INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT QIO Request Submission Requirements New 6/14/2012

Topics Service Type(s) KePRO SCDHHS Website Service Type Requirements Contact Information

Prior Authorization Service Types Botox Transplant Therapies (PT, OT, SP) Home Health Mental Health Counseling PRTF/Freestanding Psyc DME Hospice Surgical Procedures Inpatient

Hospice Hospice Procedure codes T1015- GIP General Inpatient Care S9126- Routine home Care S9123- Continuous home Care S9125- Inpatient Respite Care NOTE: T2046 – Hospice Room and Board Services do not require prior approval

Hospice General Inpatient Services –Documentation required for a new admission into hospice and the request is GIP: KePRO Fax Form (unless submitted via portal) SCDHHS Election Form (DHHS 149) Initial Care Plan – needs to be current Supporting Documentation –Written Certification must be obtain prior to the submission of the other hospice procedure codes within15 business days or –If the other codes will not be requested, written certification must be obtained prior to submitting hospice claims

Hospice KePRO Outpatient Fax Form –Please make sure that all necessary information has been filled out on the KePRO fax form –Include all 3 procedure codes (GIP should also be included if that is the status of the client upon submission) –Requests for GIP should be submitted at the time of inpatient admission, and if approved, will be approved for a 30 day time span

Hospice DHHS 149 Form (Medicaid Hospice Election): –Designate an effective date for the election period to begin – For the “S” codes, the request must be submitted to KePRO within 15 business days of election of benefits. –For GIP, submission on day of admission (or next day for late day admission). –If not received within 15 business days, the request will be approved effective the date the request was received by KePRO

Hospice DHHS 149 Form

Hospice DHHS Form 151- Medicaid Hospice Physician Certification and Recertification Form 151 must be obtained within 2 calendar days after hospice care has been initiated –Signed by the Medical Director of the Hospice If Form 151 is not obtained within 2 calendar days after the initiation of Hospice care : –A verbal certification may be obtained within these 2 days –Form 151 must be obtained prior to submission of a request for prior authorization

Hospice DHHS Form 151- Medicaid Hospice Physician Certification and Recertification

Hospice Required Clinical Documentation: Plan of Care –Goals/Interventions Lab results, Diagnostic Tests, any clinical to substantiate request for hospice services Require corroboration from source other than Hospice that Hospice is appropriate.

Hospice Other Required Documentation DHHS Form 153 (Revocation Form) DHHS 154 (Discharge Form) DHHS 152 (Change Request Form)

Hospice DHHS Form 153- Medicaid Hospice RevocationDHHS Form 153- Medicaid Hospice Revocation Complete DHHS form 153 Designate an effective date to revoke Hospice Submit Form 153 to DHHS within 5 business days of revocation of benefits Mail a copy of the form to the nursing facility or ICF/MR DHHS Form 154- Medicaid Hospice Discharge Designate an effective date to discontinue Hospice Submit form to DHHS within 5 working days of the effective date of discharge DHHS Form 152- Medicaid Hospice Provider Change Request Complete all appropriate portions of Form 152 Submit a copy of Form 152 to DHHS within 5 business days Send a copy to the receiving Hospice Provider within 2 days

Hospice DHHS Form 153- Medicaid Hospice Revocation

Hospice DHHS Form 154- Medicaid Hospice Discharge

Hospice DHHS Form 152- Medicaid Hospice Provider Change Request Form

South Carolina Web Site

Forms Navigate to Form Tab to obtain Documents such as: Fax and Justification forms

Outpatient Fax Form

KePRO Outpatient Fax Form cont.

Registration for Atrezzo Connect Provider Portal INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT

How To Register For Atrezzo Connect Website Address: Select “ Registration For Atrezzo Connect” (Slide 3) Enter your 10 digit National Provider Identifier (NPI) number and Legacy South Carolina Medicaid provider ID Select a unique user name and password & complete required user information

Atrezzo Connect Atrezzo Connect allows for: – Secure access to Atrezzo Connect (Provider Portal) – Provider will be able to access letters by Case/Request, Respond/Send messages To/From KePRO

Required Information for Security Verification The provider must enter information to verify authenticity for security reasons Registration Code: – SCDHHS Legacy ID

Simple -5 Step Registration Process Start by clicking the Atrezzo Login button on the SCDHHS-KePRO website

Login Page You will be brought to this login page

Step 2 – Enter NPI and Legacy ID Enter your organization’s NPI number and Legacy Provider ID = Provider Registration Code Click NEXT

Step 3 – Terms of Agreement Review Terms of Agreement. Upon acceptance, you will be taken to setup for User information.

Step 4 – Verify Address Click on the correct address(s) for the new account (this associates your user information with these locations) If all apply, check all of them Click SELECT

Step 5 – Enter Account Information Enter user account information User Name, Password, First/Last Name, and Fax Number are required fields! Click NEXT-This will take you to the Password setup and security question Slide) Passwords do not expire. Minimum 8 characters required.

Successful Completion Successful Completion of setup, takes you to the Home Page

View all request and Create new request Click Member to search using Member id or Last name/DOB Click Request/Case to search using Case id, Member info or Request info

Create Preferences, Manage User accounts and New Provider Registration Use this tab to change your password or update your contact information View Atrezzo User Guide and View FAQs

Account Administrator All information submitted for registration under Provider/Facility Information will represent as the Provider Portal Administrator (Group Admin). The Group Admin is responsible for managing and creating all Submitting User accounts for your NPI # – Create other Group Admins’ & Admin Users – Set Preferences, i.e. Diagnosis and Procedure codes, etc

KePRO Contacts

37 Thank You!