Comagine HealthWyoming Medicaid

Skilled Nursing Services Refresher TrainingAugust 15 and 16, 2019

Teresa Kirn, RN IQCIClinical Nurse Specialist

Lisa LayneNon-Clinical Manager

Qualis Health & HealthInsight have joined forces to do great things.

Together, we’re reimagining health care.

Who We Are: A national, nonprofit, health care consulting firm working collaboratively with patients, providers, payers and other stakeholders to reimagine, redesign and implement sustainable improvements in the health care system

Our Mission:Together, with our partners, we work to improve health and to create a better health care system so that people and communities will flourish.

About Us• Our services:

• Care Management• Systemwide Quality Improvement• Consulting and Research• Health IT and Analytics

• Providing care management to Medicaid and private contracts since 1984

• Office locations in Alabama, Alaska, California, District of Columbia, Idaho, Nevada, New Mexico, Oregon, Utah and Washington state

What We Do• Contract with Wyoming Medicaid to review for select

outpatient services: • Skilled Nursing (SN) reviews for waiver plans • Durable Medical Equipment (DME) • Home Health Services (HHS)• Physical Therapy (PT), Occupational Therapy (OT) and Speech

Therapy (ST)• Behavioral Health (BH) visits

• Utilize InterQual® (IQ), state guidelines and organizational policies to conduct reviews

• Offer web-based and telephonic provider education

What We Don’t Do

We do not receive financial incentives to deny or limit services

Objectives

• How to submit a Skilled Nursing (SN) services prior authorization (PA) request for waiver plans

• How to submit additional pertinent clinical information when requested by Comagine Health via the Comagine Health Provider Portal (CHPP)

• How to check the status of a SN services PA request

Comagine Health Provider Portal

http://www.qualishealth.org/sites/default/files/WY-Medicaid-QHPP-User-Guide.pdf

Comagine Health website:

1. Enter your user/login ID in the User ID field2. Enter the password in the Password field3. Click Submit

Comagine Health Provider Portal cont.

CHPP User Acceptance Agreement

After reviewing the agreement, click on:• I Agree – allows you to fully log on to the CHPP• I Disagree –will navigate you back to the CHPP login page

UM Services(Step 4 - CHPP)

• Select Add Services• Complete all fields except for the Service Type, Modifier and UCR

Cost in $• Use HCPC S9123 or T1002 only• Save

UM Services cont.(Step 4 - CHPP)

• Once saved you will not be able to edit a service line.• To delete:

• Click the delete icon under Action

Add Notes(Step 7- CHPP)• Contact information

• Responses for additional information requests• Clinical information - not included on the Prior Authorizations of Skilled

Nursing Services form

Add Documents(Step 8 - CHPP)

• Upload (PDF or Word only)• Required Prior Authorization of Skilled Nursing Services form• Physician’s orders

.tif files are not a compatible format to upload

Dashboards and Alerts

The dashboard allows you to view your requests• OP - opens the request• Episode ID – abstract view

Dashboards and Alerts cont.

Monitor alerts for updates

Community Choice WaiverAges served 19 years and older

Eligibility Plan Code WLTCHCPC code S9123 (1 Hour)Required documentation:

Annually (all required): • Orders to include: reason for SN assessment and treatment, physician’s signature • Request for Prior Authorization of Skilled Nursing Services

Modifications (all required):• Request for Prior Authorization of Skilled Nursing Services

Review process: 1. Submit annual prior authorizations through the CHPP2. If you disagree with a decision (denied or reduced services), you may request a second

review through the CHPP within 30 days of the decision3. The provider will contact the case manager of denial or reductions , who notifies the

participant 4. A participant can request a reconsideration with the State of WY Medicaid5. A participant may request a Fair Hearing within 30 days of the case managers notification6. Modifications will be submitted as needed, second reviews are allowed and will follow the

process for annual reviews

Examples of technical denials:

• Missing required documentation (see required documentation above)• Incomplete required documentation• Lack of appropriate signatures on required documentation• Non-compliance of state and federal regulations

Comprehensive WaiverAges served 21 years and olderEligibility codes COAW: 21 years of age and olderHCPC code T1002 (15 minutes)Required documentation:

Annually (all required): • Orders to include: reason for SN assessment and treatment, physician’s signature • Request for Prior Authorization of Skilled Nursing Services

Modifications (all required):• Request for Prior Authorization of Skilled Nursing Services

Review process: 1. Submit annual prior authorizations through the CHPP2. If you disagree with a decision (denied or reduced services), you may request a second

review through the CHPP within 30 days of the decision3. The provider will contact the case manager of denial or reductions , who notifies the

participant 4. A participant can request a reconsideration with the State of WY Medicaid5. A participant may request a Fair Hearing within 30 days of the case managers notification6. Modifications will be submitted as needed, second reviews are allowed and will follow the

process for annual reviews

Examples of technical denials:

• Missing required documentation (see required documentation above)• Incomplete required documentation• Lack of appropriate signatures on required documentation• Non-compliance of state and federal regulations

Supports WaiverAges served 21 years and olderEligibility codes SUAW: 21 years of age and olderHCPC code T1002 (15 minutes)Required documentation:

Annually (all required): • Orders to include: reason for SN assessment and treatment, physician’s signature • Request for Prior Authorization of Skilled Nursing Services

Modifications (all required):• Request for Prior Authorization of Skilled Nursing Services

Review process: 1. Submit annual prior authorizations through the CHPP2. If you disagree with a decision (denied or reduced services), you may request a second

review through the CHPP within 30 days of the decision3. The provider will contact the case manager of denial or reductions , who notifies the

participant 4. A participant can request a reconsideration with the State of WY Medicaid5. A participant may request a Fair Hearing within 30 days of the case managers notification6. Modifications will be submitted as needed, second reviews are allowed and will follow the

process for annual reviews

Examples of technical denials:

• Missing required documentation (see required documentation above)• Incomplete required documentation• Lack of appropriate signatures on required documentation• Non-compliance of state and federal regulations

Submission Information• Comagine Health only reviews for skilled nursing

visits: • Initial RN assessment for waiver is billed directly to the

State of WY • We do not review for respite or CNA/HHA visits

• The start date and end date must match the PA form

• Calculating the number of visits:• The requested number will need to match your PA/MD

orders • Dates on an authorization letters will correlate with

the medical necessity determination date

Required Documentation• Signed MD order • Skilled Nursing (SN) PA form with following:

• Signature of Registered Nurse (as listed in Box-5):• Handwritten/Digitally authenticated signature

• LVN or LPNs may not complete an assessment or sign the PA form

• All boxes need to be completed on the form or use the n/a option

• The frequency and duration needs to match any notes and orders submitted

• Box 18 - list residential services on their plan (i.e. Assisted Living Facility, Community Living Services)

• Skilled nursing services must supplement, but not replace services

Documented Details• Box 1: Request type

• New participant = initial request• Existing participant = renewal request• Change to existing authorization = modification

• Box 16: Orders for Discipline and Treatments• A narrative about the participant and their needs • Frequency, duration and rationale is required for all services

• Example: Weekly medication management to set up medication box as this person has Rheumatoid Arthritis and can no longer open the bottles. The person lives alone and has no one to assist them.

Modifications

• Copy of current SN authorization• Updated PA form and MD orders with rationale

• Box 16 rationale example: The participant was recently hospitalized for heart failure. SN visits to increase to weekly visits from monthly for education, weight monitoring and medication adjustments for new diagnosis.

• Dates on an authorization letters will correlate with the medical necessity determination date

Training WebEx Schedule

• August 15, 2019:

10:00 – 11:00am (MST)

• August 16, 2019:

1:00 – 2:00pm (MST)

Waiver Letter Example

Comagine Health Contact Information

Comagine Health Phone: (800) 783-8606

Fax: (877) 810-9255

Teresa Kirn RN IQCIClinical Nurse Specialist (208) 383-5960 TKirn@comagine.org

Lisa LayneNon-Clinical Manager (206) 288-2385 LLayne@comagine.org

Yvette Stratton RN BSN CCMDirector, AK/WY Medicaid & Private Services

(206) 288-2443 YStratton@comagine.org

Deon Westmorland RN BSN CCMAssociate Vice President (206) 288-2347 DWestmorland@comagine.org

Comagine HealthUtilization Review Toll-free Phone: (800) 783-8606 Toll-free Fax: (877) 810-9265

Utilization Review Hours 8:30am to 7:00pm MST Monday through Friday

Questions