MEDICAID PRIOR AUTHORIZATION TRANSITIONfl.eqhs.com/Portals/10/Dec 2013 Presentation...

MEDICAID PRIOR AUTHORIZATION

TRANSITION

Prepared for:

Mississippi Medicaid General Dentists, Oral and Maxillofacial Surgeons, and Orthodontists

November 2013

December 1, 2013

The Road Ahead

2 12/8/2013 DENTAL PROVIDER EDUCATION

PRESENTATION

Today’s Goals and Objectives What stays the same and what changes?

When does the new process begin?

What do I need to know?


PRESENTATION

What stays the same?

Admin Code and DOM regulations are the same for all Dental Services. No change.


PRESENTATION

What is changing?

The Prior Authorization Process changes effective December 1, 2013

• Where and when you send the authorization request

• Envision is only used for checking eligibility and claims

• No DOM forms

• Who reviews the request

• Timeframes for submitting your request

• Increased speed of approvals and communication


PRESENTATION

When does the new process begin?

Effective December 1, 2013

• eQHealth will perform prior authorization reviews of general dental, oral and maxillofacial surgical, and orthodontia services


PRESENTATION

What happens to requests for services prior to December 1, 2013?

Services requested prior to December 1, 2013

• Continue to submit requests via Envision through November 30, 2013

• DOM will continue to process these requests

• Any service approved by DOM will remain in effect

• Requests previously submitted to DOM should not be resubmitted to eQHealth


PRESENTATION

eQHealth has a 16 year Utilization Management partnership with DOM

• Our multidisciplinary review team includes:

• Mississippi licensed registered nurses, dental hygienists, dental assistants, dentists, orthodontists, and oral maxillofacial surgeons

• The review team is overseen by our Dental Director, Dr. James “Ron” Philley


PRESENTATION

What do we need to

know?

• Admin Code and DOM Regulations

• eQHealth Systems & Review Process 9 12/8/2013

DENTAL PROVIDER EDUCATION PRESENTATION

Getting to Know Mississippi Division of

Medicaid (DOM) Dental Coverage

For comprehensive information about Dental services covered, limitations and exclusions; the following are important resources to be familiar with:

• Mississippi Administrative Code Title 23 Medicaid, Part 204, Dental Services

• Mississippi Medicaid Provider Reference Guide (PRG 204)

• Medicaid Dental Fee Schedule

• Medicaid Dental Fee Schedule – Outpatient Hospital

• Remember there is no change to DOM regulations regarding what codes need prior authorization or when codes need prior authorization. The only change is where and how you submit your prior authorization requests

12/8/2013 DENTAL PROVIDER EDUCATION

PRESENTATION 10

http://www.medicaid.ms.gov/Manuals/Title 23 Part 204 Dental Services.pdf

http://www.medicaid.ms.gov/Manuals/ProviderReferenceGuide/DentalServices.pdf

http://www.medicaid.ms.gov/Fees/DentalFeeSch.pdf

http://www.medicaid.ms.gov/Fees/Outpatient Dental Fee.pdf




Will all Dental service codes require prior authorization (PA) on December 1, 2013?

Good question, the answer is No but let’s take a closer look


PRESENTATION

Orthodontia: Codes Always Require PA

All Current Dental Terminology (CDT) Codes and Descriptors are copyrighted 2013 by the American Dental Association. Orthodontia CDT© Codes always require PA

D8670 - PERIODIC ORTHDONTIC TREATMENT VISIT (AS PART OF CONTRACT)

D8080 - COMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADOLOSCENT DENTITION

D8999 UNSPEC ORTHODONTIC PROCEDURE, BY REPORT


PRESENTATION 12

General Dental Codes: Always Require PA (No change from existing requirements)

All Current Dental Terminology (CDT) Codes and Descriptors are copyrighted 2013 by the American Dental Association. Dental CDT© Codes that always require PA

D0321 -OTHER TEMPOROMANDIDULAR JOINT RADIOGRAPHIC IMAGES BY REPORT

D0999 - UNSPEC DIAGOSTIC PROCEDURE BY REPORT

D2750 - CROWN-PORCELAIN FUSED TO HIGH NOBILE METAL

D2751 - CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL


PRESENTATION 13



D2752 - CROWN-PORCELAIN FUSED TO NOBILE METAL

D2940 - PROTECTIVE RESTORATION POST REMOVAL

D2952 - POST AND CORE IN ADDITION TO CROWN, INDIRECTLY FABRICATED

D2999 - UNSPEC RESTORATIVE PROCEDURE BY REPORT

D3346 - RETREATMENT-INTERIOR BY REPORT


PRESENTATION 14



D3347 - RETREATMENT-BICUSPID BY REPORT

D3348 - RETREATMENT-MOLAR BY REPORT

D3999 - UNSPEC ENDODONTIC PROCEDURE,BY REPORT

D5110 - COMPLETE UPPER

D5120 - COMPLETE LOWER

D5211 - UPPER PARTIAL-RESIN BASED (INC ANY CONVENTIONAL CLASPS, RESTS)


PRESENTATION 15



D5212 - LOWER PARTIAL-RESIN BASED (INC ANY CONVENTIONAL CLASPS, RESTS

D5955 - PALATAL LIFT PROSTHESIS DEFINITIVE

D6999 - UNSPEC FIXED PROSTHODONTIC PROCEDURE, BY REPORT

D7251 - CORONECTOMY-INTENTIONAL PART TOOTH REMOVAL

D7272 - TOOTH TRANSPLANTATION

D7280 - SURGICAL ACCESS OF UNERUPTED TOOTH


PRESENTATION 16



D7288 - BRUSH BIOPSY-TRANSEPITHELIAL SAMPLE COLLECTION

D7490 - RADICAL RESECTION OF MAXILLA OR MANDIBLE

D7860 - ARTHROTOMY

D7940 - OSTEOPLASTY-FOR ORTHOGNATHIC DEFORMITIES

D7943 - OSTEOTEMY - MANDIBULAR RAMI WITH BONE GRAFT, INC OBTAINING GRAFT

D7946 - LEFORT I BASED (MAXILLA TOTAL)


PRESENTATION 17



D7947 - LEFORT I BASED (MAXILLA SEGMENTED)

D7948 - LEFORT II OR III (OSTEOPLASTY OF FACIAL BONES - MID FACE)

D7949 - LEFORT II OR III - WITH BONE GRAFT

D7950 - OSSEOUS,OSTEOPERIOSTEAL, OR CARTILLAGE GRAFT OF MANDIBLE OR MAXILLA AUTOGENOUS OR NONAUTOGENOUS, BY REPORT

D7955 - REPAIR OF MAXILLAFACIAL SOFT AND/OR HARD TISSUE DEFECT

D7981 - EXCISION OF SALIVARY GLAND BY REPORT


PRESENTATION 18



D7983 - CLOSURE OF SALIVARY FISTULA

D7991 - CORONOIDICTOMY

D7999 - UNSPEC ORAL SURGERY PROCEDURE, BY REPORT

D9110 - PALLIATIVE (EMERGENCY) TREATMENT OF DENTAL PAIN- MINOR PROCEDURES

D9940 - OCCLUSAL GUARDS, BY REPORT

D9999 - UNSPEC ADJUNCTIVE PROCEDURE, BY REPORT


PRESENTATION 19

Additional Dental Codes: Only requires PA when dollar benefit limit reached for all beneficiaries

(No change from existing requirements)

Refer to DOM Dental Fee Schedule Professional Services and DOM Dental Fee Schedule Outpatient Hospital for a current listing of CDT codes requiring PA after exceeding expenditure specified in Administrative Code and Fee Schedule, (greater than $2500 per state fiscal year July 1 – June 30)


PRESENTATION 20

Before You Get Started: Checkpoint #1


PRESENTATION 21

Did you check beneficiary eligibility?

You are responsible for verifying a Medicaid beneficiary’s eligibility each time the beneficiary appears for service. You are also responsible for confirming the person presenting the card is the person to whom the card is issued

Verify eligibility by access any of the following services:

• Website verification: Envision

• Automated Voice Response System (AVRS) at 1-866-597-2675

• Provider/Beneficiary Services Call Center at 1-800-884-3222

• Using personal computer (PC) software or point of service (POS) swipe card verification device

https://msmedicaid.acs-inc.com/msenvision/index.do



PRESENTATION 22

The following beneficiaries require prior authorization

by eQHealth:

• Fee-for-service EPSDT eligible beneficiaries

• Fee-for-service non EPSDT eligible beneficiaries once the service limit has been exceeded

• Dual Coverage (Private Insurance and Medicaid)

The following beneficiaries do not require prior

authorization by eQHealth:

• Beneficiaries enrolled in Mississippi Coordinated Access Network (MSCAN), or CHIP

• Beneficiaries in COE 29, Family Planning Waiver

• Beneficiaries with no Medicaid coverage for the date of service

Note: The Federal Government is requiring Medicaid programs to change their categories of eligibility by January 1, 2014. Making sure you check eligibility becomes a business necessity


PRESENTATION 23

Select your eQSuite™ Web Administrator


Selecting Your Key Players


PRESENTATION 24

Who is the best person to be the eQ Suite™ Web Administrator?

When is this information due to eQHealth? What type of skills should this person have?


PRESENTATION

Get Your Provider Contact Form

Visit our Web site at

ms.eqhs.org


PRESENTATION 26

http://ms.eqhs.org/



PRESENTATION 27

Effective December 1, 2013, discontinue using all DOM prior

authorization forms

•DOM forms will be replaced by eQHealth’s automated Web based review submission process


PRESENTATION 28

To assist with helpful reminders please welcome your Prior Authorization buddy. Pete the PA Parrot

Before You Get Started: Checkpoint #3 General Dental & Oral Maxillofacial

(Non-Orthodontia)


PRESENTATION 29

Please ensure your documentation supports your responses to the following questions


(Non-Orthodontia)


PRESENTATION 30

Review Questions – The following pages detail the questions you will need to answer for general

dentistry and oral maxillofacial codes in our Web based review system

• Note: A printable version of this form can be found at http://ms.eqhs.org and used as a reference tool

http://ms.eqhs.org/


(Non-Orthodontia)


PRESENTATION 31

• Textbox

Question 1:

What is the reason for the treatment authorization request?

• Textbox

Question 2:

Please address why this is the most cost effective and clinically appropriate treatment option to address the patient's dental needs

• Textbox

Question 3:

What is the five year prognosis of the requested treatment procedure?


(Non-Orthodontia)


PRESENTATION 32

• Yes

• No

• Textbox

Question 4:

Is this treatment for initial placement of a prosthesis? If yes, please describe if this is

maxillary or mandibular.

• MM/DD/YYYY

Question 5:

If treatment is for repair or replacement of a prosthesis, please provide the following:

Is this maxillary or mandibular, full or partial, and the date it was inserted

Whether the original can be worn or is in use now.

Whether the original can be repaired



PRESENTATION 33

A copy of the patient's radiograph is required.

To submit you can upload the file directly or create a barcode fax coversheet. These options are available by clicking the

[Link Attachments to this Review] button after submitting the review. You may also mail a copy of the radiograph to:

eQHealth Solutions Attn: Dental

460 Briarwood Drive, Suite 300 Jackson, MS 39206

Note: eQHealth Solutions Review Team can not start the review process until we receive the radiograph. Uploading or faxing is the most efficient and quickest

method. Radiographs mailed without the unique patient bar code will delay the review and will be returned to your office for identification

eQHealth is required by DOM to return all radiographs to you following the completion of our review

Before You Get Started: Checkpoint #3 Orthodontia


PRESENTATION 34

Please ensure your documentation supports your responses to the following questions



PRESENTATION 35

Review Questions – The following pages provide a reference outlining the questions you will be

required to complete when submitting a request for Orthodontia services. All questions are online in eQ

Suite™, eQHealth Solutions Web based review module

• Note: A printable version of this form can be found at http://ms.eqhs.org and used as a reference tool

http://ms.eqhs.org/



PRESENTATION 36

•Yes

•No

•Textbox

Question 1:

Is this a request to transfer services to another

dentist/dental practice? If yes, please list the

month and year treatment was started with the other Dental practice and reason

for transfer



PRESENTATION 37

• Cleft lip, cleft palate and other craniofacial anomalies

• Overjet of 9 millimeters or more

• Reverse overjet of 2 millimeters or more

• Extensive hypodontia with restorative implications (more than one tooth per quadrant) requiring pre-prosthetic orthodontics

• Anterior open bites greater than 4 millimeters

• Upper anterior contact point displacements greater than 4 millimeters

• Individual anterior tooth crossbites with greater than a 2 millimeter discrepancy between retruded contact position and intercuspal position

• Impinging overbite with evidence of gingival or paletal trauma

• Impeded eruption of teeth (except third molars) due to crowding, displacement, presence of supernumerary teeth, retained primary teeth, and any pathologic cause; unless extraction of the displaced teeth or adjacent teeth, requiring no orthodontic treatment would be more expedient.

• Other: Please explain

Question 2:

Please select the reasons for the

orthodontic request: Select all that apply.



PRESENTATION 38

• Textbox

Question 3:

Medicaid Orthodontic Initial Assessment Form (OIAF) total

score:

• http://ms.eqhs.org/

Note: It is only necessary to provide us with the total score as long as all of the questions are answered; however, the

complete form/worksheet and instructions are available at:

http://ms.eqhs.org/



PRESENTATION 39

Required: A copy of the patient's radiograph and photographs are required.

1. Upload or fax a copy of the OrthoCAD file or other electronic image. These options are

available by clicking the [Link Attachments to this Review] button after submitting the review. The system generates a patient specific tracking number that safely and securely attaches all

information to the orthodontia request. OR; 2. Submit the patient's tooth mold to us by mailing along with our system generated patient

specific bar-coded coversheet to:

eQHealth Solutions Attn: Orthodontics

460 Briarwood Drive, Suite 300 Jackson, MS 39206

Note: eQHealth Solutions Review Team can not start the review process until we receive the radiographs, photographs and mold. Uploading is the most efficient and quickest method.

Molds mailed without the unique patient bar code will delay the review and will be returned to your office for identification

eQHealth is required by DOM to return all molds to you following the completion of our review

Before You Get Started: Checkpoint #3 When should I send my request to eQHealth?


PRESENTATION 40

New Service/Admission

• Routine/elective/planned office procedures or outpatient hospital procedures (less than 24 hours) - submit the PA request a minimum of seven (7) business days prior to the planned service date

• Urgent or Emergent conditions submit as soon as possible, but no later than seven (7) business days after the dental service is performed. Remember to write in the note section the reason for delay in submitting was due to an urgent/emergent condition.

• Reminder: Inpatient hospitalizations (24 hours or more) for dental treatment refer to Inpatient Acute Care Provider Manual –PA requests are submitted online by the hospital or pre-cert line

Before You Get Started: Checkpoint #3 When should I send my request to eQHealth?


PRESENTATION 41

Retrospective:

• Applies to beneficiaries with retroactive eligibility; and the beneficiary has already received the service/procedure

• Submitting the review request to eQHealth as soon as eligibility is confirmed is preferred. However, the maximum amount of time to submit a claim is within one (1) year of the retroactive eligibility determination date

• If services are in progress when the retroactive eligibility is determined, submit a new service/admission review request

Know the codes requiring PA, and rules in Administrative Code and DOM Regulation

Check beneficiary eligibility

Collect answers to review questions and plan ahead for timeframes for submitting PA requests and processing of your request

Congratulations now you are ready to send the information to eQHealth

A Quick Checklist Review Before You Get Started:


PRESENTATION 42

The next step of the transition journey

Checkpoint #4 Learning how to use our Web tool

• eQUniversity

• Review Process and eQSuite ™

• Web Administrator Registration

• Support and Training


PRESENTATION


PRESENTATION 44


PRESENTATION 45


PRESENTATION 46


PRESENTATION 47


PRESENTATION 48


PRESENTATION 49

GENERAL DENTISTRY AND SURGICAL


PRESENTATION 50

ORTHODONTICS


PRESENTATION 51


52

GENERAL DENTISTRY AND SURGICAL

12/8/2013


53 12/8/2013


54 12/8/2013


PRESENTATION 55


PRESENTATION 56


PRESENTATION 57


PRESENTATION 58


PRESENTATION 59


PRESENTATION 60

Beginning 12/1/13: What will eQHealth do with your request?


PRESENTATION 61

eQHealth Solutions First Level Reviewers – dental hygienist, nurses trained in dental services and/or dentists

• Apply Admin Code and DOM regulations

• Apply DOM approved medical necessity guidelines

• May request additional information – “Pending a review”

• Approve services based on DOM regulations and guidelines

• Refer requests they can not approve to a second level reviewer

12/8/2013 DENTAL PROVIDER EDUCATION PRESENTATION

62

eQHealth Solutions Second Level Reviewers – dentists, oral & maxillofacial surgeons, and orthodontists

• May contact the ordering physician/dentist to obtain additional information – “Pending a review”

• Approve services

• Partially approve services

• Deny services


PRESENTATION 63

National Guidelines for Dental and Orthodontia Services

eQHealth Solutions uses DOM approved National Clinical Guidelines (referred to as Clinical Guidelines) as tools when making clinical determinations concerning the medical necessity of care. These guidelines are available at http://ms.eqhs.org


PRESENTATION 64

What is a Pend? • Pends are questions submitted to providers from either a

first level reviewer or a second level reviewer that generally involve a need for clarification or additional information before a review can be completed

• Pends may occur anytime there are:

– Questions about the information that has been submitted

– Missing required information


PRESENTATION 65

How Do I Know I’ve Been Pended?

eQSuite™ will provide information about your request/case at all times

• eQSuite™ is accessible 24 hours a day, 7 days a week to check the status of your request/case, including pend messages

• The image on the left highlights where to respond to a pend question. The upper box will contain the question. The lower box is where you may respond

• eQHealth will contact the “review submitter” or physician’s office by phone to inform you of the information needed to complete your request. If you are not available we will leave a message to check eQSuite


PRESENTATION 66

How Do I Respond To a Pend?

Responding to pends as soon as possible keeps the review process progressing

• You can respond to pends online via the eQSuite™


PRESENTATION 67

Should I Like Being Pended?


PRESENTATION 68

How do I prevent being

pended?

Is getting Pended good?


PRESENTATION 69

The up side about a pended review is that it opens a line of communication between eQHealth and the dental practice

The down side, the review process stops until you respond

Applying a few easy tips can keep your review moving along

To prevent pends or apendaphobia:

• Don’t copy and paste clinical information into reviews

• Attend eQUniversity trainings

• Answer the pend question completely and accurately

• If you feel you are receiving numerous pends, immediately consult an eQUniversity Team Member at 601-360-4961 for assistance

Pend Prevention Tips


PRESENTATION 70

How Many Business Days Does eQHealth Have To Process Your Review?


PRESENTATION 71

• New Service/Admission review requests: 7 business days

• Retrospective review requests: 20 business days (Retrospective eligibility only)

eQHealth completes requests for services as quickly as possible, but within specific timeframes. The timeframe depends on when the service is anticipated to occur (new request/admission review) or has occurred. The review completion timeframe is measured from the date eQHealth receives your request.

Denials


PRESENTATION 72

What Is a Denial?


PRESENTATION 73

A denial occurs when any portion of requested services are not approved

Clinical Denial – Any portion of requested services are not approved by a second level reviewer for a clinical reason

Reconsiderations


PRESENTATION 74

Reconsiderations - “Another Look”

•Must be requested within 30 calendar days of the denial notification

•Beneficiary or provider may request a reconsideration


PRESENTATION 75


• A reconsideration is another look at your request/case by a different eQHealth Solutions second level reviewer (a different dentist/physician who was not involved in the original denial decision)

• Available when eQHealth issues a clinical denial

• The denial notification will have specific instructions for requesting a reconsideration

• HELPLINE assistance is available by calling 1-866-740-2221


PRESENTATION 76


• Outcomes:

• Upheld – no change in original decision to deny. Denial remains in place. Administrative Appeal rights explained in the reconsideration denial outcome notice

• Modified – part of the request is approved and the remainder is denied

• Overturned – original decision to deny the request/service is reversed and approved. A Treatment Authorization Number (TAN) is generated; And,

• Approval information is sent daily to the fiscal intermediary


PRESENTATION 77

Appeals


PRESENTATION 78

DOM Administrative Appeal Right

• If a reconsideration is Upheld or Modified(partially approved) ONLY the beneficiary, parent, legal guardian/caregiver may request an administrative appeal of the eQHealth determination

• Administrative Appeals must be requested in writing to DOM within 30 calendar days of the reconsideration notification date

• DOM performs the Administrative Appeal/Hearing


PRESENTATION 79

A Helpful Transition Aide for December 1, 2013

Do not use existing DOM Dental or Orthodontia forms – eQSuite™ replaces DOM forms. Our web site ms.eqhs.org has a sample copy of all questions to assist in planning ahead

Know the Rules - Admin Code and DOM regulations

• Check Eligibility prior to every visit

• Eligibility changes will be occurring on 1/1/2014

• Answer the questions thoroughly in eQSuite™

• Plan ahead to allow time for eQHealth to process the request

By12/1/13: Send your completed Provider Contact Form to eQHealth via email at [email protected] OR call 601.360.4961. Completing this form allows your eQSuite™ Administrator to setup access for submitting PA requests. If you do not have a form download one at ms.eqhs.org


PRESENTATION 80

eQUniversity will continue to provide education support to you:

• Monthly and Quarterly webinars

• Education materials posted on website ms.eqhs.org

• HELPLINE 1-866-740-2221

• Tailored educational offerings to meet your needs


PRESENTATION 81

November 2013 and going forward

• Training is free

• No limit on the number of times you can attend

• Idea: Incorporate eQUniversity into your new employee orientation


PRESENTATION 82

November 2013 and going forward


PRESENTATION 83


PRESENTATION 84

For additional training and links to resources:

Visit our Web site at

ms.eqhs.org


PRESENTATION 85


PRESENTATION

Thank you for attending…..


PRESENTATION 87

MEDICAID PRIOR AUTHORIZATION TRANSITIONfl.eqhs.com/Portals/10/Dec 2013 Presentation...

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Transcript of MEDICAID PRIOR AUTHORIZATION TRANSITIONfl.eqhs.com/Portals/10/Dec 2013 Presentation...