KY Medicaid Utilization Management Program

Tracy Treat
Sr. Manager Operations
KY Medicaid Utilization Management Program
Early Periodic Screening, Diagnosis and Treatment
Services (EPSDT) and Orthodontia
Regulatory Criteria
• Early Periodic Screening, Diagnosis and Treatment - Special
Services- (EPSDT-SS)
– 907 KAR 11:034 Early and periodic screening, diagnosis, and
treatment services and early and periodic screening, diagnosis,
and treatment special services
– 907 KAR 11:035 Payments for early and periodic screening,
diagnosis, and treatment services and early and periodic
screening, diagnosis, and treatment special services
• Orthodontia
– 907 KAR 1:026, Dental Services, coverage shall be specifically
for members requiring orthodontic treatment when medically
necessary to correct disabling malocclusions
11-Jul-14
© SHPS, Inc. | Confidential
Page 2
EPSDT-SS Review Process and
Timeframes
•
EPSDT-SS service request are facsimile based process that is initiated by
the provider
–
•
The provider faxes in the required documentation to begin a service determination specific to
the review type. Fax (800) 807-7840 or (800) 807-8843
EPSDT-SS Review Types, Forms and Timeframes:
– Durable Medical Equipment – MAP 9 and Certificate of Medical Necessity (CMN)
required
• Prior Authorization for rental or purchase 1 – 90 days
– Private Duty Nursing – MAP 650, Work/school statement, and clinical notes
required.
• Prior Authorization six (6) months
– Therapies – MAP 650, therapy evaluation and progress notes required.
• Prior Authorization for six (6) months
– Enterals and Supplies that are not covered under DME – MAP 9 and CMN
required.
• Prior Authorization three (3) months
– Prescribed Pediatric Extended Care (PPEC) – PPEC PA Form, PPEC Leveling
Tool, PPEC Level Form, Work/School Statement and plan of care are required.
• Prior Authorization three (3) months
11-Jul-14
© SHPS, Inc. | Confidential
Page 3
EPSDT Review Criteria
• DME items are reviewed based on the DME Fee Schedule.
• PPEC rates based on Level I-IV.
• PDN rates are based on DMS guidelines.
• Retrospective reviews are completed for services that were provided
within ninety (90) days after Medicaid Card issue date
11-Jul-14
© SHPS, Inc. | Confidential
Page 4
Orthodontia Review Process
• The review process for Orthodontia
– Orthodontia service request are initiated by the provider via mail(US
Mail, Fed-Ex or other Carriers).
• The provider mails in the required documentation and the completed
Medicaid MAP forms (see below) to support the request :
• MAP 9 Kentucky Medicaid Program Orthodontic Services
Agreement or
• MAP 306 Temporomandibular joint (TMJ) form
• MAP 396 Kentucky Medicaid Program Orthodontic Evaluation Form
•
•
The provider also submits the X-rays and dental molds to Carewise Health
for review
The review covers the initial, six month and final phase of the process, and
the review of the fee level (Phase 1 and Phase 2), removable or fixed
appliances and for TMJ related services.
Page 5
Lack of Information
Lack of Information
EPSDT-SS
 If additional information is needed by the reviewer at Carewise Health a Lack of
Information letter will be generated.
 The requesting provider will have fourteen (14) days from the date of the letter to
submit the information required to complete the review.
 If the requested information is not submitted within the 14 days, Carewise Health,
will issue a Lack of Information denial.
 The provider may submit complete information at any time following the issuance
of a denial letter. Upon receipt of this request, a new review will be conducted.
Orthodontia
 Orthodontia does not have a formal LOI process. There is a "Hold" process in
which we fax an internal department form to advise the provider of what is
needed to complete the review as well as give a courtesy call.
 Carewise Health will hold the case for 2 weeks, at that time if there is no
response, Carewise Health will mail the records back to the requesting provider.
11-Jul-14
© SHPS, Inc. | Confidential
Page 6
Physician Referral
• Physician Referral
– If the initial physician reviewer is unable to determine medical
necessity of the service being requested, the case will be
referred to another 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.
11-Jul-14
© SHPS, Inc. | Confidential
Page 7
Reconsideration Process
• The reconsideration process allows the recipient, his/her
legal guardian, or provider to dispute a medical necessity
denial of a service 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 30 calendar days from the date of the
written notice of denial for Orthodontia and 10 calendar days for
EPSDT-SS
– Carewise Health will conduct the reconsideration for and render a
determination within 3 days of the request.
– Carewise Health will issue a letter communicating the
determination.
11-Jul-14
© SHPS, Inc. | Confidential
Page 8
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.
11-Jul-14
© SHPS, Inc. | Confidential
Page 9
Reconsideration Overturned
• If the reconsideration determination overturns the
original decision, a prior authorization will be issued.
11-Jul-14
© SHPS, Inc. | Confidential
Page 10
Orthodontia Pro Rate Process
Orthodontia Appeal process for Pro-Rate Reviews involves
two steps:
– (a) a resolution meeting, followed by
– (b) an administrative hearing.
• A request for a resolution meeting shall be made within thirty (30)
calendar days of the date of notification, and shall be directed to
the Commissioner, Department for Medicaid Services, Cabinet
for Health and Family Services.
• If providers request a resolution meeting and disagree with the
decision rendered from the resolution meeting, they may file an
appeal of the resolution meeting decision within thirty (30) days
of the date of the decision
Page 11
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
11-Jul-14
© SHPS, Inc. | Confidential
Page 12
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)
11-Jul-14
Prior Authorizations, Waiver
Eligibility
© SHPS, Inc. | Confidential
Page 13
Contact Information
Tracy Treat
502-326-4512
[email protected]
Pam Smith
502-209-3159
[email protected]
11-Jul-14
© SHPS, Inc. | Confidential
Page 14

Download Report