INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT - PowerPoint Presentation

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INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT

South Carolina KePRO QIO Request Submission Requirements

New 6/14/2012Slide2

Topics

Service Type(s)

KePRO SCDHHS Website

Service Type Requirements

Contact InformationSlide3

Prior Authorization Service Types

Therapies – (PT, OT, SP)

Home Health

HospiceSlide4

South Carolina Web SiteSlide5

Forms

Navigate to Form Tab to obtain Documents such as: Fax and Justification formsSlide6

Therapies – PT, OT , and SP

21 years and Older - OP Hospital

Under 21–OP Hospital and Private setting Medicare Primary –   Medicare claim denied or benefits exhausted – Then Medicaid PA could be obtainedMedicare Hospice- Therapy is not related to the illness.

Provider Manual - Hospital Services provider manual, not the Private Rehab  provider manualEvaluation = 1 Follow up session(s) - 1 unit = 15minutes See Hospital Provider Manual - Section 4-74 to 76 for Codes requiring PA and appropriate Unit designationSlide7

Therapies-PT,OT,SP

Therapy codes:

92506 92507925089260792608

92609926109700197002970039700497012

9701697018970229702497026970289703297033

970349703597036

Therapy codes:9711097112

97113971169712497140971509753097532

97533975359753797542975979759897605

9760697750977559776097761

97762Slide8

Home Health

Home Health covered services:

Nursing servicesHome health aide

PT, OT, SPSlide9

KePRO will review for the following procedure codes:

T1030- Nursing care in home by Registered nurse

T1031- Nursing care by a Licensed Practical nurseT1021- Home Health Aide VisitT1028- Assessment Visit DME EvaluationA9900- SuppliesS9127- Social Work visit, in the homeS9128- Speech Therapy

S9129- Occupational TherapyS9131-Physical Therapy Home HealthSlide10

Recipients may receive up to 50 home health skilled nursing, PT, OT, SP visits per fiscal year without prior authorization.

Prior authorization is required for services beyond the first 50 visits

1 unit = 1 visit

Home HealthSlide11

Request for extended service beyond the initial authorization period must be submitted to KePRO prior to the last authorized day in the certification period

Provider has two business days to respond to additional information pend notices.

If no response received to pend, the request will be forwarded for Higher level review or administratively deniedProviders have two business days to respond to Insufficient information request If no response received to pend, the request will be closed requiring re-submission for Prior authorization

Home HealthSlide12

Hospice

Effective October 1, 2012, all requests for Hospice Services for Medicaid-only Recipients will need to be submitted to KePRO for Prior AuthorizationSlide13

Hospice

Hospice Procedure codes

T1015- GIP General Inpatient CareS9126- Routine home Care

S9123- Continuous home CareS9125- Inpatient Respite Care Slide14

Hospice

Required Documentation:

KePRO Outpatient Fax FormDHHS 149 (Election Form)DHHS 151 (Physician Certification Form)

Plan of Care (POC)DHHS 153 (Revocation Form)- If applicableDHHS 154 (Discharge Form)- If applicableDHHS 152 (Change Request Form)- If applicable

Clinical documentation to support requestSlide15

Hospice

KePRO Outpatient Fax Form

Please make sure that all necessary information has been filled out on the KePRO fax formInclude 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 spanSlide16

Hospice

DHHS 149 Form (Medicaid Hospice Election):

To be eligible to elect Hospice under Medicaid:Person must be certified as being terminally ill.Person is considered terminally ill if he or she has a medical prognosis that his or her life expectancy is 6 months or less, if the disease runs its normal course

Hospice coverage is available for an unspecified number of days.The days are subdivided into election periodsTwo 90-day periods eachAn unlimited number of subsequent periods of 60 days eachSlide17

Hospice

DHHS 149 Form (Medicaid Hospice Election):

Designate an effective date for the election period to beginThe request must be submitted to KePRO within 15 business days of election of benefitsIf not received within 15 business days, the request will be approved effective the date the request was received by KePROSlide18

Hospice

DHHS 149 FormSlide19

Hospice

DHHS Form 151- Medicare Hospice Physician Certification and Recertification

Hospice must ensure the following conditions are met:Written certification statements must be obtained within 2 calendar days after hospice care has been initiatedSigned by the Medical Director of the Hospice or the physician member of the Hospice interdisciplinary group

Signed by the person’s attending physician (if the individual has an attending physician)Slide20

Hospice

DHHS Form 151- Medicare Hospice Physician Certification and Recertification

Hospice must ensure the following conditions are met:If written certification if not obtained within 2 days after the initiation of Hospice care:A verbal certification may be obtained within these 2 daysA written certification must be obtained prior to submission of a request for prior authorizationSlide21

Hospice

DHHS Form 151- Medicare Hospice Physician Certification and Recertification

Hospice must ensure the following conditions are met for recertification:The Hospice must obtain (no later than 2 calendar days after the beginning of that period):A written certification statement completed by the medical director of the hospice or the physician member of the Hospice’s interdisciplinary group

Must include the physician’s signatureA statement that the individual’s medical prognosis is of a life expectancy of 6 months or less, if the terminal illness runs its normal courseSlide22

Hospice

DHHS Form 151- Medicare Hospice Physician Certification and RecertificationSlide23

Hospice

Revocation

A beneficiary may revoke the election of Hospice care at any timeThe individual loses any remaining days in the Hospice benefit period and regular Medicaid benefits are reinstated effective the date of the revocationThe individual may at any time elect to receive Hospice coverage for any other Hospice election period for which he or she is eligible. Slide24

Hospice

DHHS Form 153- Medicaid Hospice Revocation

To revoke Hospice, the individual must:Complete DHHS form 153Designate an effective date to revoke HospiceSubmit Form 153 to KePRO within 5 business days of revocation of benefits

Mail a copy of the form to the nursing facility or ICF/MRSlide25

Hospice

DHHS Form 153- Medicaid Hospice RevocationSlide26

Hospice

Discharge

: Discharge of an individual may occur for the following reasons:The individual expiresThe individual is noncompliantThe individual is determined to have a prognosis greater than 6 months

The individual moves out of the Hospice’s geographically defined service areaIf discharging for reasons other than death, the Hospice provider must send a copy of the Medicaid Hospice Discharge Statement to the beneficiary or responsible party upon dischargeSlide27

Hospice

DHHS Form 154- Medicaid Hospice Discharge:

Form 154 must be completedDesignate an effective date to discontinue HospiceSubmit form to KePRO within 5 working days of the effective date of dischargeSlide28

Hospice

DHHS Form 154- Medicaid Hospice DischargeSlide29

Hospice

DHHS Form 152- Medicaid Hospice Provider Change Request Form

Form 152 is to be used when an individual chooses to change the designation of the particular Hospice from which he or she elects to receive Hospice Care in each election periodTo change the designation of Hospice providers, the individual must notify their current Hospice provider that they which to change HospicesSlide30

Hospice

DHHS Form 152- Medicaid Hospice Provider Change Request Form

The Hospice provider that is releasing the beneficiary must:Complete all appropriate portions of Form 152Submit a copy of Form 152 to KePRO within 5 business daysSend a copy to the receiving Hospice ProviderSlide31

Hospice

The receiving Hospice Provider must:

Receive a copy of Form 152 within 2 business days of the effective date of changeForward a completed copy to the SCDHHS Hospice Program Manager within 5 business days of the effective date of receiving Hospice’s first day of service to be included for billingMail a copy of the form to the nursing facility or ICF/MR

For Medicaid only beneficiaries, Form 152 can be faxed to KePROSlide32

Hospice

DHHS Form 152- Medicaid Hospice Provider Change Request FormSlide33

DME

Effective October 1,2012 the following two codes will require prior authorization request from KePRO:

S8189- Tracheostomy Supply, not otherwise classifiedL0638- Lumbar-sacral orthotic (SLO)

Providers must attach pricing information on claims for procedure codes that are manually pricedSlide34

Outpatient Fax Form Slide35

KePRO Outpatient Fax Form cont. Slide36

KePRO ContactsSlide37

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Thank You!