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

Office of Health Improvement (803)

Provider Services Center  Provider Services Center (Individual Programs, Provider Reps) (Individual Programs, Provider Reps) No longer available  Claims inquiries; Assistance with edits; Eligibility; Enrollments, etc. Enrollments, etc.  Online inquiry at  Hard copy claims/ ECFs continue to be sent to the: P.O. Box 1415

KePRO’s reviews are based on McKesson’s InterQual Criteria; other nationally recognized standards of care; unless otherwise directed by DHHS. June 1, KePRO became operational June 15, 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

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

 Edit Service requires PA from KePRO - no PA on claim.  Edit Service requires PA from KePRO – PA is not valid.  Edit IP admission requires PA from KePRO

 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. another PA.  If DOS is after June 1 st, a KePRO authorization is required.  Communicate with KePRO CS Rep. They will assign a new number and fax this to you. assign a new number and fax this to you.

 PT/OT/ST – Are the 3 criteria still required to be met. As of June 1, 2012 KePRO uses InterQual criteria for As of June 1, 2012 KePRO uses InterQual criteria for determining medical necessity. determining medical necessity.  DME – Repair and Replacement codes - for miscellaneous codes for wheelchair should be sent to DHHS if purchase was for wheelchair should be sent to DHHS if purchase was authorized by DHHS. authorized by DHHS.  If admission is denied can we bill observation. Only if observation is ordered by the physician. Only if observation is ordered by the physician.

How do we handle cases where patient received eligibility How do we handle cases where patient received eligibility after the service. 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.

Does a patient in SC Solutions require a PA. 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 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.

 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) RSP Indicator MCHM = Managed Care (MCOs) MCCM = Medical Homes Networks (MHNs)

 Provider Manual updated each month. Change Log shows what’s changed. Change Log shows what’s changed.  Bulletins – Sign-up for E-Bulletins   KePRO website:

Prior Authorizations (KePro) (855) Customer Services (855) Fax