implantable drug infusion therapy. Cosmetic surgery is not covered when provided solely for the purpose of improving appearance. The exclusion of cosmetic surgery does not apply to congenital deformities or deformities due to recent injury. When surgery restores or improves a physiological function, it is not considered cosmetic surgery (Provider Manual and 14VAC5-140-60). Abnormal congenital malformations and deformities, in children under the age of twenty-one (21) years, are not considered cosmetic. Medical necessity, for approval, in adults twenty-one (21) years of age and older must be clearly documented. Treatment of trauma related deformity, especially in the acute stages, is not considered cosmetic. In chronic stages, medical necessity is required. Implantable devices for the sole purpose of Substance Abuse Treatment is not covered for members twenty-one (21) years of age and older (12VAC30-50-140). There needs to be documented evidence of an organic cause of pain in order to meet pain management services, including implantable drug infusion therapy.

SRV AUTH Information Specific to Surgical Procedures (0302) requests Should the date of service request change, KEPRO will update the service authorization while considering any untimely issues. Retrospective review will be performed when a provider is notified of a member’s retroactive eligibility for Virginia Medicaid coverage. Retrospective review will also apply when Medicaid dually eligible members exhaust their Medicare coverage. Should the date of service request change, KEPRO will update the service authorization while considering any untimely issues. Retrospective review will be performed when a provider is notified of a member’s retroactive eligibility for Virginia Medicaid coverage. Retrospective review will also apply when Medicaid dually eligible members exhaust their Medicare coverage.

Faxing request to kepro Providers must use the specific fax form listed below when requesting Surgical Procedures. If the fax form is not accompanied by the request, KEPRO will reject the request and the provider must resubmit the entire request with the correct fax form. The DMAS-351 (Procedures/Devices Service Authorization Request Form) is the appropriate form to use for Surgical Procedures. Forms are available on KEPRO’s website at http://dmas.kepro.com. Providers may click on the “Forms” tab to view a listing of all KEPRO fax forms, labeled by form number and service type. Service authorization checklists may be accessed on KEPRO’s website to assist the provider in assuring specific information is included with each request for Surgical Procedures. Providers must use the specific fax form listed below when requesting Surgical Procedures. If the fax form is not accompanied by the request, KEPRO will reject the request and the provider must resubmit the entire request with the correct fax form. The DMAS-351 (Procedures/Devices Service Authorization Request Form) is the appropriate form to use for Surgical Procedures. Forms are available on KEPRO’s website at http://dmas.kepro.com. Providers may click on the “Forms” tab to view a listing of all KEPRO fax forms, labeled by form number and service type. Service authorization checklists may be accessed on KEPRO’s website to assist the provider in assuring specific information is included with each request for Surgical Procedures.

Out-of-state provider requests Out-of-State providers must be enrolled with Virginia Medicaid in order to submit a request for out-of-state services to KEPRO. If the provider is not enrolled as a participating provider with Virginia Medicaid, the provider is still encouraged to submit the request to the Contractor, as timeliness of the request will be considered in the review process. Out-of-state providers may enroll with Virginia Medicaid by going to: https://www.virginiamedicaid.dmas.Virginia.gov/wps/myportal/ProviderEnrollment. At the toolbar, at the top of the page, click on “Provider Services”, then “Provider Enrollment” in the drop-down box. It may take up to ten (10) business days to become a Virginia participating provider. Out-of-State providers must be enrolled with Virginia Medicaid in order to submit a request for out-of-state services to KEPRO. If the provider is not enrolled as a participating provider with Virginia Medicaid, the provider is still encouraged to submit the request to the Contractor, as timeliness of the request will be considered in the review process. Out-of-state providers may enroll with Virginia Medicaid by going to: https://www.virginiamedicaid.dmas.Virginia.gov/wps/myportal/ProviderEnrollment. At the toolbar, at the top of the page, click on “Provider Services”, then “Provider Enrollment” in the drop-down box. It may take up to ten (10) business days to become a Virginia participating provider.

Out-Of-State Providers not enrolled in Virginia Medicaid KEPRO will pend the request back to the provider for twelve (12) business days to allow the provider time to become successfully enrolled. If the provider responds with the necessary information within the twelve (12) business days, the request will continue through the review process and a final determination will be made on the service request. If KEPRO does not receive the information to complete the processing of the request within the twelve (12) business days, the request will be rejected, as the service authorization cannot be entered into MMIS without the providers National Provider Identification (NPI). Once the provider is successfully enrolled, the provider must resubmit the entire request. KEPRO will pend the request back to the provider for twelve (12) business days to allow the provider time to become successfully enrolled. If the provider responds with the necessary information within the twelve (12) business days, the request will continue through the review process and a final determination will be made on the service request. If KEPRO does not receive the information to complete the processing of the request within the twelve (12) business days, the request will be rejected, as the service authorization cannot be entered into MMIS without the providers National Provider Identification (NPI). Once the provider is successfully enrolled, the provider must resubmit the entire request.

Review process for out-of-state providers Procedures may be performed out-of-state only when the service cannot be performed in Virginia and/or meet any of the circumstances below. Services provided out-of-state for circumstances other than these specified reasons, shall not be covered. For out-of-state facilities request, the Contractor will need to apply item number three (3) and four (4). The medical services must be needed because of a medical emergency; Medical services must be needed and the recipient’s health would be endangered if they were required to travel to their state of residence; The state determines, on the basis of medical advice, that the needed medical services, or necessary supplementary resources, are more readily available in the other state; It is the general practice for recipients in a particular locality to use medical resources in another state. Procedures may be performed out-of-state only when the service cannot be performed in Virginia and/or meet any of the circumstances below. Services provided out-of-state for circumstances other than these specified reasons, shall not be covered. For out-of-state facilities request, the Contractor will need to apply item number three (3) and four (4). The medical services must be needed because of a medical emergency; Medical services must be needed and the recipient’s health would be endangered if they were required to travel to their state of residence; The state determines, on the basis of medical advice, that the needed medical services, or necessary supplementary resources, are more readily available in the other state; It is the general practice for recipients in a particular locality to use medical resources in another state.

Review process for out-of-state providers (CONT’D) For out-of-state facilities request, the Contractor will need to apply items number three (3) and four (4) on the previous slide. If the provider is unable to establish items three (3) and four (4), the Contractor will: If surgery requested is gastric bypass/bariatric surgery, then supply the provider with a list of CMS certified hospital in Virginia for gastric bypass/bariatric surgery. Pend the request for twenty (20) days. Have the provider research and confirm items three (3) and four (4) and submit back to the Contractor their findings. Should the provider not respond or not be able to establish items three (3) and four (4), the request can be administratively denied. This decision is supported by 12VAC30-10-120 and 42 CFR 431.52. For out-of-state facilities request, the Contractor will need to apply items number three (3) and four (4) on the previous slide. If the provider is unable to establish items three (3) and four (4), the Contractor will: If surgery requested is gastric bypass/bariatric surgery, then supply the provider with a list of CMS certified hospital in Virginia for gastric bypass/bariatric surgery. Pend the request for twenty (20) days. Have the provider research and confirm items three (3) and four (4) and submit back to the Contractor their findings. Should the provider not respond or not be able to establish items three (3) and four (4), the request can be administratively denied. This decision is supported by 12VAC30-10-120 and 42 CFR 431.52.

DMAS Helpline information The “HELPLINE” is available to answer questions Monday through Friday, 8:00 a.m. to 5:00 p.m., except on holidays. The “HELPLINE” is available to answer questions Monday through Friday, 8:00 a.m. to 5:00 p.m., except on holidays.

resources KEPRO Website: https://dmas.KEPRO.com DMAS Web Portal: https://www.virginiamedicaid.dmas.Virginia.gov For any questions regarding submission of Service Authorization requests, please contact KEPRO at 1-888-827-2884 or 1-804-622-8900. For claims or general provider questions, please contact the DMAS Provider Helpline at 1-800-552-8627 or 1-804-786-6273. KEPRO Website: https://dmas.KEPRO.com DMAS Web Portal: https://www.virginiamedicaid.dmas.Virginia.gov For any questions regarding submission of Service Authorization requests, please contact KEPRO at 1-888-827-2884 or 1-804-622-8900. For claims or general provider questions, please contact the DMAS Provider Helpline at 1-800-552-8627 or 1-804-786-6273.

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