Home Health Services Provider Manualfl.eqhs.com/Portals/1/Home Health Provider Manual...

Home Health Services Provider Manual Section I – Introduction

Table of Contents

May 30,2011 Effective: June 1, 2011

Proprietary Page 1 of 64

TABLE OF CONTENTS

Table of Contents ....................................................................................................................... 1

About AHCA and Florida Medicaid ............................................................................................. 3

The Florida Agency for Health Care Administration ................................................................ 3

AHCA’s Mission ...................................................................................................................... 3

Florida Medicaid Program ....................................................................................................... 3

Medicaid Utilization Management Requirements .................................................................... 4

About eQHealth Solutions .......................................................................................................... 6

Company Information, Mission, Vision and Values ................................................................. 6

eQHealth Solutions Locations and Clients .............................................................................. 6

CMUMP accessibility and contact information ............................................................................ 8

Submitting Prior Authorization (Review) Requests ................................................................. 8

When You Need Information or Assistance ............................................................................ 8

Submitting Supporting Documentation.................................................................................... 9

Requesting a Reconsideration of a Medical Necessity Denial ...............................................10

Quick Reference: Contact Information ..................................................................................10

Overview: Home Health Services Utilization Management ........................................................12

Authority ................................................................................................................................12

Utilization Management Program Components ......................................................................12

Review Requirements ...............................................................................................................13

Services and Codes Subject to Prior Authorization ................................................................13

Review Request Submission .................................................................................................14

Supporting documentation .....................................................................................................14

Review Request Submission Timeframes .............................................................................15

Review Completion Timeframes ............................................................................................16

Fair Hearings .........................................................................................................................17

Submitting PA Requests and Supporting documentation ..........................................................18

Essential References .............................................................................................................18

Submitting Prior Authorization Requests ...............................................................................18

Submitting Supporting Documentation...................................................................................19

First and Second Levels of Review ...........................................................................................20

First Level Review .................................................................................................................20

Second Level Review ............................................................................................................21

HH services Prior Authorization Process ...................................................................................23


Table of Contents



HH Services Line Items .........................................................................................................23

Automated Administrative Screening .....................................................................................23

Nurse Reviewer Administrative Screening of the Entire Request ...........................................23

Nurse Reviewer Line Item Screening ....................................................................................24

Nurse Reviewer Actions Following the Clinical Screening .....................................................25

First Level Medical Necessity Review Process ......................................................................26

Second Level (Physician Peer) Review Process ...................................................................28

Reconsideration Reviews ......................................................................................................30

Fraud and Abuse Reporting ...................................................................................................31

PDN – PPEC Care Coordination ...............................................................................................32

Purpose of the PDN – PPEC Care Coordination Program .....................................................32

Care Coordination Program Components ..............................................................................32

Who Performs PDN – PPEC Care Coordination ....................................................................32

PDN – PPEC Care Coordination Process ..............................................................................33

Comprehensive Care Monitoring Program for Home Health Visits in Miami-Dade County ........36

Program Authority and Purpose.............................................................................................36

Program Features .................................................................................................................36

Face-to-Face Recipient Visit Purpose....................................................................................36

Data Analyses and Onsite Record Review ............................................................................37

Appendix A - Definitions ............................................................................................................39

Appendix B – Intentionally Left Blank ........................................................................................57

Appendix C – Parent – Legal Guardian School Schedule .........................................................58

Appendix D – Work Schedule Statement from Employer ..........................................................59

Appendix E – Physician Visit Documentation ............................................................................60

Appendix F – Personal Care Provider POC ..............................................................................61

Appendix G – Parent – Legal Guardian Station of Work Schedule ............................................63

Appendix H – Parent – Legal Guardian Medical Limitations ......................................................64


About AHCA and Florida Medicaid



ABOUT AHCA AND FLORIDA MEDICAID

THE FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION

The Florida Agency for Health Care Administration (AHCA or Agency) was statutorily created by Chapter 20, Florida Statutes. The Agency champions accessible, affordable, quality health care for all Floridians. It is the state’s chief health policy and planning entity. AHCA is the single state agency responsible for administering Florida’s Medicaid program which currently serves over 2.8 million Floridians. As such it develops and carries out policies related to the Medicaid program. The Medicaid program is administered by the Agency’s Division of Medicaid.

AHCA’S MISSION

AHCA’s mission is Better Health Care for All Floridians.

FLORIDA MEDICAID PROGRAM

Florida implemented the Medicaid program in 1970 to provide medical services to low-income people. A major expansion of the program occurred in 1989 when the United States Congress mandated that states provide all Medicaid services allowable under the Social Security Act to children 20 years of age and under.

Medicaid programs differ from state-to-state. The federal government sets the general guidelines and each state decides how to run its program. In Florida, the Florida legislature determines who qualifies for Medicaid, what services are covered, and how much to pay for the services.

Florida’s Medicaid program is comprised of a variety of delivery systems including:

Fee-for-service (FFS)

The FFS system serves Medicaid recipients who are not eligible for or enrolled in one of the following Medicaid delivery systems: MediPass, Managed Care or Disease Management.

FFS recipients may receive services from any FFS provider enrolled in Medicaid.

Providers are reimbursed for covered billed services as established through the General Appropriations Act and as outlined in the Medicaid state plan.

Over one-third of the Medicaid population receives services through the FFS program.

Medicaid Provider Access System (MediPass)

MediPass, one of Florida’s managed care delivery systems, is the primary care case management program.

The program is designed to build a relationship between families and the primary care physician (PCP) by creating a medical home, assuring access to care, decreasing inappropriate utilization and reducing costs.

PCPs provide primary care and authorize specialty care for their patients.

Certain services, such as vision, hearing, dental, behavioral health and family planning are not managed by the PCP.





MediPass providers are offered a monthly case management/enrollee fee and reimbursed on a fee-for-service basis.

Provider Service Networks (PSNs)

A PSN is a network organized or operated by a health care provider, or group of affiliated providers (including minority physician networks and emergency room diversion programs).

PSNs must provide a substantial portion of health care items and services under a contract directly through the provider or group of affiliated providers.

PSNs are required to ensure their patients have access to all Medicaid state plan services, with a few exceptions, and a complete network of providers.

PSNs are reimbursed on either a FFS or prepaid capitation basis.

Health Maintenance Organizations (HMO)

HMOs provide a substantial portion of health care services to a defined population of Medicaid recipients.

HMOs are required to ensure enrollees have access to all Medicaid state plan services and a complete network of providers. (HMO networks are not limited to Medicaid providers.)

HMOs are reimbursed on a capitation basis

Comprehensive information about AHCA and the Florida Medicaid Program is available at http://ahca.myflorida.com and www.mymedicaid-Florida.com

MEDICAID UTILIZATION MANAGEMENT REQUIREMENTS

Both Federal regulations and State Statutes require implementation of utilization management strategies for Medicaid health care services. The Code of Federal Regulations 42 C.F.R. 456 directs states to implement utilization controls that safeguard against unnecessary or inappropriate use of Medicaid services, protect against excess payments and assess the quality of health care services.

In addition to 42 CFR 456, various Florida State Statutes direct the Agency to implement a utilization management program for Medicaid services. Statutes applicable for particular types of Medicaid services are listed in the following table:

Medicaid Service Applicable State Statute or Regulation

Inpatient medical/surgical services Section 409.905 (5) (a) Florida Statutes

Care Management Program: Neonatal intensive care services

Section 409.905 (5) (e) Florida Statutes

Home health services Section 409.905 (4) Florida Statutes

Therapy services (physical, occupational, speech language and respiratory)

Section 409.912 (42) Florida Statutes

Care Management Pilot Project: Home health, private duty nursing and personal care services in Miami-Dade

Section 32 Chapter 2009-223, Laws of Florida

http://ahca.myflorida.com/

http://www.mymedicaid-florida.com/





In fulfilling its statutory obligations, AHCA contracts with a federally designated Quality Improvement Organization (QIO) to implement the Agency’s Comprehensive Medicaid Utilization Management Program (CMUMP). CMUMP includes the following Medicaid services:

Inpatient medical and surgical services

Home health services

Prescribed pediatric extended care (PPEC) services

Therapy services (physical, occupational, speech language and respiratory)


About eQHealth Solutions

May 30, 2011 Effective: June 1, 2011


ABOUT eQHEALTH SOLUTIONS

COMPANY INFORMATION, MISSION, VISION AND VALUES

eQHealth Solutions is a non-profit, multi-state health care quality improvement, medical cost management and health information technology company providing a wide range of effective and efficient solutions for our clients. Services include care coordination, utilization review, quality improvement, wellness services and quality review for home and community based waiver services. eQHealth Solutions is a leader in assisting providers to embrace health information technology (HIT) to improve the quality of care provided to patients / recipients.

Corporate Mission

“Improve the quality and value of health care by using information and collaborative relationships to enable change”

Corporate Vision

“To be an effective leader in improving the quality and value of health care in diverse and global markets”

Corporate Values

Pursuit of innovation;

Integrity in the work we do;

Sharing the responsibility for achieving corporate goals;

Treating people with respect;

Delivering products and services that are valuable to customer;

Fostering an environment of professional growth and fulfillment;

Engaging in work that is socially relevant; and

Continuous quality improvement.

eQHEALTH SOLUTIONS LOCATIONS AND CLIENTS

Florida

eQHealth Solutions was awarded the contract in 2011 by Florida’s Agency for Health Care Administration (AHCA or Agency) to serve as its Medicaid Quality Improvement Organization (QIO). On behalf of the Agency, our Florida location provides diverse medical cost and quality management services in a variety of inpatient and non-inpatient settings. Our main office is located in the Tampa area.

Louisiana

Under a federal contract with the Center for Medicare and Medicaid Services (CMS) since 1986, our office in Louisiana serves as the state’s Medicare QIO. As the Louisiana QIO, eQHealth Solutions assists providers achieve significant improvements in areas such as heart attack and pneumonia care, nursing home quality, home care delivery, prevention and wellness and adoption of electronic health records.


About eQHealth Solutions



Mississippi

Under contract with the State of Mississippi’s Division of Medicaid (DOM) since 1997, eQHealth Solutions serves as the utilization management and QIO to provide health care quality and utilization management services in a variety of inpatient and non-inpatient settings.

Illinois

Under contract with the Illinois Department of Healthcare and Family Services (HFS), since 2002, eQHealth Solutions serves as the Medicaid QIO, providing acute inpatient quality of care and utilization management, designing and conducting quality of care studies and quality review services for home and community based waiver services.

For more information about eQHealth Solutions visit www.eqhealthsolutions.com or http://fl.eqhs.org (Florida specific information).

http://www.eqhealthsolutions.com/

http://fl.eqhs.org/


CMUMP Accessibility and Contact Information



CMUMP ACCESSIBILITY AND CONTACT INFORMATION This section provides information about accessing the Comprehensive Medicaid Utilization Management Program (CMUMP) and provides important contact information. At the end of this section we provide a quick reference guide of web site links and toll free telephone and facsimile (fax) numbers.

SUBMITTING PRIOR AUTHORIZATION (REVIEW) REQUESTS Prior authorization (PA) review requests are submitted to eQHealth Solutions (eQHealth) through our proprietary, HIPAA-compliant web-based system, eQSuite, at http://fl.eqhs.org. The system is accessible 24 hours a day, seven days a week.

WHEN YOU NEED INFORMATION OR ASSISTANCE AHCA and eQHealth are committed to delivering exceptional service to our customers. We offer a variety of ways for you to efficiently obtain the information or assistance you need. In the following sections we identify, by topic or type of assistance needed, useful resources.

Questions about the CMUMP For questions or information about the Comprehensive Medicaid Utilization Management Program, the following resources are available:

Resources available on our Website: http://fl.eqhs.org:

♦ Frequently Asked Questions (FAQs): The FAQs are under the “Provider Resources” tab.

♦ This manual: Home Health Services Provider Manual

♦ Training presentations: Copies of training and education presentations are available under the “Training/Education” tab.

eQHealth Solutions customer service staff: Toll free number 855-444-3747. (See “Submitting General Inquiries” for hours of operation.)

Florida Medicaid Website’s provider portal: http://portal.flmmis.com/FLPublic

♦ Click on Provider Support, then

♦ Click on Provider Bulletins or Provider Notices

Questions about Submitting PA Requests or about Using eQSuite eQSuite User Guide for Home Health Services and User Guide for PDN/PC Services

available on our Website: http://fl.eqhs.org

eQHealth’s Website: http://fl.eqhs.org. (See “Questions about the CMUMP” for especially helpful resources available on our Website.)

Checking the Status of a PA Request or Submitting an Inquiry about a Request Check the status of a previously submitted PA request: Use your secure eQSuite login

and check the information in your review status report.

Submit an inquiry using eQSuite’s helpline module. You may use it when you have a question about a previously submitted PA request.





Both options are available 24 hours a day. Although using eQSuite is the most efficient way to obtain information about PA requests, you also may contact our customer service unit. (See “eQHealth Solutions Customer Service”.)

eQHealth Solutions Customer Service For general inquiries, inquiries that cannot be addressed through eQSuite, or if you have a complaint, contact our customer service staff.

The toll free customer service number is: 855-444-3747. Staff are available 8:00AM – 5:00PM Monday through Friday, excluding the following State-observed holidays:

New Year’s Day Martin Luther King Day

Memorial Day Independence Day

Labor Day Veterans Day

Thanksgiving Day Christmas Day

If you call during non-business hours, you will have the option of leaving a message. Calls received after non-business hours are answered by our customer staff the following business day.

If you have a complaint and would prefer to submit it in writing, send it to:

eQHealth Solutions, Inc. Florida Division

5802 Benjamin Center Dr. Suite #105

Tampa, Fl 33634

Obtain Comprehensive Information about Medicaid Policies For comprehensive information Medicaid services, coverage, limitations and exclusions, administrative policies and claims submission, there are a number of important resources:

Florida Provider General Handbook

Florida Home Health Services Coverage and Limitations Handbook

Florida Medicaid Provider Reimbursement Handbook, CMS-1500

These Handbooks are available through either of the following Web links:

http://mymedicaid-Florida.com.

http://portal.flmmis.com/FLPublic

♦ Click on Provider Support, then

♦ Click on Provider Handbooks.

SUBMITTING SUPPORTING DOCUMENTATION The various types of review requests must be accompanied by specific supporting documentation. (See Section II – Prior Authorization Requirements: Required Supporting Documentation.) You may submit it by:

Uploading and directly linking the documentation to the review record, or





Downloading eQHealth’s fax cover sheet(s) and faxing the information to our toll-free fax number: 855-321-3747

REQUESTING A RECONSIDERATION OF A MEDICAL NECESSITY DENIAL If eQHealth renders a medical necessity denial for all of some of the requested services, the ordering physician, provider and recipient each may request a reconsideration review. Home health services providers submit reconsideration requests through our web site: http://fl.eqhs.org. Physicians who use eQSuite also may submit requests through the system. Recipients and physicians may request reconsiderations by:

Phone: toll free number 855-977-3747

Fax: toll free number 855-677-3747

U.S. mail, sent to:

eQHealth Solutions, Inc Florida Division 5802 Benjamin Center Dr. Suite 105 Tampa, FL 33634

QUICK REFERENCE: CONTACT INFORMATION eQHealth Solutions (eQHealth)

♦ Submit a prior authorization request: Web site (24x7): http://fl.eqhs.org

♦ Submit additional information (24x7):

• Upload and directly link the information to the eQSuite record, or

• Download the eQHealth cover sheet and fax the information to 855-321-3747.

♦ Submit a reconsideration review request by:

• Web: http://fl.eqhs.org

• Phone (physicians and recipients): 855-977-3747

• Fax (physicians and recipients): 855-677-3747

• U.S. mail, sent to:


♦ Obtain information about a previously submitted prior authorization request:

eQSuite’s provider review status reports or helpline module: available 24x7

♦ Customer service: 855-444-3747

• Speak with a customer service representative 8:00 AM – 5:00 PM Eastern Time, Monday through Friday except State-approved holidays.





• Leave a message 24x7.

• U.S. mail, sent to:


Agency for Health Care Administration (AHCA)

♦ Website for general information: http://ahca.myflorida.com

♦ Provider support

• Portal: https://portal.flmmis.com/FLPublic Click on Provider Support on the left side of the screen, or

• http://mymedicaid-Florida.com


Home Health Services Program Overview



OVERVIEW: HOME HEALTH SERVICES UTILIZATION MANAGEMENT

AUTHORITY

Federal Code 42 C.F.R 456

The Code of Federal Regulations, 42 C.F.R directs States to implement utilization controls that safeguard against unnecessary or inappropriate use of Medicaid services, protect against excess payment and assess quality of services.

Section 409.905 (4), Florida Statutes

Section 409.905 (4), Florida Statutes direct the Agency for Health Care Administration (Agency or AHCA) to implement a utilization management program which includes prior authorization of home health services.

Section 32 Chapter 2009-223, Laws of Florida

Section 32 Chapter 2009-223, Laws of Florida strengthened the requirements for authorization of services under the Medicaid home health program and identified parameters under which the Agency may pay for home health services. The bill also directed AHCA to implement a home health services utilization management (UM) program that goes beyond a predominant focus on utilization review.

The Bill also requires the Agency implement a comprehensive care management pilot program for Medicaid recipients receiving home health visits in Miami-Dade County.

UTILIZATION MANAGEMENT PROGRAM COMPONENTS

In fulfilling its regulatory and statutory obligations, the Agency has established a comprehensive Medicaid utilization management program (CMUMP) that includes the following services provided by eQHealth Solutions:

Prior authorization of all home health services:

Home health visits (skilled nursing and aide visits)

Private duty nursing (PDN) services

Personal care services (PCS or PC services)

PDN care coordination for recipients who qualify for services provided in a PPEC center. (This program component is scheduled to begin in November 2011.)

Care monitoring for recipients receiving home health visits in Miami-Dade County

Retrospective review of a sample of home health services medical records.

Comprehensive information about Medicaid policies and authorization requirements is available in various Florida Medicaid publications. (See Section II – Prior Authorization Requirements: Submitting PA Requests and Supporting Documentation: Essential References.)

Home Health Services Provider Manual Section II – Prior Authorization Requirements

Review Requirements



REVIEW REQUIREMENTS

This section provides summary information about the following home health services UM program requirements:

Services and codes subject to prior authorization

Review request submission

Supporting documentation

Review request submission timeframes

Review completion timeframes

Fair hearings

SERVICES AND CODES SUBJECT TO PRIOR AUTHORIZATION

Only certain Healthcare Common Procedure Coding Systems® (HCPCS) codes and modifiers are subject to review by eQHealth. They are identified, by type of service, in the following tables.

Home Health Visit Codes

Code Modifier Modifier Description

T1030 RN visit.

T1030 GY RN visit to dually-eligible recipient.

T1031 LPN visits.

T1031 GY LPN visits to dually-eligible recipient.

T1021 TD Home health aide (HHA) visit-associated with skilled nursing services.

T1021 TD GY Home health aide (HHA) visit-associated with skilled nursing services to dually-eligible recipient.

T1021 Home health aide (HHA) visit-unassociated with skilled nursing services.

T1021 GY Home health aide (HHA) visit-unassociated with skilled nursing services to dually-eligible recipient.

Private Duty Nursing Codes

Code Modifier Description of Service

S9123 Private duty nursing rendered by a RN (2 to 24 hours per day).

S9123 TT Private duty nursing rendered by a RN (2 to 24 hours per day) provided to more than one recipient in the same setting.

S9123 UF Private duty nursing rendered by a RN (2 to 24 hours per day) provided by more than one provider in the same setting.

S9124 Private duty nursing rendered by a LPN (2 to 24 hours per day).

S9124 TT Private duty nursing rendered by a LPN (2 to 24 hours per day) provided to more than one recipient in the same setting.


Review Requirements




S9124 UF Private duty nursing rendered by a LPN (2-24 hours per day) provided by more than one provider in the same setting.

Personal Care Service Codes


S9122 Personal care rendered by a home health service provider (1 to 24 hours per day).

S9122 TT Personal care rendered by a home health service provider (1 to 24 hours per day), provided to more than one recipient in the same setting.

S9122 UF Personal care rendered by a home health service provider (1 to 24 hours per day), provided by more than one provider in the same setting.

REVIEW REQUEST SUBMISSION

All prior authorization (PA or review) requests are submitted electronically using eQSuite. For general information about eQSuite, see Section II – Prior Authorization Requirements: Submitting PA Requests and Supporting Documentation. You may download the eQSuite User Guide for Home Health Services and the User Guide for PDN/PCS Services from our web site: http://fl.eqhs.org.

SUPPORTING DOCUMENTATION

Documentation Substantiating Service Necessity

Documentation substantiating the need for services must be submitted with the review request.

Required Documentation

For information about what supporting documentation is required for what types of providers and services, go to our Web site: http://fl.eqhs.org. The information is located under Provider Resources: Forms and Downloads. Documentation requirements may differ for home health agencies and for unlicensed independent or group personal care services provider.

Home health agencies: See the resource titled, “Home Health Services Required Supporting Documentation”.

Unlicensed independent or group personal care providers: See the resource titled, “Unlicensed Independent Personal Care Services Required Supporting Documentation”.

These essential resources provide detailed information about what documentation is required, for which home health services it is required and when it is required.

Forms

For some documentation a particular form is required. For others there may be a choice of forms. The forms that must or may be used are specified in the resources cited in the preceding section, “Required Documentation”. For some documentation requirements AHCA has developed special forms that may be used. They may be downloaded from our Web site: http://fl.eqhs.org. Go to Provider Resources: Forms and Downloads. They also are included in the appendix section of this manual:

http://fl.eqhs.org/

http://fl.eqhs.org/

http://fl.eqhs.org/


Review Requirements



Appendix HH_C: Parent/Legal Guardian School Schedule

Appendix HH_D: Work Schedule Statement from Employer (This form is completed by an individual’s employer.)

Appendix HH_E: Physician Visit Documentation

Appendix HH_F: Personal Care Services Plan of Care Services (only for use by unlicensed personal care services providers)

Appendix HH_G: Parent/Legal Guardian Statement of Work Schedule (This form is for individuals who are self-employed. It must be notarized.)

Appendix HH_H: Parent/Legal Guardian Medical Limitations

How to Submit Documentation

For information about how to submit supporting documentation, in this manual please refer to Section II – Prior Authorization Requirements: Submitting PA Requests and Supporting Documentation.

Documentation for Recipients Having Dual Eligibility

Medicaid does not reimburse for services that can be reimbursed by Medicare. However Medicaid may reimburse for eligible, medically necessary services that exceed Medicare’s limits and are within Medicaid’s limits.

For these situations providers must submit with their review requests proof that Medicare benefits have been exhausted. Acceptable documentation is a PDF copy of the Medicare Explanation of Benefits (EOB) notice attached to the review request and recording the benefits exhausted information in eQSuite data fields.

Without evidence that Medicare limits are exhausted, eQHealth cancels the request, issuing a technical denial, and does not proceed with review.

REVIEW REQUEST SUBMISSION TIMEFRAMES

There are six types of review requests. For each there is a required timeframe for submitting the request.

Admission review (initial authorization)

Prior authorization is recommended.

If it is not possible to obtain all required supporting documentation before services must be not initiated, submit the request within five business days of initiating services.

Continued stay (reauthorization) review

Prior authorization is required.

Submit the request up to 14 calendar day before the end of the current approval period.

Modification review (if there is a change in the recipient’s clinical status)


Review Requirements



Authorization is required if, during an active approval period, a change in the recipient’s clinical condition creates a need for an increase or other change in the previously approved services.

Submit the request as soon as the need is identified and

The additional services are ordered by the physician, and

A revised plan of care (POC) is developed.

Modification review (if there is an unexpected change in the caregiver’s school or work schedule)

This is applicable only for private duty nursing (PDN) services

Authorization is required.

Retrospective review

Performed when Medicaid eligibility is retroactively determined.

Submit the request as soon as eligibility is confirmed and within one year of the eligibility determination. (If eligibility is determined while services still are in progress, submit an admission review request.)

Reconsideration review

Performed after an adverse determination if the physician, home health (HH) services provider and/or recipient requests review by another physician.

Submit the request within 10 business days of the date of the denial notification.

REVIEW COMPLETION TIMEFRAMES

Reviews are completed within particular timeframes. The timeframe depends on the type of HH service and review. It also depends on whether a face-to-face visit with the recipient is required. (See Section III – Prior Authorization Process: HH Services Prior Authorization Process and Section III – Prior Authorization Process: Comprehensive Care Monitoring Program for Home Health Visits in Miami-Dade County.) Lastly, the timeframe may depend on whether the request must be reviewed a physician. The review completion timeframe is measured from the date we receive all required information.

Home health visits (skilled nursing and aide visits)

Admission, continued stay and modification requests not requiring a recipient visit

When the services can be approved by a nurse: Within one business day

When physician review is required: Within two business days

Admission, continued stay and modification requests requiring a recipient visit: Within five business days (regardless of whether physician review is necessary)

Retrospective review: Within 20 business days (regardless of whether physician review is necessary)

Reconsideration review: Within three business days of the reconsideration request


Review Requirements



Private duty nursing and personal care services

Admission, continued stay and modification requests

When the services can be approved by a nurse: Within one business day

When physician review is required: Within three business days

Retrospective review: Within 20 business days (regardless of whether physician review is necessary)

Reconsideration review: Within three business days of the reconsideration request

FAIR HEARINGS

Recipients (or their legal representatives) whose services are denied, suspended, terminated or reduced by the Agency may appeal the adverse decision. An adverse determination includes one resulting from a medical necessity denial rendered by eQHealth Solutions.

The Agency does not grant a hearing if:

The sole issue is a federal or state law requiring an automatic change adversely affecting some or all recipients, or

The adverse determination is a result of the recipient’s physician’s order.

The fair hearing may be requested through a written statement to the local Medicaid Area Office or the Department of Children and Families (DCF). An opportunity for a hearing must be granted to any recipient, or a recipient’s parent or legal guardian, when the Agency (or eQHealth when conducting review) denies, terminates, suspends or reduces services.

eQHealth includes the process for requesting a fair hearing (hearing notice) with its notice of adverse determination mailed to the recipient or the recipient’s authorized representative. The fair hearing request may be made no later than 90 calendar days from the date the adverse determination is mailed.

When a fair hearing is requested as a result of an eQHealth determination, eQHealth provides all information about the request to the Agency or the Agency’s designee and may actively participate in the fair hearing.


Submitting PA Requests and Supporting Documentation



SUBMITTING PA REQUESTS AND SUPPORTING DOCUMENTATION

ESSENTIAL REFERENCES

Providers are encouraged to download and save or print the following Florida Medicaid references:

Florida Medicaid references:

Florida Medicaid Provider General Handbook

Florida Medicaid Home Health Services Coverage and Limitations Handbook

Prescribed Pediatric Extended Care Services Coverage and Limitations Handbook

Provider Reimbursement Handbook, CMS-1500

All are available through the following web sites:

https://portal.flmmis.com/FLPublic. For the General and Coverage and Limitations Handbooks click on Provider Support and then Handbooks. For the reimbursement handbooks select Fee Schedules.

http://mymedicaid-Florida.com. Click on Public Information for Providers

eQHealth Solutions’ Home Health Services Provider’s eQSuite User Guide. The Guide is available through http://fl.eqhs.org

SUBMITTING PRIOR AUTHORIZATION REQUESTS

Prior authorization (PA or review) requests are submitted electronically using eQHealth’s proprietary web-based software, eQSuite.

eQSuite

Key System Features

Among eQSuite’s many features are:

Secure HIPAA-compliant technology allowing providers to electronically record and transmit most information necessary for a review to be completed.

Secure transmission protocols including the encryption of all data transferred.

System access control for changing or adding authorized users.

24x7 access with easy to follow data entry screens.

Rules-driven functionality and system edits which assist providers by immediately alerting them to such things as situations for which review is not required.

A reporting module that provides the real time status of all review requests.

A helpline module through which providers may submit questions about a particular PA request.

https://portal.flmmis.com/FLPublic

http://mymedicaid-florida.com/

http://fl.eqhs.org/


Submitting PA Requests and Supporting Documentation



Minimal System Requirements

Providers’ system requirements for using eQSuite are minimal. You will need:

Computer with Intel Pentium 4 or higher CPU and monitor.

Windows XP SP2 or higher.

1 GB free hard drive space.

512 MB memory.

Internet Explorer 7 or higher, Mozilla Firefox 3 or higher, or Safari 4 or higher.

Broadband internet connection.

eQHealth Solutions’ personnel will send information to your agency or, for individual providers, to you. The information will explain everything you need to know to access eQSuite.

Each provider designates a Web administrator, and eQHealth will assign a user ID and password for him or her. The administrator, who need not have any information systems technical background, will have access rights to create and maintain user IDs and passwords for each user in your company. Managing system access is a user-friendly, non-technical process.

SUBMITTING SUPPORTING DOCUMENTATION

Certain supporting documentation is needed with prior authorization requests. (See Section II – Prior Authorization Requirements: “Review Requirements”: Supporting Documentation.) You may submit it by one of two methods:

Upload and directly link the information to the eQSuite review record.

Download eQHealth’s fax cover sheet(s) and submit the information using our 24x7 accessible toll-free fax number: 855-377-3747

For providers who choose to fax the documentation, we provide downloadable special fax cover sheets. Each fax cover sheet includes a bar code that is specific to the particular recipient and for the type of required information. For example, there is a specific cover sheet for the plan of care. The review specific fax cover sheets are available for download and printing as soon as the review request is completely entered in eQSuite.

DO NOT REUSE OR COPY BAR CODED FAX COVER SHEET(S) – THEY ARE RECIPIENT AND DOCUMENT SPECIFIC.

Home Health Services Provider Manual Section III – Prior Authorization Process

First and Second Levels of Review

Date: March 2011 Effective: June 1, 2011

Proprietary First & Second Levels of Review Page 20 of 64

FIRST AND SECOND LEVELS OF REVIEW

eQHealth Solutions provides two levels of review. They are distinguished by their:

Clinical credentials.

Determinations they may render and how they render those determinations.

With the exception of reconsideration reviews, all home health (HH) service review requests are processed by 1st level reviewers (clinical or nurse reviewers). Reconsideration requests are addressed by physician reviewers. (See “Second Level Review”). For a detailed explanation of the review process, refer to Section III – Prior Authorization Process: HH Services Prior Authorization Process.

FIRST LEVEL REVIEW

First Level Reviewer Credentials

Our 1st level reviewers are Florida licensed registered nurses who have at least two years home health experience. Clinical reviewers who review private duty nursing (PDN) and personal care (PC) services authorization requests also have at least two years pediatric care experience.

First Level Review Determinations

First level reviewers may render one of the following review determinations:

Approve the medical necessity of the services as requested. The determination includes approval of a particular number and frequency of units and the duration of the service.

Pend the request for additional or clarifying information from the provider.

Refer the request to a physician reviewer. This determination is rendered when:

The clinical reviewer’s criteria, guidelines and/or length of stay (LOS) policies are not satisfied.

During a face-to-face recipient visit a potential or clear discrepancy is found between the information submitted for the request and that obtained during the visit.

The authorization request is for aide services only. The request does not include any skilled nursing services.

Technical denial of the request: This non-clinical determination is rendered when there is non-compliance or inconsistency with an eligibility requirement or with any Agency administrative policy or rule.

Clinical reviewers may not render an adverse determination. When the clinical reviewer is not able to approve the services on the basis of the complete information provided, (s)he must refer the request to a second level (physician peer) reviewer.

First Level Review Clinical Decision Support Tools

When performing review 1st level reviewers apply Agency-approved clinical criteria, guidelines and policies to substantiate the medical necessity of the services. The applicable decision support tools depend on the type of HH services for which authorization is requested and may depend on the recipient’s age.

Home health visits (skilled nursing and HH aide services)





InterQual® ISD-HC Severity of Illness (SI) and Intensity of Service (IS) Criteria for Home Care:

Skilled nursing visits: InterQual® Criteria for Adult and Pediatric Skilled Services

Aide visits for recipients 21 years and older: InterQual® (Adult) Paraprofessional Criteria

Proprietary criteria and LOS determination policies: Clinical Criteria for Aide Visits for Recipients Under Age 21.

Private duty nursing personal care services: Proprietary clinical criteria and LOS determination policies

Proprietary criteria and LOS policy: Clinical Criteria for Personal Care Services for Recipients Under Age 21

Proprietary criteria and LOS policy: Clinical Criteria for Private Duty Nursing Services for Recipients Under Age 21

SECOND LEVEL REVIEW

Second Level Reviewer Credentials

Second level (physician peer) reviewers meet all requirements in Section 409.9131, Florida Statutes. They:

Are Florida-licensed physicians of medicine, osteopathy or dentistry, located in Florida and in active practice.

Are board certified in the specialty for the service they are asked to review. For PDN services, the physician reviewer (PR) is board certified in pediatrics and has at least five years recent experience in pediatric care.

Are on staff at or have active admitting privileges in at least one Florida hospital.

Physician reviewers may not review any request for which a known or potential conflict of interest exists.

Physician Reviewer Role

Physician peer reviewers review all:

Authorization requests that cannot be approved by a 1st level reviewer.

Requests for reconsideration of an adverse determination.

The review is performed by a PR who is of the same or similar specialty as the ordering physician. For complete information about the physician reviewer process and the factors physician reviewers consider refer to Section III – Prior Authorization Process: HH Services Authorization Process: Second Level (Physician) Review.

Second Level Review Determinations

For general reviews, a PR may render one of the following determinations:

Approval of the services as requested.

Pend the request for additional or clarifying information from the ordering physician.





Denial: All services are found not to be medically necessary.

Partial denial: This determination is a finding that some of the services, the frequency and/or duration of services are not medically necessary. The result is a reduction in approved services.

When a request for a reconsideration of an adverse determination is submitted, the reviewing physician renders one of the following determinations:

Uphold the original adverse determination.

Modify the original determination, approving a portion of the services.

Reverse the original determination, approving the services as originally requested.


HH Services Prior Authorization Process



HH SERVICES PRIOR AUTHORIZATION PROCESS

In this section we explain the prior authorization (review) process for home health services. The general review process essentially is the same for all types of home health services and (with the exception of reconsideration requests) for all types of authorization requests. However the type of service and/or authorization request may influence:

Administrative requirements.

Supporting documentation requirements.

Whether care coordination is implemented.

Whether a face-to-face to recipient visit is required prior to rendering a medical necessity determination.

The maximum service approval period.

Providers are encouraged to review the requirements information in Sections I and II of this manual and to be thoroughly familiar with the information in the applicable Florida Medicaid provider handbooks and reimbursement manuals.

In the following sections we explain the review process for:

Admission review requests.

Continued stay requests.

Modification review requests.

Retrospective review requests.

Any service-specific process differences are noted. Since there are several process differences for reconsideration requests, the reconsideration review process is discussed separately.

HH SERVICES LINE ITEMS

When providers submit authorization requests, each home health (HH) service for which authorization must be itemized. That is, each service code must be entered in eQSuite as a separate line item. For example, if authorization is requested for both skilled nursing and aide services, a separate line item is required for each. For each service to be provided, the number of service units, the frequency, and the duration must be provided. A determination is rendered for each line item.

AUTOMATED ADMINISTRATIVE SCREENING

When the review request is entered in eQSuite the system applies a series of edits to ensure review is required and that all eligibility, coverage and administrative requirements are satisfied. When there is a failed administrative requirement, the review request is cancelled.

The system prohibits further review processing.

The requesting provider is notified electronically.

NURSE REVIEWER ADMINISTRATIVE SCREENING OF THE ENTIRE REQUEST

When no exclusions are encountered by eQSuite, the system routes the request for first level screening and review. The nurse reviewer evaluates the entire request for compliance with any





Medicaid policies or other administrative requirements that cannot be applied by eQSuite and for compliance with supporting documentation requirements.

Administrative Requirements Screening

When the nurse reviewer identifies an administrative issue/policy breach, the request is technically denied (cancelled). The requesting provider is notified electronically through eQSuite. The reason for the cancellation is specified. Since a technical denial is rendered for an administrative reason, not a clinical or medical necessity reason, it is not subject to reconsideration.

The recipient is notified in writing of the technical denial and may request a fair hearing.

Supporting Documentation Screening

Required supporting documentation must be submitted with the authorization request, must be clear, legible and current and must comply with all AHCA policies. These include the type of documentation required and the documentation content. Refer to Section II – Prior Authorization Requirements: Review Requirements: Supporting Documentation.

If all required supporting documentation is not received with the request, the nurse reviewer pends the request. The provider is notified electronically that the information must be received within one business day. If it is not, the review request is suspended (cancelled), and the requesting provider is notified electronically. If the information is submitted at a later date eQHealth will re-open the review and review will be performed for services beginning from the date the information was received.

NURSE REVIEWER LINE ITEM SCREENING

Administrative Screening

When there are no issues requiring a cancellation of the entire authorization request, the clinical reviewer performs an administrative screening of each individual service line item. The nurse reviewer evaluates each line item to ensure:

Each service is eligible for coverage and no review exclusion exists.

The supporting documentation requirements applicable to each service are satisfied. (See “Supporting Documentation Screening” above)

If a review exclusion exists or an administrative requirement or policy is not satisfied for a particular line item, the first level reviewer issues a technical denial for that service line item. The provider is notified electronically through the system status report that a technical denial has been rendered. The particular service/line item for which the technical denial is rendered is specified. A technical denial, rendered for an administrative reason, is not subject to reconsideration. However the recipient may request a fair hearing.

When no review exclusions exist and there is compliance with all Agency policies and administrative requirements, the first level reviewer next screens the clinical information for completeness and compliance with policies.

Screening Clinical Information and Pending Review Requests

Screening for Complete Clinical Information

The nurse reviewer screens the submitted clinical information to ensure it is sufficient to complete the medical necessity review. Beginning in November 2011, for PDN services, the first





level reviewer also will screen the information to ensure it is sufficient to determine whether the recipient qualifies for prescribed pediatric extended care (PPEC) services. (See Section III – Prior Authorization Process: PDN – PPEC Care Coordination.)

When additional clinical information is required or when the available information requires clarification, the first level reviewer pends the review request and specifies the information or clarification needed.

Pended and Suspended Review Requests

When the nurse reviewer pends a review request:

An advisory email is generated to the requesting provider. The provider accesses the review record to determine what additional information is needed.

The requested information must be submitted within one business day.

If eQHealth does not receive the information within one business day of the notification, the review request is suspended and no further review processing occurs.

The provider is notified through the system status report that the request is suspended.

If the information is submitted at a later date, eQHealth re-opens the request and reviews those services beginning from the date the complete information was received.

Screening for High Risk or High Use Recipients

Our data management system maintains a comprehensive history of all services previously authorized for a recipient. Regardless of the type of home health service, the prior authorization process includes screening historical and current information to identify recipients who may be at risk for high or inappropriate utilization. First level reviewers may request from the provider additional or clarifying information when a recipient is identified as being potentially high risk. They also may consult with a physician reviewer before proceeding with medical necessity review.

NURSE REVIEWER ACTIONS FOLLOWING THE CLINICAL SCREENING

Except for services for which a technical denial was issued, when all information has been submitted and the clinical information screening is completed, the nurse reviewer proceeds to the next step. The action the nurse takes depends on the type of service for which authorization is requested. It also depends on whether the services are included in the Comprehensive Care Monitoring Program in Miami-Dade County. (See Section III – Prior Authorization Process: Comprehensive Care Monitoring Program Home Health Visits in Miami-Dade County.)

All Services, Except HH Visits in Miami-Dade County

Home health visits (skilled nursing or a combination of skilled nursing and HH aide visits): Perform the medical necessity review

Home health aide visits without skilled nursing services: Refer to a PR.

Personal care services: Perform the medical necessity review.

Private duty nursing services

Effective June 1, 2011: Perform the medical necessity review.





Beginning November 2011: Conduct the medical necessity review and determine whether the recipient qualifies for PPEC services. If so, implement PDN – PPEC care coordination.

Home Health Visits in Miami-Dade County

Home health aide visits without skilled nursing services: Complete a face-to-face recipient visit. Then refer to a PR.

Exception: If an admitting authorization request for these services was immediately preceded by a reviewed inpatient stay, the recipient visit may be waived. However review by a physician still is required. This exception is not applicable to continued stay or retrospective review authorization requests.

Any skilled nursing or aide services if there is an identified or possible inconsistency between information submitted by the provider and the information in supporting documentation: Refer to a PR.

Any skilled nursing or aide services for which a focused review or other intervention trigger is encountered: Implement the action(s) directed by AHCA.

FIRST LEVEL MEDICAL NECESSITY REVIEW PROCESS

When performing medical necessity review the first level reviewer evaluates all clinical information recorded in eQSuite and evaluates the information in the supporting documentation. The reviewer evaluates each service line item individually and renders a separate determination for each.

Approvals

Medical Necessity Approval

First level reviewers apply criteria to determine whether services are medically necessary or are otherwise allowable. The criteria used for the various types HH services review are listed in Section III – Prior Authorization Process: First and Second Levels of Review: First Level Review Clinical Decision Support Tools.

Service Duration Approval

After the medical necessity of services has been substantiated through criteria satisfaction, the nurse reviewer determines the number of units of service, the frequency and the duration that may be approved. The maximum service duration approved by a nurse reviewer is a matter of policy and depends on the type of services. In no event will the number, frequency and duration approved exceed that ordered by the physician, requested by the provider or permitted by policy. The maximum service duration a first level reviewer may approve for medically necessary services is shown below:

Home Health Visits: 60 calendar days.

Personal care (PC) services: The maximum service duration depends on whether the parent or caregiver is attending school.

If the parent or caregiver attends school: To the date of the end of the school term or through 180 calendar days, whichever is less.

If the parent or caregiver is not attending school: 180 calendar days.






As of June 1, 2011: 180 calendar days.

Beginning in November 2011, the maximum approved service duration will depend on whether the child qualifies for PPEC services. (See “PDN Services: Evaluation for PPEC Eligibility” below.)

If a child receiving PDN services qualifies for PPEC services: 30 calendar days.

If the child does not qualify for PPEC services: 180 calendar days.

PDN Services: Evaluation for PPEC Eligibility

Beginning in November 2011, when it is determined a recipient’s PDN services are medically necessary, the first level reviewer also will determine whether the child qualifies for enrollment in PPEC services. If so:

Once PPEC services are established, PDN services will be certified only as a wraparound service.

The clinical reviewer will work with the caregiver and providers to facilitate transition to the PPEC services. (See Section III – Prior Authorization Process: PDN – PPEC Care Coordination.)

Approval Notifications

When all criteria and service duration policies are satisfied the nurse approves the services as proposed by the provider and approval notifications are generated.

Provider notifications

Electronic notifications are generated for providers. When the determination is rendered, eQSuite immediately generates an email notification to the provider who requested the review. The email advises the provider to log in to eQSuite and check the secure web-based provider review status report. The provider then may access the report to see the determination.

Within one business day of the determination we electronically post a written determination notification. Providers may access the notification by using their eQSuite secure log on. The notifications can be downloaded and printed.

The approval information is transmitted to the Medicaid fiscal agent.

The fiscal agent transmits the prior authorization (PA) number to eQHealth.

Within 24 hours of our receipt of the PA number, we update the provider’s review status report to include the PA number.

The approval information includes the last date certified. This date serves as the trigger to submit a continued stay review request if the patient will not be discharged from HH services on or before the date following the last day certified. Sample notifications are available on our web site: http://fl.eqhs.org.

Recipient notifications: The recipient (or legal representative) receives a written notification. It is mailed within one business day of the determination.

http://fl.eqhs.org/





Referral to a Physician Reviewer

First level reviewers may not render an adverse determination. They refer to a physician peer reviewer any authorization request they cannot approve. This includes requests when criteria are not satisfied and when the requested service duration exceeds that which may be approved by a nurse. It also includes requests for services which, by policy, must be reviewed by a PR. (See “Nurse Reviewer Actions Following the Clinical Screening” earlier in this section.)

When the first level reviewer refers a review request to a physician reviewer the requesting provider receives notification of the referral. The notification methods and process are as explained in the preceding section for approvals.

SECOND LEVEL (PHYSICIAN PEER) REVIEW PROCESS

Process Overview

When we schedule physician reviews every effort is made to match the care being reviewed to a physician of the same specialty. Physicians who review PDN is board certified in pediatrics and has at least five years recent experience in pediatric care.

The PR uses his/her clinical experience and judgment and considers all of the following factors:

As applicable for the patient and for the services under review, whether the services for which authorization is requested are eligible for reimbursement

Whether the services for which authorization is requested conform to the Agency’s definition of medical necessity. (See Appendix A – Definitions.)

As applicable for the patient and for the services under review, consistency with other applicable Agency definitions such as the definition of medically complex.

The patient’s:

Current clinical condition, diagnosis and prognosis.

Treatment plan and whether it is adequate and appropriately customized to meet the patient’s unique needs.

Progress toward meeting treatment plan goals and whether the maximum medical benefit has been achieved.

Given the patient’s clinical status, whether there is an available and appropriate less intensive, less restrictive or more conservative care option.

Generally accepted professional standards of care.

The PR may approve (authorize) the services on the basis of the information provided. Or the PR may determine additional information is needed and pend a review request while attempting to obtain the information from the attending or ordering physician.

Approval on the basis of available information: When the available information substantiates the medical necessity of the services, the number of service units and the fre4quency and duration of services, the PR approves the services as requested and the review is completed. Notifications are issued as described under “First Level Medical Necessity Review Process: Approval Notifications”.

When additional information is required: If the PR is not able to approve the services on the basis of the available information, (s)he attempts to speak with the attending or





ordering physician to obtain additional or clarifying information. PRs do not render adverse determinations without first attempting to speak with the physician.

PR pended review requests: If the ordering physician is not available when our physician calls, the PR may issue a pend determination at that time. The particular information required is documented in the review record.

The requesting provider receives an electronic notification of the pended review. The information must be provided within one business day. (See “Nurse Reviewer Line Item Screening – Screening Clinical Information: Pended and Suspended Review Requests” earlier in this section.)

If the requested information is not received within one business day, the PR renders a determination on the basis of the information that is available.

Adverse Determinations

Only a PR may render an adverse determination. As noted in the preceding section, prior to rendering an adverse determination our PR will attempt to have a peer-to-peer discussion with the ordering physician.

There are two types of adverse determinations: denial and partial denial. (See Section III – Prior Authorization Process: First and Second Levels of Review: Second Level Review Determinations.)

Denial

The physician reviewer may render a (full) medical necessity denial of one or more service line item(s).

The requesting provider receives immediate electronic notification, via email and the eQSuite review status report, of the denial.

Within one business day of the determination, a written notification of the denial is posted electronically for the provider. The notice may be downloaded and printed. Written notifications are faxed or mailed to the ordering physician and to the recipient or the recipient’s legal representative.

The written notification includes information about the providers’ and recipient’s right to a reconsideration of the adverse determination.

The recipient’s notification also includes information about his/her right to request a fair hearing through the Agency.

Partial Denial (Service Modification or Reduction in Services)

The physician also may render a partial denial for one or more services. (See “Adverse Determinations” in Appendix HH_A – Definitions.) When a partial denial is rendered, some of the services are approved and some are denied. Therefore there is a reduction in the services for which authorization was requested, but there is not a full denial of the services. This adverse determination may involve a denial of the number of units requested, the frequency and/or the duration of the service(s).

For partial denials:

Notifications are issued to all parties as described in the preceding section, “Denial”.





The approval information is transmitted to the fiscal agent. The provider’s eQSuite status report is updated with the PA number as previously described for approval determinations.

RECONSIDERATION REVIEWS

Any party may request a reconsideration of an adverse determination. The only exception is when the physician or provider expresses agreement with the adverse determination. In that case the right to reconsideration is waived.

The written notification of the adverse determination includes information about the right to request reconsideration. It also includes information about how to request reconsideration review.

The reconsideration request must be received within 30 calendar days of the date of the adverse determination.

Home health services providers request reconsideration through eQSuite. Physicians who do not have access to eQSuite and recipients may submit reconsideration requests by fax, phone or mail.

The requesting party should submit additional or clarifying information.

Providers may submit the information using one of the methods discussed in Section II – Prior Authorization Requirements: Submitting PA Requests and Supporting Documentation.

Physicians and recipients (or their legal representatives) may submit the additional information by fax or phone.

Home health services providers are strongly encouraged to serve as the coordination entity for the physician and recipient and to submit any additional information on behalf of all.

Administrative Screening of Reconsideration Requests

When a reconsideration request is received it is screened to ensure it complies with administrative requirements. It must be received within the required timeframe and must be submitted by a party who is entitled to request a reconsideration. When the request does not conform to administrative requirements:

The request is denied.

The requesting party is notified electronically or (for a physician and recipient) in writing that the request is denied.

Processing Valid Reconsideration Requests

Only a physician peer reviewer may conduct a reconsideration review. When a valid reconsideration request is received:

Any additional information submitted by fax is linked to the review record. Information submitted by phone is documented in eQSuite.

The review is scheduled for a peer-matched physician reviewer who was not involved in the original determination.





Conducting the Review

The physician peer reviewer evaluates all available information including previous information and all additional information submitted. The review is performed according to the process described for all second level reviews. The physician peer reviewer considers all factors outlined in Section III – Prior Authorization Process: First and Second Levels of Review.

Types of Determinations and Determination Implications

A determination is rendered for each service line item for which a reconsideration is requested. When reconsideration is requested for multiple services, there may be a different determination for each. The determination may be one of the following:

Modify: Some of the services are approved and some continue to be denied.

Reverse: The services are approved as originally requested. The original adverse determination is over-turned.

Uphold: The original denial is maintained.

When the reconsideration determination results in a modification or reversal of the original determination:

The determination and notification will specify the approved number of units, the frequency and the duration. The approved “through date” serves as the provider’s trigger to submit a reauthorization request when services are planned beyond that date.

The approval information is transmitted to the fiscal agent. The provider’s review status report is updated with the PA number within 24 hours of eQHealth’s receipt of the number when a PA was not previously issued.

The reconsideration determination is final. When the determination is to modify or uphold the original adverse determination, no further reconsideration is available. However the recipient may request a fair hearing.

Completion Timeframe and Notifications

Reconsideration reviews are completed within three business days of our receipt of a complete and valid request. Notifications are issued to all parties by the methods and within the timeframes described for all second level review determinations.

FRAUD AND ABUSE REPORTING

eQHealth immediately notifies the Agency of any instance of potential fraud or abuse. The Agency provides direction in what, if any, alteration in the review process is required as a result of the reported incident.


PDN-PPEC Care Coordination

June 1, 2011 Effective: June 1, 2011


PDN – PPEC CARE COORDINATION

PURPOSE OF THE PDN – PPEC CARE COORDINATION PROGRAM

The PDN – PPEC care coordination program described in this section is expected to be implemented in November 2011. Although certain processes outlined here may be revised before the implementation date, the goal and concept and the fundamental program components are not expected to change. Prior to the implementation date, eQHealth Solutions will offer special provider training for this program.

The Florida Medicaid prescribed pediatric extended care (PPEC) services program enables children with medically complex conditions to receive medical care at a non-residential pediatric center. PPEC centers provide a cost effective and less restrictive alternative to private duty nursing or institutionalization and reduce the isolation homebound children may experience.

Beginning in November 2011, when a request for private duty nursing services is submitted, a first level reviewer will conduct the standard medical necessity review explained in Section III – Prior Authorization Process: HH Services Prior Authorization Process. When PDN services are determined to be medically necessary, the nurse reviewer also will determine whether the child’s needs can be met safely and appropriately through a PPEC center instead of through private duty nursing services. If so, the nurse will work with the caregiver and the providers to facilitate the child’s transition from PDN services to PPEC services.

CARE COORDINATION PROGRAM COMPONENTS

For any child receiving medically necessary PDN services, the PDN – PPEC care coordination program will include the following services:

Assessment to determine whether the needs can be safely and appropriately met in a PPEC center.

For a child who qualifies for PPEC services, facilitating the child’s transition from PDN services to a PPEC. Activities performed include:

Identifying available PPEC centers.

Educating the parent or legal guardian regarding PPEC services and Medicaid policies.

Working with the current PDN provider and the selected PPEC provider to support a smooth transition.

Approving the PPEC services and, if they are medically necessary, PDN services as a wraparound to the PPEC services.

WHO PERFORMS PDN – PPEC CARE COORDINATION

The same clinical (first level) reviewers who perform PDN and PCS medical necessity review also will perform PDN – PPEC care coordination. (Refer to Section III – Prior Authorization Process: First and Second Levels of Review.) As necessary they will be supported by eQHealth’s home health review director, by our medical director, associate medical director or by a second level (physician peer) reviewer who is a pediatrician.





PDN – PPEC CARE COORDINATION PROCESS

Automated Screening for PPEC Center Availability

A criterion for eligibility for PPEC services is that a PPEC center must be within a one hour drive of the child’s residence. Our review data system includes mapping functionality that will automatically identify PPEC centers meeting this criterion.

All PPEC centers meeting the one hour driving time criterion will be displayed for the clinical reviewer.

When no PPEC center is identified, the clinical reviewer will be alerted by the system and the child will be excluded from further consideration for PPEC services. The standard PDN prior authorization process then will proceed as described in Section III - Prior Authorization Process: HH Services Prior Authorization Process.

Evaluation for PPEC Eligibility

Evaluation of Submitted Information

When a PPEC center is available within the required geographic range, the clinical reviewer will determine whether the child meets other qualifying indicators for PPEC services. This will be done by comparing the qualifying indicators with information entered in eQSuite by the provider and with information contained in the supporting documentation. (Refer to Section II – Prior Authorization Requirements: Required Supporting Documentation.) When necessary, the reviewer contacts the PDN provider for additional or clarifying clinical information.

PPEC Eligibility Indicators

To qualify for PPEC services, the child must meet the following medical need indicators:

Medical necessity criteria and guidelines

The child:

Must be medically stable.

Not have a communicable disease or illness.

Not have a diagnosis that would result in immune-suppression.

Must be able to tolerate traveling to and from the PPEC.

PDN Service Approval

Approval Duration

The first level reviewer’s service duration approval of PDN services will depend on whether the PPEC eligibility indicators are satisfied.

When the indicators are satisfied, the reviewer will approve PDN services for 30 days.

When the indicators are not satisfied, the reviewer will approve PDN services for a maximum 180 days.

Refer to Section III – Prior Authorization Process: HH Services Prior Authorization Process.





PDN Reauthorization When a Child is Eligible for PPEC Services

When PDN services are medically necessary as a wraparound for days or hours when the PPEC center cannot provide the services, the PDN services will be approved.

When a PPEC center has not been selected by the parent or legal guardian, additional PDN services beyond the current authorization period will be denied.

Care Coordination

When a child is eligible for PPEC services, the clinical reviewer will implement the care coordination process.

Availability Verification

The nurse reviewer will contact each PPEC center meeting the one hour driving distance criterion to verify whether:

Space is available.

The center can accept the child based on the child’s clinical needs and age.

The center is open during the hours needed.

Parent or Legal Guardian (Initial) Interaction

Our nurse will initiate telephone contact with the child’s parent or legal guardian to:

Provide education about the services provided by PPECs and the benefits of those services over home care.

Verify the child is able to travel, is not immune-suppressed and has no communicable disease or illness.

When applicable, discuss PPEC as an available option if the child requires ventilator support and that PDN services will be authorized when the parent or guardian declines PPEC.

Discuss work and/or school schedules, parent or guardian limitations and potential hours for which the PPEC center services would be used.

Provide the list of available PPEC centers and the contact information.

Discuss the fact that PDN services will be approved for 30 days while PPEC transition occurs.

Instruct the parent or guardian about his or her responsibility for:

Contacting the child’s attending physician to obtain an order for PPEC.

Selecting a PPEC center.

Contacting the PPEC center to obtain an assessment of the child and to have the PPEC initiate a prior authorization request.

Informing the eQHealth nurse of the selected PPEC center.

Instruct the parent or guardian about the need to complete all transition actions, including PPEC service initial prior authorization, within the 30 day PDN authorization period.





When the parent or guardian selects the PPEC center our nurse will record the information in eQSuite.

Parent or Legal Guardian (Follow-up) Interaction

When the PDN authorization is scheduled to expire within the next 10 calendar days and the selected PPEC has not been confirmed with eQHealth, our nurse will initiate a telephone follow up contact with the parent or guardian. The nurse will:

Obtain a status of the arrangements made to date.

Provide additional education as needed or assistance as requested.

Remind the parent or guardian that, prior to the expiration of the PDN authorization period:

If a PPEC center is not selected, additional PDN services will not be authorized, and

The PPEC center must have sufficient time to obtain authorization for the services it will provide.

Approval of PPEC Services and Follow-up Interactions

When the selected PPEC center submits the prior authorization request, the clinical reviewer will evaluate all information submitted by the PPEC as well as all information from the PDN provider’s records. The nurse will determine the exact hours for which:

PPEC services can be approved as medically necessary.

PDN wraparound services can be approved as medically necessary.

Our nurse will contact the parent or guardian and the appropriate providers to inform them of the:

Approved PPEC hours and days of the week and the duration of the PPEC certification period.

(When applicable) Approved PDN wraparound hours.

When PPEC and, as applicable, PDN wraparound services are believed necessary beyond the approval period (the approved “through” date), each provider must submit a service reauthorization request up to 14 calendar days prior to the end of the current approval period.


Care Monitoring Program for HH Visits



COMPREHENSIVE CARE MONITORING PROGRAM FOR HOME HEALTH VISITS IN MIAMI-DADE COUNTY

PROGRAM AUTHORITY AND PURPOSE

Florida Senate Bill 1986, passed in the 2009 Legislative Session, requires that the Agency for Health Care Administration (Agency or AHCA) implement a comprehensive care management pilot project or program (CCMP) for recipients receiving home health visits in Miami-Dade County. The purposes of the program are to:

Ensure home health (HH) visits are medically necessary.

Ensure quality care for recipients receiving HH services.

Verify the delivery of services.

Reduce aberrant billing practices.

PROGRAM FEATURES

The Miami-Dade County CCMP includes a variety of utilization management strategies. Depending on the nature of the services and available information, the strategies may be implemented independently or in combination.

Prior authorization of HH visits

Face-to-face recipient visits in particular situations

Consultation with the ordering physician

Data analyses

Onsite review of recipient medical record and/or administrative record

Agency-requested targeted interventions

FACE-TO-FACE RECIPIENT VISIT PURPOSE

The purpose of the face-to-face visit is to validate the information supplied by the provider. Information entered in eQSuite and contained in supporting documentation is compared with a visual assessment of the recipient.

Situations Requiring an In-Person Visit

An eQHealth registered nurse performs the assessment in the recipient’s residence when:

A prior authorization request is for home health aide visits, without skilled nursing visits.

Exception: If an admitting (initial) authorization request for aide visits without skilled services was immediately preceded by an inpatient stay reviewed by eQHealth, the requirement for the recipient visit may be waived. This exception is not applicable to continued stay or retrospective review requests; and, as for all requests for aide visits without skilled nursing services, physician review is required. (See Section III – Prior Authorization Process: Nurse Reviewer Actions Following the Clinical Screening.)

There is inconsistency between the information entered in eQSuite and contained in the required supporting documentation.





The Agency (AHCA) has requested an in-person assessment for a particular recipient.

Timeframe for Conducting the Visit

Within one day of our receipt of complete information, including all required supporting documentation, we contact the recipient or parent or legal guardian by phone to schedule the visit date and time. The visit is scheduled to occur within two days of our receipt of all information.

Prior Authorization Implications

When a face-to-face visit is required the medical necessity review is not performed until the assessment is complete.

After the visit is complete, medical necessity review proceeds as described in Section III - Prior Authorization Process: HH Services Prior Authorization Process.

If for any reason the visit cannot be completed after we have made two attempts, the prior authorization request is suspended.

The provider is notified electronically that the review request is suspended.

If we are granted access later we will reopen the review request and will review services beginning from the date we are able to perform the recipient visit.

In comparison to the general review process for home health visits, notable CCMP prior authorization process modifications are:

eQHealth PRs always review authorization requests if there is any inconsistency between the information the provider entered in eQSuite and that contained in the supporting documentation.

When a face-to-face visit is required, the medical necessity review is not performed until the visit is complete.

The prior authorization determination is rendered within five business days of eQHealth’s receipt of all required information. (Refer to Section II – Prior Authorization Requirements: Review Requirements.)

DATA ANALYSES AND ONSITE RECORD REVIEW

eQHealth analyzes prior authorization and claims data to identify aberrant utilization, billing and practice patterns. When an aberrant pattern is identified, we conduct more in-depth analyses to determine if the pattern is explainable. Pattern validation typically involves review of a sample of medical and/or administrative records.

When onsite record review is required to validate a pattern, the reviews are conducted by eQHealth registered nurse auditors. The nurse auditors are supported as needed by our Miami-Dade County project director and by our medical director (or physician designee).

The site visit is pre-scheduled and provider(s) are notified in advance of the records that need to be available for review.

When the pattern involves a particular recipient, records from more than one agency or physician office may be required.

When our nurse auditor is not granted access or required records are not available, we notify the Agency.





Based on the outcome of the analyses and/or record reviews an Agency-approved problem-oriented intervention may be implemented. Examples of such interventions include:

General or targeted provider or physician education.

Focused or intensified prior authorization requirements for particular recipients, providers or clinical conditions.

Home Health Services Provider Manual Definitions

Appendix A



APPENDIX A - DEFINITIONS


Appendix A

Date: May 9, 2011 Effective: June 1, 2011

Proprietary Glossary Page 40 of 64

Term Acronym or Abbreviation

Definition

Abuse

(in the context of “fraud and abuse”)

Provider practices that are inconsistent with generally accepted business or medical practices and that result in an unnecessary cost to the Medicaid program or in reimbursement for goods or services that are not medically necessary or that fail to meet professionally recognized standards for health care. (Per Section 409.913(1)(a), Florida

Statute (F.S.) (Also see “Fraud.)

Adverse determination (as it relates to utilization management findings)

A general term for any unfavorable medical necessity or appropriateness finding resulting from a physician’s review of the health care services for which authorization (approval) is requested.

An adverse determination may be a (full) denial of the medical necessity of inpatient or non-inpatient services or a partial denial. Partial denials result in a reduction of covered services.

Denial: All planned services and the associated length of stay are found to be not medically necessary or appropriate.

Partial denial:

Inpatient services: A finding that a portion of the hospitalization is not medically necessary or appropriate.

Non-inpatient services: A finding that a portion of the services is not medically necessary or appropriate. The partial denial may be associated with the number of units of service, the frequency of services and/or the duration of services.

Providers and recipients may request a reconsideration of an adverse determination.

Also see “Non-certification”, “Reconsideration” and “Technical denial”.

Agency for Health Care Administration

Agency or

AHCA

The agency is the Medicaid agency for the state, as provided under federal law.

Approval (as it relates to a prior authorization or utilization review determination)

See “Certification determination”.

Assisted living facility ALF ALF means any building or buildings, section or distinct part of a building, private home, boarding home, home for the aged, or other residential facility, whether operated for profit or not, which undertakes through its ownership or management to provide housing, meals, and one or more personal services for a period exceeding 24 hours to one or more adults who


Appendix A




Definition

are not relatives of the owner or administrator.

ALFs are licensed pursuant to Chapter 429, Part I, F.S.

Assistive care services Services provided to eligible recipients in assisted living facilities (ALFs), adult family care homes (AFCHs), and residential treatment facilities (RTFs)

Centers for Medicare and Medicaid Services

CMS The federal agency within the United States Department of Health and Human Services (HHA) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the State Children's Health Insurance Program (SCHIP), and health insurance portability standards.

Certification determination or certified services

The prior authorization or utilization review finding that health care services are medically necessary and appropriate. (See “Utilization review”.) This determination also is referred to as an approval and is rendered by a physician or a 1st level reviewer supported by decision support tools including clinical criteria, guidelines or algorithms.

Children’s Medical Services and Children’s Medical Services Network

CMS A division of the Florida Department of Health that provides children with special health care needs with a family centered, managed system of care through the CMS Network. “Children with special health care needs” means those children younger than 21 years of age who have chronic physical, developmental, behavioral, or emotional conditions and who also require health care and related services of a type or amount beyond that which is generally required by children.

The CMS Network is administered by the Department of Health, Children’s Medical Services.

Clinical reviewer See “First level reviewer”.

Clinically unproven procedures

See “Experimental or clinically unproven procedures”.

Concurrent review Utilization review performed while health care services are in progress. (See “Utilization review”.)

Continued stay (or service) review

A prior authorization or utilization review performed after the initial review and while services are still being provided. (See “Utilization review”.)

Criteria (clinical) In the context of prior authorization, utilization review, or utilization management, the National Committee for Quality Assurance (NCQA) defines criteria as “Systematically developed, objective and quantifiable statements used to assess the appropriateness of specific health care decisions,

http://en.wikipedia.org/wiki/Medicare_(United_States)

http://en.wikipedia.org/wiki/Medicaid

http://en.wikipedia.org/wiki/State_Children%27s_Health_Insurance_Program

http://en.wikipedia.org/wiki/State_Children%27s_Health_Insurance_Program

http://en.wikipedia.org/wiki/Health_insurance


Appendix A




Definition

services and outcomes.”

Among other tools, eQHealth’s 1st level reviewers apply criteria to assist them in determining the medical necessity of particular health care services delivered in particular sites of care. (See “InterQual® Criteria”.) If the criteria are satisfied, the reviewer may certify (approve) the medical necessity of the services. If the criteria are not satisfied, the case is referred to a physician to make the medical necessity determination.

Custodial care Care, which does not provide continued medical or paramedical attention, given to assist a person in performing daily living activities.

Denial

(as it relates to a prior authorization or utilization review determination)

See “Non-certification determination” and “Adverse determination”.

Dually-eligible recipient An individual who is eligible for both Medicaid and Medicare benefits.

Electronic Data Systems EDS The Medicaid fiscal agent. (See fiscal agent.)

Experimental or clinically unproven procedures

“Experimental” or “Experimental and clinically unproven” or “Investigational” as related to drugs, devices, medical treatments or procedures means:

(a)1. The drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug Administration (FDA) and approval for marketing has not been given at the time the drug or device is furnished; or

2. Reliable evidence shows that the drug, device or medical treatment or procedure is the subject of on-going phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or

3. Reliable evidence shows that the consensus among experts regarding the drug, device, or medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, toxicity, safety, or efficacy as compared with the standard means of treatment or diagnosis.

4. The drug or device is used for a purpose that is not approved by the FDA.

(b) Reliable evidence shall mean only published reports and articles in the authoritative medical and scientific literature; the written protocol or protocols used by the treating facility or the


Appendix A




Definition

protocol(s) of another facility studying substantially the same drug, device or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or medical treatment or procedure. (Per Chapter 59G-1.010, Florida Administrative Code (F.A.C.)

Fair Hearing “Fair Hearing” means the opportunity afforded any Medicaid applicant or recipient, for whom there has been a determination to deny, reduce or terminate benefits or services, except when the determination is due solely to a law or policy requiring an automatic change, to have one or more impartial officials who have not been directly or indirectly involved in the initial determination of the action in question render a final decision based on information submitted for review pursuant to the hearing standards contained in federal regulations. (Per Chapter 59G-1.010, F.A.C.)

Recipients (or their legal representatives) whose services are denied, suspended, terminated or reduced by AHCA may appeal the adverse decision. Such an adverse determination includes one that results from a medical necessity denial rendered by eQHealth Solutions.

The Agency does not grant a hearing if:

The sole issue is a federal or state law requiring an automatic change adversely affecting some or all recipients, or

The adverse determination is a result of the recipient’s physician’s order.

The appeal is requested through a written statement. The Agency then must grant an opportunity for a hearing to any recipient, or a recipient’s parent or legal guardian, if the Agency (or eQHealth Solutions when conducting review) denies, terminates, suspends or reduces services.

eQHealth includes the hearing notice with its notice of adverse determination mailed to the recipient or the recipient’s authorized representative. The appeal request may be made no later than 90 calendar days from the date the hearing notice is mailed.

First level determination 1st level determination

A prior authorization or review decision rendered by a 1st level reviewer. (See “First Level Reviewer”.) A 1st level determination is one of the following:

Certification of services Referral to a physician reviewer Pend: a determination that additional information is

needed and requesting the information from the provider


Appendix A




Definition

Technical denial or cancellation of the authorization request due to AHCA administrative policy rules

First level reviewer (also referred to as a clinical reviewer)

1st level reviewer

An eQHealth Solutions employee or contractor who maintains an active Florida license as applicable for his clinical profession and who meets all other AHCA-defined credentials required to perform utilization management services and to render medical necessity certifications (approvals). The term includes the licensed professionals who directly or indirectly supervise the staff or contractors and who themselves may perform utilization management services.

eQHealth’s 1st level reviewers include:

Registered nurses (inpatient, home health and PPEC services. Also, with the Agency’s prior approval, therapy services).

Physical therapists (therapy services). Occupational therapists (therapy services). Speech-language pathologists (therapy services).

In performing their work, 1st level reviewers rely on a variety of clinical decision support tools including criteria and guidelines. They cannot render adverse determinations. Only a 2nd level reviewer (physician) may do that.

Fiscal agent FA A private corporation under contract with AHCA to receive and process Medicaid claims. (See EDS.)

Fiscal year A budgetary, financial reporting or cost accounting time period, 12 months in length. The state of Florida’s fiscal year is July 1 through June 30.

Florida Medicaid Management Information System

FMMIS or

MMIS

“Florida Medicaid Management Information System (FMMIS)” means the computer system used to process Florida Medicaid claims and to produce management information relating to the Florida Medicaid program. (Per Chapter 59G-1.010, F.A.C.)

Florida’s computer system that contains provider and recipient records and eligibility data.

Fraud

(in the context of “fraud and abuse”)

“Fraud” means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law. (Per Chapter 59G-1.010, F.A.C.) (Also see “Abuse”.)

Guidelines (clinical) The U.S. Dept. of Health and Human Services’ National Heart Lung and Blood Institute (NHLBI) states that clinical guidelines “…define the role of specific diagnostic and treatment modalities in the diagnosis and management of patients”. The purpose of guidelines is to support health care


Appendix A




Definition

decision-making by “describing a range of generally accepted [treatment] approaches…”

In contrast with strict criteria and prescriptive protocols, guidelines provide recommendations for management of particular diseases or conditions. When referencing guidelines, emphasis is placed on the importance of exercising sound, situation-specific clinical judgment. Recommendations contained in guidelines are based on findings that certain diagnostic or therapeutic practices have been found “to meet the needs of most patients in most circumstances”, [but clinical] “…judgment…remains paramount [in developing] treatment plans that are tailored to the specific needs and circumstances of the patient.” (NHLBI)

Compare with “Criteria (clinical)”.

Health Insurance Portability and Accountability Act (of 1996)

HIPAA The Act includes three major Rules: 1) Administrative Simplification (AS); 2) Security; 3) Privacy

The AS provisions require national standards for electronic health care transactions and national identifiers for providers, health plans and employers. (Also see “National Provider Identifier”.)

Healthcare Common Procedure Coding System

HCPCS Healthcare Common Procedure Coding System (HCPCS) means the national method of classifying written descriptions of diseases, injuries, conditions, procedures, and supplies using alphabetic and numeric designations or codes. (Per Chapter 59G-1.010, F.A.C.)

Home health services HH services Medically necessary services which can be effectively and efficiently provided in a recipient’s place of residence.

Services include nurse and home health aide home health visits, private duty nursing and personal care services for children, therapy services, medical supplies, and durable medical equipment.

Florida Medicaid reimburses home health services provided to an eligible recipient when it is medically necessary to provide the services in the place of residence. Medicaid does not reimburse HH services solely due to age, environment, convenience or lack of transportation.

HH services require prior authorization by eQHealth Solutions (eQHealth).

Home health visit HH visit A face-to-face contact between a registered nurse, licensed practical nurse, or a home health aide and recipient at his place of residence.

Under Florida Medicaid, a home health visit is not limited to a


Appendix A




Definition

specific length of time. It is defined as an entry into the recipient’s place of residence, for the length of time needed to provide the medically necessary nursing or aide services.

Home health visits are limited to a maximum of four intermittent visits per day. The may be any combination of licensed nurse and home health aide.

HH visits must be prior authorized by eQHealth Solutions.

Medicaid does not reimburse for travel time associated with a home health visit.

Homebound Medicaid may reimburse home health services for an eligible recipient who is under the care of an attending physician and who, because of his condition, is confined to the place of residence. (See “Place of residence”.)

To be considered homebound the recipient must require service that, due to a medical condition, illness or injury must be delivered at the place of residence rather than an office, clinic or other outpatient facility because:

Leaving home is medically contraindicated and would increase the medical risk for exacerbation or deterioration of the condition; or

The recipient is unable to leave home without the assistance of another person.

Household member Parents, stepparents, spouse, siblings, sons, daughters, or any person with custodial or legal responsibility for a Medicaid recipient.

Medicaid does not reimburse for HH visits and PCS provided by household members.

Independent personal care provider

An individual who renders personal care services (PCS) directly to recipients and does not employ others for the provision of personal care services.

These providers must enroll in the Medicaid program and meet minimum age, training and work or equivalent education experience requirements.

Independent care providers may not render home health personal care services for their own children or members of their households. (There may be an exception for the CDC+ recipients)

Independent personal care group provider

An unlicensed group (agency) enrolled to provide personal care services (PCS) that has one or more staff employed to perform the services. All employees of the group provider must meet the qualifications and requirements specified for the provision of PCS and are enrolled in the Medicaid program as an individual personal care provider.


Appendix A




Definition

International Classification of Diseases coding system

ICD-9-CM “ICD-9-CM Diagnosis and Procedure Codes” means the International Classification of Diseases, 9th Revision, and Clinical Modification, which is a method of classifying written descriptions of diseases, injuries, conditions, and procedures using alphabetic and numeric designations or codes.

InterQual® Criteria Proprietary, copyrighted measures used by eQHealth’s 1st level reviewers for certain categories of health care services to assist them in determining whether the services are medically necessary.

If the criteria are failed, the 1st level reviewer refers the case to a physician (2nd level) reviewer for a medical necessity determination. (Also see “Criteria (clinical)”)

Length of stay or length of service

LOS A period during which health care services are provided. Length of stay generally refers to an inpatient period and length of service to the period of non-inpatient services. However the term length of stay often is used for both.

Medicaid Identification Card

MIC A temporary proof of Medicaid eligibility that the recipient may use until he receives his Medicaid gold card. It is also referred to as an AMIC.

Medicaid Provider Access System and Program

MediPass “Medicaid Physician Access System (MediPass)” means the physician primary care case management waiver program.

A primary care, case management program designed to assure Medicaid recipients access to care, decrease inappropriate service utilization, and control costs.

The program is available statewide. MediPass primary care providers are responsible for providing or arranging for the recipient’s primary care and for referring the recipient for other necessary medical services.

Medically complex “Medically complex” means that a person has chronic debilitating diseases or conditions of one or more physiological or organ systems that generally make the person dependent upon 24-hour-per-day medical, nursing, or health supervision or intervention. (Per Chapter 59G-1.010, F.A.C.)

Medically fragile “Medically fragile” means an individual who is medically complex and whose medical condition is of such a nature that he is technologically dependent, requiring medical apparatus or procedures to sustain life, e.g., requires total parenteral nutrition (TPN), is ventilator dependant, or is dependent on a heightened level of medical supervision to sustain life, and without such services is likely to expire without warning. (Per Chapter 59G-1.010, F.A.C.)


Appendix A




Definition

Medically necessary or medical necessity

Medically necessary or medical necessity means that the medical or allied care, goods, or services furnished or ordered must:

(a) Meet the following conditions:

1. Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain; 2. Be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient’s needs; 3. Be consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational; 4. Be reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide; and 5. Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient’s caretaker, or the provider.

(b) “Medically necessary” or “medical necessity” for inpatient hospital services requires that those services furnished in a hospital on an inpatient basis could not, consistent with the provision of appropriate medical care, be effectively furnished more economically on an outpatient basis or in an inpatient facility of a different type.

(c) The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, good or services medically necessary or a medically necessity or a covered service. (Per Chapter 59G-1.010, F.A.C.)

Also see “Service requirements”.

Medically Needy Program The Florida Medicaid Provider General Handbook (Chapter 3) provides the following description of the Medically Needy Program: “A Medically Needy recipient is an individual who would qualify for Medicaid, except that the individual’s income or resources exceed Medicaid's income or resource limits.

On a month-by-month basis, the individual’s medical expenses are subtracted from his income. If the remainder falls below Medicaid’s income limits, the individual may qualify for Medicaid for the day he became eligible until the end of the month.”


Appendix A




Definition

As stated in Chapter 1, of the Handbook, “Recipients who are enrolled in the Medically Needy Program must meet their share of cost and the Department of Children and Families must determine if the recipient is eligible for Medicaid on the provider’s service date.”

Milliman Care Guidelines® eQHealth Solutions maintains a license agreement for its 1st level reviewers to use these proprietary clinical guidelines when performing utilization review or utilization management for certain health care services. The evidence-based guidelines include a broad range of criteria, care pathways, length of stay targets, an array of other medical necessity assessment tools, and a comprehensive bibliography to assist reviewers. (Also see “Guidelines (clinical))”.

National Provider Identifier NPI HIPAA Administrative Simplification Standards. The NPI is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses use the NPI’s in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-digit number.

Newborn (Neonate) An infant from birth through the first 28 days of life.

Non-certification A prior authorization or review determination rendered by a physician when health care services are not medically necessary or appropriate. That is, based on the available clinical information, the physician reviewer cannot certify (attest to) the medical necessity or appropriateness of the services.

Also referred to as a medical necessity denial, this adverse determination may only be rendered by a physician. (Also see “Adverse determination”.)

Partial denial (as it relates to utilization management findings)

See “Adverse determination”.

Pend (or pended) review The status of a review request when additional clinical information is needed to complete the review. eQHealth informs the provider that the review request is pended for additional information. The provider is asked to submit the information within one business day. (Also see “Suspended Review”.)

Personal care services PCS or PC services

PCS are to provide medically necessary assistance with activities of daily living that support a recipient’s medical care needs.

Florida Medicaid reimburses for PCS for qualified recipients


Appendix A




Definition

younger than 21 years of age who:

Have complex medical problems; and Require more individual and continuous care than can be

provided through a home health aide visit.

Personal care services must be provided according to an individualized plan of care in the recipient’s place of residence or, under authorized situations, outside the place or residence. The services may be provided by:

Home health agencies, or Independent personal care providers

Personal care services require prior authorization by eQHealth Solutions.

Place of residence Where a Medicaid recipient lives. May include:

Recipient’s private home. Assisted living facility (ALF) Group home. Foster or medical foster care home. Any home where unrelated individuals reside together in a

group.

Plan of care POC “Plan of care” or “Plan of treatment” means an individualized written program for a recipient that is developed by health care professionals based on the need for medical care established by the attending physician and designed to meet the health and/or rehabilitation needs of a patient. (Per Chapter 59G-1.010, F.A.C.)

It must identify the medical need for services, appropriate interventions, and goals and expected health outcomes. Plans of care for particular services such as home health and therapy may be associated with Agency-defined requirements specific to the type of service. These will be stated in the applicable Florida Medicaid Provider Handbook.

Prescribed Pediatric Extended Care Center and Program

PPEC

“Prescribed Pediatric Extended Care (PPEC) Center” means

any facility that is licensed by the Office of Licensure and

Certification pursuant to Chapter 391, F.S., and which

undertakes through its ownership or management to furnish,

for a portion of the day, basic services to three or more

medically complex children who are not related to the owner

or operator by blood, marriage, or adoption and who require

such services. (Per Chapter 59G-1.010, F. A. C.)

As stated in the Florida Medicaid Home Health Services


Appendix A




Definition

Coverage and Limitations Handbooks (Chapter 2), “[a]

recipient who is medically able to attend a prescribed pediatric

extended care (PPEC) center and whose needs can be met

by the PPEC shall be provided with PPEC services instead of

private duty nursing services.”

Medicaid recipients who may qualify for PPEC services are those who:

Are younger than 21 years of age; Have a medically complex condition (See definition.); Are medically stable; Require short, long-term, or intermittent continuous

therapeutic interventions or skilled nursing supervision; and

Have no communicable disease or illness.

Prior authorization PA A request submitted to the fiscal agent (FA), Medicaid or a quality improvement organization (QIO) for approval to deliver Medicaid covered medical or allied care, goods, or services in advance of the delivery of the care, goods, or services.


PDN “Private duty nursing” means nursing services for recipients who require more individual and continuous care than is available from a visiting nurse or routinely furnished by the nursing staff of the hospital or nursing facility (Per Chapter 59G-1.010, F. A. C.) Private Duty Nursing Services are individual and continuous care provided by licensed nurses in the recipient’s home.

Following is summary information about PDN services excerpted from the Florida Medicaid Home Health Services Coverage and Limitations Handbook:

PDN services are medically necessary skilled nursing services that may be provided in a child’s home or other authorized setting to support the care required by the child’s complex medical condition.

Florida Medicaid reimburses PDN services for recipients younger than 21 years of age who:

Have complex medical conditions; and Require more individual care than can be provided

through a home health nurse visit.

PDN services are authorized to supplement care provided by parents and caregivers. They must participate in providing care to the fullest extent possible.

Medicaid does not reimburse PDN services provided solely for the convenience of the child, parent or caregiver. Nor does Medicaid reimburse PDN services for respite care.


Appendix A




Definition

Medicaid limits PDN services to a minimum of two continuous hours and a maximum of 24 continuous hours/per day. If the service is less than two per day, it is considered a visit and must be billed as a home health (HH) visit.

PDN services may be rendered by a parent or legal guardian who has a valid Florida nursing license and is employed by a Medicaid-enrolled HH agency. The agency must provide particular documentation and there are other restrictions.

PDN services require prior authorization by eQHealth Solutions.

Also see “Short-term private duty nursing”.

Protected health information

PHI Information created or received from or on behalf of a HIPAA-defined Covered Entity as defined in 45 CFR 160.103 which include provisions for strictly safeguarding the confidential nature of an individual’s information. PHI includes not only an individual’s medical/clinical information but also demographic information that identifies the individual or about which there is a reasonable basis to believe, can be used to identify the individual.

Provider “Provider” means a person or entity that has been approved for enrollment and has a Medicaid provider agreement contract in effect with the department. (Per Chapter 59G-1.010, F. A. C.) It is a general term used to describe any entity, facility, person, or group who is enrolled in the Medicaid program and renders services to Medicaid recipients and bills for Medicaid services.

Provider Service Network PSN An integrated health care delivery system owned and operated by Florida hospitals and physician groups. It is a Medicaid managed care option for recipients residing in certain geographic regions of the State.

Quality Improvement Organization

QIO A federally designated organization as set forth in Section 1152 of the Social Security Act and 42 CFR Part 476. (QIOs were formerly called Peer Review Organizations [PROs].) They are firms that operate under the federal mandate to provide quality and cost-management services for the national Medicare Program and for states’ Medicaid programs.

The Center for Medicare and Medicaid Services (CMS) oversees the national Medicare QIO Program, and it requires that states contract with QIOs to assist them in managing the cost and quality of health care services provided to Medicaid recipients. By law, the mission of the federal QIO Program is to improve the effectiveness, efficiency, economy, and quality of services delivered to recipients.

CMS reports that “Throughout its history, the Program has


Appendix A




Definition

been instrumental in advancing national efforts to motivate providers in improving quality, and in measuring and improving outcomes of quality.”

Recipient “Recipient” or “Medicaid recipient” means any individual whom the Agency, Department of Children and Family Services or the Social Security Administration on behalf of the Department of Children and Family Services determines is eligible, pursuant to federal and state law, to receive medical or allied care, goods, or services for which the Agency may make payments under the Medicaid program and is enrolled in the Medicaid program. (Per Chapter 59G-1.010, F. A. C.)

Reconsideration A second review of health care services for which an adverse determination was rendered by a physician and which is performed by a physician who was not involved in the original determination. It may be requested by the treating physician, other provider of the services, and/or the recipient.

The outcome of a reconsideration may be one of the following:

Modified - Some of the services are certified (approved) and some continue to be non-certified (denied).

Reversed – Services are certified (approved) as originally submitted. The original determination is over-turned.

Upheld – The original non-certification (denial) is maintained.

Retrospective review Utilization review performed after health care services have been completed or were otherwise concluded.

Second level reviewer 2nd level reviewer

A Florida-licensed physician who meets all physician reviewer credentialing requirements established by AHCA and who is employed or contracted by eQHealth Solutions to perform utilization management services. The term includes individual physicians as well as the physicians who directly or indirectly supervise them and who themselves may perform utilization management services.

Only a 2nd level reviewer may render an adverse determination. (Also see “First level reviewer” and “Adverse determination”.)

Service authorization “Service authorization” means the approval required from the designated authority for reimbursement for certain Medicaid services. (Per Chapter 59G-1.010, F. A. C.)

Service limit or limitation “Service limit” or “service limitation” means the maximum amount, duration, or scope of a Medicaid covered service. (Per Chapter 59G-10.01, F. A. C.)


Appendix A




Definition

Service requirements Medicaid reimburses for services that are determined medically necessary and do not duplicate another provider’s services. In addition, the services must meet the following criteria:

The service must be individualized, specific, and consistent with symptoms or confirmed diagnosis of illness or injury under treatment, and not in excess of the recipient’s needs.

The services cannot be experimental or investigational; The services must be reflective of the level of service that

can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide; and

The services must be furnished in a manner not primarily intended for the convenience of the recipient, the recipient’s caretaker or the provider.

The fact that a provider prescribed, recommended or approved medical or allied care, goods or services does not, in itself, make them medically necessary or a covered service. See “Medically necessary or medical necessity” and “Experimental or clinically unproven procedures.”

Share of cost The amount of medical expenses that must be deducted from an enrolled Medically-Needy recipient’s income to make him eligible for Medicaid.

Short-term private duty nursing

Short-term PDN

Short-term private duty nursing means services provided for a time span limited by the nursing needs surrounding a specific acute medical event. Example: Orthopedic surgical procedure requiring more nursing intervention than is available in an intermediate care facility for the developmentally disabled (ICF/DD) during the initial recuperation period.

Skilled nursing Chapter 59G-4.290, F.A.C provides the criteria for skilled nursing. It states:

“(3) Skilled Services Criteria.

(a) To be classified as requiring skilled nursing or skilled rehabilitative services in the community…, the recipient must require the type of medical, nursing or rehabilitative services specified in this subsection. (b) Skilled Nursing. To be classified as skilled nursing service, the service must meet all of the following conditions: 1. Ordered by and remain under the supervision of a physician; 2. Sufficiently medically complex to require supervision, assessment, planning, or intervention by a registered nurse.


Appendix A




Definition

3. Required to be performed by, or under the direct supervision of, a registered nurse or other health care professionals for safe and effective performance; 4. Required on a daily basis; 5. Reasonable and necessary to the treatment of a specific documented illness or injury; and 6. Consistent with the nature and severity of the individual’s condition or the disease state or stage.”

Supporting documentation Supporting documentation is particular documentation required at the time of an authorization request for particular services such as home health and therapy. The nature of the required documentation may vary according to the type of service and the type of authorization request. The required information is specified in the applicable Florida Medicaid Provider Handbook.

Supporting documentation is administratively required information, not additional clinical information, needed to complete a review.

Suspended review The status of a review request when a provider is notified that additional clinical information is needed to complete a review, but the provider does not submit the requested information within the required one business day timeframe.

A suspended review is a cancellation of the provider’s review request. If the requested information is submitted at a later date, the review request is unsuspended. (Also see “Pend (or pended) review” and “Unsuspended review”.)

Technical denial A determination that there is a breach of a Medicaid eligibility requirement or of an administrative requirement or policy, as determined by the Agency. Review is not performed for services for which a technical denial is rendered. Examples of situations that result in a technical denial are:

Patient is not eligible for Medicaid for the period for which authorization is requested.

Recipient is ineligible for a particular health care service. The provider is ineligible. The content or documentation requirements for particular

supporting documentation do not conform to Agency policy.

The authorization request duplicates another service request.

Since a technical denial is an administrative determination, not a medical necessity determination, it is not subject to reconsideration unless the required documentation is submitted. However the recipient may request a fair hearing.


Appendix A




Definition

Third party An individual, entity, or program, excluding Medicaid, that is, may be, could be, should be, or has been liable for all or part of the cost of medical services related to any medical assistance covered by Medicaid.

Third party liability TPL “Third party” means an individual, entity, or program, excluding Medicaid, that is, may be, could be, should be, or has been liable for all or part of the cost of medical services related to any medical assistance covered by Medicaid. (Per Chapter 59G-1.010, F. A. C.).

Thomson Healthcare Norms

A compilation of normative length of stay (LOS) data that may be compared with the actual or possible LOS for a particular individual and/or regionally or nationally.

eQHealth Solutions maintains a product license permitting use of the proprietary norms. For certain health care services, first level reviewers reference them as a guide when considering the certifiable (approved) LOS for a particular individual, at a particular point in time. The LOS normative data take into consideration the individual’s diagnosis, age, procedure(s) and comorbidities.

Title XIX “Title XIX” means the sections of the federal Social Security Act, 42 U.S.C. s. 1396 et seq., and regulations there under, that authorizes the Medicaid program. (Per Chapter 59G-1.010, F. A. C.).

Unsuspended review The status of a review request when a provider submits all additional clinical information that was needed to complete a review. When all required information is submitted, eQHealth “unsuspends” the review request and completes the review. (Also see “Suspended review” and “Pend (or pended)” review.)

Urgent situation and services

An urgent situation occurs when health care services are needed to immediately relieve pain or distress for medical problems such as injuries, nausea, fever, and services needed to treat infectious diseases and other similar conditions. (Also see “Emergency medical condition or situation”.)

Utilization review UR The evaluation of the appropriateness, necessity, and quality of services billed to Medicaid. It also means the evaluation of the use of Medicaid service by recipients.


Appendix A



APPENDIX B – INTENTIONALLY LEFT BLANK

PARENT OR LEGAL GUARDIAN SCHOOL SCHEDULE

Vis i t AHCA on l ine a t h t tp : / /ahca.myf lor ida.com

2727 Mahan Dr i ve , MS# Ta l lahassee, F lor i da 32308

For use by the Provider:

Recipient’s Name: ______________________________ Recipient Medicaid ID: ________________

This form must be completed by a school Advisor or representative.

Parent/Legal Guardian Name: Name of School: Address: Semester: Fall Spring Summer Year: ___________

Class Schedule: (Include class hours for each day):

Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Sunday:

Name of School Representative: Title: Telephone Number: ( ) Signature: Date:

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Appendix C

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PARENT OR LEGAL GUARDIAN WORK SCHEDULE



This form must be completed by a Supervisor at the place of employment. Parent/Legal Guardian Name: Name of Employer: Address:

Work Schedule: (Include work hours for each day)

Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Sunday: If employee works a variable work schedule, please indicate the number of hours per week, this employee works: ___________________________________

Supervisor Name:

Title:

Telephone Number: ( )

Signature:

Date:

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Appendix D

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PHYSICIAN VISIT DOCUMENTATION FORM

This form must be completed by the physician ordering home health services.

Date: Medicaid Recipient Name: Physician Name: Physician Address: Physician Telephone Number: ( ) Diagnosis(es): Date of the recipient’s last examination or consultation in your office: __________________ Please describe the patient’s ongoing need for home health services: ____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

I hereby certify that I have examined the above named recipient on ______________ and have ordered home health services to treat the recipient’s acute or chronic medical condition as described above. Signature of Physician: National Provider Identifier: ___________________

Pursuant to 409.905 (4) (c), Florida Statutes: In order for Medicaid to reimburse for home health services, the physician ordering the services must have examined the recipient within the 30 days preceding the initial request for the services and biannually thereafter.

After completion of this form, please send directly to the recipient’s home health agency.

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Appendix - E

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Personal Care Services Plan of Care For Use by Unlicensed Independent Personal Care Providers

1

PATIENT INFORMATION

ALLERGIES:

Certification Request: (check one) Initial Recertification Certification Period: / / / / From To (Re-certification required every 180 days)

Medicaid ID Number (10 digits):

MediPass Authorization # (if applicable): -

Last Name:

First Name:

Gender:

Date of Birth: / /

County of Residence:

Street Address:

AHCA Area Office:

City:

State:

Zip Code:

PROVIDER INFORMATION

Name:

Provider Medicaid ID Number: -

Street Address:

Phone #: ( ) -

City:

State:

Zip Code:

PATIENT MEDICAL AND SOCIAL INFORMATION

1. Diagnosis(es):

ICD-9 Code(s) (Provided by a Physician):

Written Description: Date of Diagnosis:

. / /

. / /

. / /

2. Medications (Dose/Route/Frequency):

3. Durable Medical Equipment & Supplies Used by the Recipient:

4. Special Nutritional Needs/Diet:

5. How does the patient eat? (check one): Feeds Self Needs Assistance G-Tube

6. Functional Limitations:

7. Ambulation/Permitted Physical Activities:

8. Safety Measures Required:

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Appendix - F

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Patient Name: ________________________

Personal Care Services Plan of Care For Use by Unlicensed Independent Personal Care Providers

2

9. Mental/Neurological Status (Note: If seizures present, describe how often they occur and what the patient does

during the seizure activity):

10. Breathing Difficulty (check one): Yes No If yes, please explain:

11. Parent/Guardian Work/School Hours and Days:

12. Parent/Guardian physical limitations in caring for child:

13. Number of other children in the home: 14. Age of other children in the home:

15. Special needs of other children in the home (if applicable):

SERVICE INFORMATION

16. Specific Hours/Days of Service (prescribed by the physician):

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

17. Services Provided (please check all that apply): Bathing and Grooming Oral Hygiene Oral Feedings and Fluid Intake

Toileting and Elimination Range of Motion and Positioning

Other

18. Expected Health Outcome (check one): Excellent Good Poor Unchanged

19. Rehabilitation Potential (check one): Excellent Good Poor Unchanged

20. Supervision of Services Provided (check one): Agency Parent/Guardian

21. Discharge Plan (leave blank, if not applicable):

PHYSICIAN CERTIFICATION

I certify that personal care services are medically necessary for activities of daily living that support this individual’s medical needs.

Signature of Physician: Date / /

Physician Name: Date Seen By Physician: / /

SIGNATURES

Signature of Recipient/Legal Guardian: Date / /

Legal Guardian/Parent Printed Name:

Signature of Provider: Date / / ATTACH PRESCRIPTION

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PARENT OR LEGAL GUARDIAN STATEMENT OF WORK SCHEDULE



This form must be completed by the Parent or Legal Guardian and then Notarized. Parent/Legal Guardian Name: Name of Employer: Address: Telephone Number: ( )

Work Schedule:

(Include work hours for each day)

Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Sunday:

If you work a variable work schedule, please indicate the number of hours per week that you work: ___________________________________

The information above is true and valid to the best of my knowledge.

Parent/Legal Guardian Signature:

Date: Notary Signature:

Notary Printed Name:

Notary Address:

Notary Telephone Number:

Date:

Seal

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Appendix - G

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PARENT OR LEGAL GUARDIAN MEDICAL LIMITATIONS

Vis i t AHCA on l ine a t h t tp : / /ahca.myf lor ida.com

2727 Mahan Dr i ve , MS# Ta l lahassee, F lor i da 32308



This form must be completed by the Parent or Legal Guardian’s Physician. Date: Patient Name: Physician Name: Physician Address: Physician Telephone Number: ( ) Please describe any medical limitation or disability that the above named individual may have that would limit their ability to participate in the care of a patient with complex medical needs (e.g. lifting restrictions, developmental disorder, bed rest for pregnancy, etc.): ____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

If limitation/disability is temporary, please document the expected timeframe for resolution. Signature of Physician: National Provider Identifier: ___________________ ____________________________________________________________________________

Signature of Parent/Legal Guardian:_______________________________________________ (By my signature, I am allowing release of this information to be used for the purpose of determining authorization for my child.)

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Appendix H

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