1. 2018 IHCP Annual Workshop Prior Authorization
Good Afternoon, my name is David hoover. I am the provider representative for Region 5, which includes Kokomo, Logansport, Muncie, Decatur and Portland, Indiana. Today we will briefly go over MDwise as a whole and I will give some updates on things happening in the new year.
Prior Authorization
HHW-HIPP0582 (9/18)

2. Prior Authorization Appeals Resources Questions
Agenda
MDwise History
Updates
Eligibility
Prior Authorization
Timelines
Prior Authorization Appeals
Resources
Questions

3. 2007: MDwise selected to provide care through the Healthy Indiana Plan
MDwise History
1994: MDwise founded as Indiana-based nonprofit health care company Central Indiana Managed Care Organization, Inc. (CIMCO), utilizing a delivery system model
2001: CIMCO teamed up with IU Health Plan and formed into MDwise, Inc., serving more than 55,000 Hoosier Healthwise members.
2007: MDwise begins service Care Select (now Hoosier Care Connect) members
2007: MDwise selected to provide care through the Healthy Indiana Plan
2018: MDwise acquired by Michigan-based McLaren Health Care; one of Michigan’s largest integrated health systems
MDwise’s history began back in 1994 when we were founded as CIMCO. From 2001 to 2014, MDwise offered medical coverage to Indiana residents through the Hoosier Healthwise, Hoosier Care Connect, formerly Care Select, HIP and Marketplace programs. Our focus shifted over the last couple of years from all 4 medical programs to just Hoosier Healthwise and HIP. And in 2017, MDwise was purchased by McLaren Health Care, a Michigan-based health system with a significant health plan operation across the state of Michigan.

4. Who Is McLaren Health Care?
Is one of the largest integrated health care systems in Michigan
Owns 15 hospitals, including Barbara Ann Karmanos, nationally renowned for their cancer care and outcomes
Employs over 500 physicians
Trains over 550 residents annually
Has a workforce of over 20,000
Owns McLaren Health Plan, who covers over 265,000 members in Medicaid, commercial, and Medicare Supplemental markets.

5. MDwise – McLaren Synergies
Sharing Best Practices between MDwise and McLaren Health Plan, such as:
Care Management
Opioid Crisis Management
Effectively managing inappropriate ER utilization
Streamlining Prior Authorizations
Pay for Value Physician Incentive programs
Claims adjudication
Results are Demonstrating:
Improvement in health care outcomes for our members
Enhanced access for members
Greater administrative efficiencies, which allow more health care dollars to be spent on the actual delivery of medical care

6. Updates
Effective 1/1/19:
MDwise is restructuring it’s Delivery System model to:
Improve claim payment timeliness and accuracy
Streamline and reduce administrative redundancy for providers
Provide greater access for our members
One Standard Authorization List
One Point of Contact for all Authorization Requests
One Claim submission address
Non-Excel Delivery System Contracts
Providers not contracted with MDwise Excel must contract to stay in network.
Effective January 1, 2019, MDwise will begin operating as a single network, MDwise Excel. This will show when checking eligibility in the MDwise Portal as well as the state systems. Along with this change, MDwise delivery system contracts will expire December 31, If you are not currently contracted as a MDwise Excel provider and want to be able to see MDwise members, you will need to contract as a MDwise excel provider. Please reach out to your dedicate provider representative to begin this process. Also changing will be out claims processing, our prior authorization process and requirements, and our MDwise portal access. All of these items are covered in this presentation, so lets get started!

7. Effective 1/1/19: Eligibility When determining eligibility, verify:
Is the member eligible for services today?
Which Indiana Health Coverage Program plan are they enrolled?
If the member is in Hoosier Healthwise or Healthy Indiana Plan, are they assigned to MDwise?
Who is the member’s Primary Medical Provider (PMP)?
Beginning in January, you will be able to utilize the state website for the members Program and MCE. The assigned network or delivery system will always be MDwise Excel. To verify a PMP, you will use the MDwise provider portal, as you do now.
Provider Healthcare Portal
MDwise Provider Portal
IHCP Program
Delivery System: MDwise Excel
MCE
Assigned PMP History
Assigned PMP

8. Effective 1/1/19 Prior Authorization One Standard Authorization List
One Point of Contact for All Authorization Requests
Submission timelines and process will not change
Go to MDwise.org for most up-to-date version of PA lists
MDwise.org
For Providers
Forms
Prior Authorization
Effective January 1st, our PA guides will update. There will be one PA list per program. The PA lists will still be housed on the Prior Authorization page. The current 2017 and prior PA lists will remain on this page to allow for review after the new year. Be sure you are reviewing the correct PA guides in the new year.

9. Prior Authorization Process
Prior Authorization (PA)
The actions taken including review of benefit coverage and medical information to determine of the requested service meets the criteria for authorization
Authorization requests
Specific forms are available from medical management to submit for service authorization
Referral (Right Choices Program Only)
Process when a members primary care provider (PMP) determines that the members conditions requires additional services provided by a physician other than a PMP
*Please note: Incomplete forms or requests lacking required information will delay
the authorization process

10. Prior Authorization Process
Service types requiring Prior Authorization include:
Services that are grouped according to service type categories (in-network or non-contracted)
Inpatient admissions
Outpatient services/procedures
Pharmacy, therapies
Home health care
Durable medical equipment
Transportation
Self-referral services (in accordance with IHCP guidelines)
MDwise follows Federal and State regulations related to second opinions, access for members with special needs, and access to women’s health specialists for female members.

11. Prior Authorization
You will need two key items when filing a request for Medical Prior Authorization (PA):
Universal Prior Authorization Form
Located on our website
Documentation to support the medical necessity for the service you are requesting to prior authorize:
Lab work
Medical records/physician notes
Test results
Therapy notes
Tips:
Completely fill out the universal PA form including the rendering provider’s NPI and TIN, the requestor’s name along with phone and fax number.
Be sure to note if PA is for a retroactive member.
Please Note: Not completely filling out the universal PA form may delay the prior authorization timeframe.
When submitting a prior authorization, always be sure your form is completely filled out and required documentation in included. IF a form is incomplete or documentation is missing, your request will be returned to you and your review timeframe will start over. Also, if you are requesting a PA for a retro active member, be sure to note this in the notes section of the form.

12. Prior Authorization Process
Please submit authorization requests via fax to the proper PA fax number listed on our Quick Contact Guide
Hoosier Healthwise:
Healthy Indiana Plan
Inpatient:
All Other Authorizations:

13. Prior Authorization Process
Authorization Updates Effective 1/1/19:
Certain radiology codes have been removed from the PA requirements.
Removed all maternity stay authorizations, even those maternity stays where the length of stay (LOS) is greater than the mandate.
Prior Authorization Guide:

14. Prior Authorization Process
Tips for submitting authorization requests
For pre-service non-urgent requests, request a date span rather than a specific date.
Submit complete clinical information at the time of the request
Be sure to provide your fax number and a secure voice mailbox number, and include a contact name and number for us to request additional clinical information if needed.
Urgent requests should be reserved for services that, if not performed, may jeopardize the health of the member and not because the request is not submitted timely.
Please note: Repeat inquiries to check the status of a requested authorization, or to ask for an expedited authorization, can slow down authorization review process.

15. Prior Authorization Process
Any authorization request that does not meet the guidelines and/or criteria is referred to a physician.
Only a physician can issue a decision to deny for medical necessity.
If a denial is issued and the provider wants to speak with the MDwise physician (Peer to Peer), the provider should follow the directions on the denial letter.
A member of the inquiry team will set up the Peer to Peer in our system and the MDwise provider will pursue contacting the requesting provider to arrange a date/time for the Peer to Peer.

16. Prior Authorization Process
After Hours
Providers can submit universal PA form to our fax numbers which are available 24 hours/day/7 days per week.
We also have direct/toll free telephone numbers for providers to call
All messages are returned within one (1) business day
Any prior authorization requests faxed after hours are processed either the next business or next calendar day depending upon the type of request.
The date the fax is received counts toward the PA resolution timeframe.
Contact information can be found on our Prior Authorization Guide

17. Prior Authorization Process
Emergency Services
MDwise member’s may seek emergency services at the nearest emergency room without authorization when they believe their condition to be an emergency.
All emergency inpatient admissions require authorization within 2 business days of the admission.
Please refer to the MDwise Prior Authorization Guide

18. Prior Authorization Process
Hospital Admissions
Prior Authorization is required for all inpatient admissions including all elective or planned inpatient admissions.
MDwise requires an authorization request within 48 hours of all emergency inpatient admissions.
It is the responsibility of the hospital to obtain authorization for all inpatient hospital admissions
Once the hospital obtains the authorization for an inpatient stay the services rendered as part of the stay do not require separate authorization
Services rendered during the stay should utilize the hospital’s admission authorization
Per IHCP, providers should bill inpatient stays that are less than 24 hours as an outpatient service.

19. Prior Authorization Process
Behavioral Health
Services that require PA:
Neuropsychological testing
Psychological testing
Inpatient psychiatric admissions
Behavioral Health members can receive outpatient therapy sessions without prior authorization per contracted billing provider
Forms can be found at:

20. Pharmacy Prior Authorizations
For Pharmacy PA’s, you would need to contact the member’s Pharmacy Benefit Manager:
MedImpact:
For all questions regarding Pharmacy PA please contact the Pharmacy Benefit Manager.
Pharmacy Resources:
Pharmacy authorizations are submitted to the Pharmacy Benefit Manager, or PBM, based on the members program. Please contact the appropriate PBM with pharmacy PA questions.
Next we will go over MDwise claims.

21. Prior Authorization Turn-Around Time
Urgent prior authorizations can take up to 3 business days
Requests for non-urgent prior authorization will be resolved within 7 calendar days.
It is important to note that resolved could mean a decision to pend for additional information.
Please Note: All emergency inpatient admissions require authorization within 2 business days of the admission.
If you have not heard response within the time frames above, contact the Prior Authorization Inquiry Team and they will investigate the issue.
PA Inquiry Line
Turn around time for authorizations depends on the urgency of the request. Emergency requests must have a PA requested within 2 business days of the date of service; urgent requests will have an outcome within 3 business days, and a non-urgent request will have a decision made within 7 business days. If you have an inquiry on a current PA, please regerence the PA quick contact guide on our website.

22. Prior Authorization Appeals
Providers can request an appeal on behalf of a member within 33 calendar days of receiving denial
Providers must request an appeal in writing to MDwise:
Attention: MDwise Customer Service Department
PO Box
Indianapolis, IN
MDwise will resolve an appeal within 20 business days and notify the provider and member in writing of the appeal decision including the next steps
If you do not agree with the appeal decision, additional appeal procedure options are available

23. Resources
Reminder:
Providers not currently participating as MDwise Excel will need to contract to continue to see MDwise members in 2019.
What is required to contract?
MDwise Excel Contract
Provider/Ancillary Enrollment Forms
W-9
Sample Claim
Providers not seeking a MDwise Excel contract are required to submit the following:
Non-Contracted Provider Set-Up Form
For providers contracted with a delivery system that is not MDwise Excel, you will be required to contract with Excel to continue to see MDwise members in You will be required to submit the signed contract, enrollment forms, a W-9 and a sample claim for payor set up.
If you are not seeking a MDwise Excel contract, we still need the Non-contracted provider set up form, a w-9 and a sample claim to make sure you are accurately set up in our claims system.
All of these documents are submitted to the address for processing.

24. Resources
Contracting Contact 1 2 5 3 4 9 6 8 7

25. Resources Contracting Contact Representative Territory Phone Email
Paulette Means
Region 1
Garrett Walker
Region 2
Michelle Phillips
Region 3, Hospice, Home Health
Jamaal Wade
Region 4
David Hoover
Region 5
Tonya Trout
Region 6
Rebecca Church
Region 7
Sean O’Brien
Region 8
Whitney Burnes
Region 9
Nichole Young
Behavioral Health
(CMHC, OTP, IMD or Residential)

26. Resources PA Quick Contact Guide
MDwise Provider Manuals
MDwise Provider Relations Territory Map
MDwise Customer Service
IHCP Provider Modules
Indianamedicaid.com

27. Questions