KY Medicaid Utilization Management Program

Tracy Treat
Sr. Manager Operations
KY Medicaid Utilization Management Program
Physician Services
Physician Services Regulatory Criteria
and Required Documentation
• Regulatory Criteria
– 907 KAR 3:005 Physician Services
– 907 KAR 3:130 Medical Necessity and Clinically Appropriate Determination Basis
– 907 KAR 3:010 Reimbursement for physicians' services
•
McKesson InterQual Criteria (IQC) ® is applied to determine medical
necessity
•
MAP Forms
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MAP 250 – Consent for Sterilization
• Must be signed, dated, and all fields completed
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MAP 251 – Hysterectomy Consent Form.
• Must be signed, dated, and all fields completed
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MAP 235 – Certification Form for Induced Abortion or Induced Miscarriage
MAP 236 – Certification Form for Induced Premature Birth
Physician Service Prior Authorization Form
MAP 9 Kentucky Medicaid Prior Authorization Form
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Clinical Review Process
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The Physician Service review process is a telephonic and facsimile based
process that is initiated by the provider
• The provider faxes in the required documentation to begin a
determination to (800) 807 – 7840 or (800) 807 – 8843
Clinical review is based on the Physician Services Fee Schedule. If the service
request requires prior authorization (PA) the below information and criteria is applied.
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Diagnosis
Procedure Code
Date of Service
Provider information
Clinical presentation: A brief history of the disease or condition that
requires treatment and include concurrent conditions or comorbidities. Includes signs and symptoms of the disease or
condition, physical exam findings, labs, imaging results, and prior or
ongoing treatment for the condition to validate the medical necessity
as required by InterQual (IQC).
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Physician Referral
• Physician Referral
– If the clinical reviewer is unable to determine medical necessity
of the service being requested, the case will be referred to a
physician.
– Carewise Health physicians have 24 hours to review referral and
render a determination.
– Providers will be notified via telephone of outcome of referral.
Denials:
If a service is denied the recipient and servicing provider will
receive a denial letter with appeal rights.
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Reconsideration Process
• The reconsideration process allows the recipient, his/her
legal guardian, or provider to dispute a medical necessity
denial of a service or level of care prior to requesting a
formal administrative hearing.
• Reconsideration request will be reviewed by a physician
who did not make the initial denial determination.
– A written request for reconsideration must be submitted to
Carewise Health within 10 calendar days from the date of the
written notice of denial.
– Carewise Health will conduct the reconsideration and render a
determination within 3 days of the request.
– Carewise Health will issue a letter communicating the
determination.
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Reconsideration Upheld or Modified
• If the determination is to uphold the denial, the recipient,
his/her guardian, or representative may request an
administrative hearing. Administrative hearings are
handled by the Hearings and Appeals Branch of the
Cabinet for Health and Family Services.
• If the reconsideration determination modifies a portion of
the original denial, the portion of the decision that
remains denied may be further disputed through an
administrative hearing. For the portion of the decision
that overturns the original denial, a prior authorization
will be issued.
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Reconsideration Overturned
• If the reconsideration determination overturns the
original decision, a prior authorization will be issued.
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Carewise Health Turn Around Time
• Carewise Health has 3 business days to
process/render a determination for
incoming initial request.
• Please check KY Health Net for PA
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Reference Page
DEPARTMENT
PHONE NUMBER
EMAIL OR WEB ADDRESS
ROLES
HP Provider Billing Inquiry
1-800-807-1232
[email protected]
Claim status, billing questions,
claims processing (Providers
ONLY)
EDI Helpdesk
1-800-205-4696
[email protected]
Electronic billing, Electronic
RA’s, PIN request and password
resets
Carewise
1-800-292-2392
Department for Medicaid
Services Member Services
1-800-635-2570
[email protected]
Questions or updates to a
members file, in relation to the
program code information.
Department for Medicaid
Services
Provider Enrollment
1-877-838-5085
[email protected]
Questions or updates to the
provider file or enrolling as a new
provider.
DCBS Contact Center
1-855-306-8959
https://prd.chfs.ky.gov/Office_Phone/index.aspx
Member eligibility, patient liability
(MAP 552), hospice election and
termination
HP Provider Field
Representatives
Varies by County
Varies by County
Provider training, personal
provider visits, conference calls,
association meetings and any
escalated issue. (Providers Only)
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Prior Authorizations, Waiver
Eligibility
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Contact Information
Tracy Treat
502-326-4512
[email protected]
Pam Smith
502-209-3159
[email protected]
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