MHS - Prior Authorizations 201 - 2022 Annual IHCP Works Seminar
PriorAuthorizations2012022 AnnualIHCP WorksSeminar1
AgendaInterQual Connect OverviewPrior Authorization (PA) Job FunctionsBehavioral Health Prior AuthorizationNICUTurning PointPrior Authorization101National Imaging MHSAssociation(NIA)Prior Authorization Appeals 1012Authorization TipsResourcesMHS TeamQuestions and Answers2
InterQual ConnectOverview3
InterQual Connect OverviewReplaced Milliman Care Guidelines (MCG)Access integrated InterQual Criteria through the provider portalComplete InterQual Criteria via Change Healthcare portalAccess resources that support the InterQual review processView and/or Print the Review SummaryCompleted Medical Review automatically included with webauthorization submissionPossible same-day approval based on outcome of a completedInterQual medical necessity review4
InterQual Connect OverviewInterQual Connect (IQC) is anintegrated medical review andconnectivity solution for payers andproviders that streamlines priorauthorizations requiring a medicalreview within existing workflows.5
InterQual Connect Process6
Prior Authorization (PA) Job Functions7
Prior Authorization Job FunctionsReferral Specialist:Are responsible for completing Auto Approvalauthorizations for the member. Newborn Deliveries Dental For procedures that an authorization request has beensubmitted, that do not require authorization such as, officevisits and select outpatient services8
Prior Authorization Job FunctionsThe Program Coordinators (PC) are responsible for completingclinical authorizations.The PC will submit the request and task it to the UtilizationManagement (UM) Clinical Review Team. The PriorAuthorization Supervisor will assign the authorization to a PANurse for review.Types of authorizations the Program Coordinators set up: Drug testingGenetic testingPain ManagementOutpatient surgeryDMEOutpatient ServicesHospiceHome HealthChiro9
Prior Authorization DocumentationNeededBariatric Surgery:Must include cardiac workup, pulmonary workup, diet and exercise logs,current lab reports, and psychologist report.Pain Management:Must have documentation of at least six weeks of therapy on area receivingtreatment.Include previous procedures/surgeries, medications, description of pain,any contra-indications or imaging studies.Include prior injection test results for injection series.Home Health:Physician’s orders and signed plan of care, including most recent MD notesabout the issue at hand.Home care plan, including home exercise program.Progress notes for medical necessity determination.10
Sub-Acute CareMHS conducts clinical review for ongoing authorization and coordination ofdischarge needs for our members in sub-acute facilities at least every 3-5days. It is important that you provide a complete current clinical update onour member’s status at each review.The review should include current information (within one day) on: Member’s condition Level of functioning (prior to admission) Medications Therapies provided Participation in therapies Progress toward goals New or amended goals Updates from care conferences Updates to our member’s plan of care Discharge plans and needs identified (home health/DME, etc.) Anticipated discharge date11
Sub-Acute Care cont.Indiana Administrative Code requires that individuals requestinga nursing facility admission to a Medicaid-certified NF meet anursing facility level of care (405 IAC 1-3-1 and 405 IAC 1-3-2.).A PASRR is required before admission and must be submittedwith the admission request and when updated according to IACrequirements.Please submit this information as requested by MHS nursereviewer every 3-5 days.12
Continuity of Care PA RequestMHS will honor pre-existing authorizations from any other Medicaidprogram during the first 30 days of enrollment or up to the expirationdate of the previous authorization, whichever occurs first, and uponnotification to MHS.Include the approval from the prior MCE with the request.*Reference: MHS Provider Manual Chapter 713
Prior Authorization (PA) RequestMHS strives to return a decision on all PA requests within two businessdays of request.Providers can update previously approved PAs within 30 days of theoriginal date of service prior to claim denial for changes to: Dates of Service CPT/HCPCS codes MHS has up to seven days to render PA decisions.PA approval requires the need for medical necessity.As of September 1, 2022, MHS implemented InterQual for authorizationmedical necessity review criteria.Medical Management does not verify eligibility or benefit limitations;Provider is responsible for eligibility and benefit verification.*Denied Authorizations must follow the authorization appeal process,not the claims appeal process; claims appeals can not change thestatus of a denied authorization.14
Behavioral Health PriorAuthorization15
Behavioral Health PriorAuthorizationFacility Services Requiring Prior Auth:Intensive Outpatient Treatment (IOT)Partial Hospitalization SUD Residential TreatmentInpatient Admisson16
Behavioral Health PriorAuthorizationPsychiatric Diagnostic Evaluation (Limited to 1 per member per year withoutauthorization)Behavioral Health Outpatient Therapy “BHOP Therapy”Electroconvulsive TherapyPsychological Testing (unless for Autism-no auth required)Developmental Testing, with interpretation and report (non-EPSDT)Neurobehavioral status exam, with interpretation and reportNeuropsych Testing per hour, face to face (unless for Autism-no auth required)ABA Services17
Behavioral Health PriorAuthorizationPlease call MHS Care Management for inpatient and partialhospitalization authorizations at 1-877-647-4848.MHS Authorization forms may be obtained on our website: BehavioralHealth Provider Forms MHS IndianaOutpatient Treatment Request (OTR) Form - Fax: 1-866-694-3649Intensive Outpatient/Day Treatment Form Mental Health/ChemicalDependency - Fax: 1-866-694-3649Applied Behavioral Analysis Treatment (OTR) - Fax: 1-866-694-3649Psychological & Neuropsych Testing Authorization Request Form - Fax:1-866- 694-3649Residential/Inpatient Substance Use Disorder Treatment PriorAuthorization Form Fax Inpatient: 1-844-288-2591; Fax Outpatient: 1-866-694-364918
Behavioral Health PriorAuthorizationLimitations on Outpatient Mental Health ServicesMHS follows the Indiana Health Coverage Programs Mental Health andAddiction limitation policy for the following CPT codes that, incombination, are limited to 20 units per provider, per calendar year.Package C Hoosier Healthwise members are eligible for 30 units perprovider, per calendar year.Code90832 - 9083490837 - 9084090845, 90846,90847, 90849, 90853DescriptionIndividual PsychotherapyPsychotherapy, with patient and/or family member &Crisis PsychotherapyPsychoanalysis & Family/Group Psychotherapy withor without patient19
NICU20
NICUInpatient NICU level or special care nursery admissions thehospital must notify MHS within two business days after theadmission date.The facility must notify MHS of an admission of an infant whoremains hospitalized after the mother is discharged, within twobusiness days. It is the responsibility of the ordering physician toobtain authorization.The facility is responsible for determining the mother’s coverageand chosen/assigned MCE.21
NICUThe facility should assume that the infant will be assigned to themother’s MCE.If the infant’s mother is not covered by an MCE at the time ofdelivery, the facility must notify MHS of the admission within 60days of becoming aware of the member’s eligibility using theUniversal IHCP Prior Authorization Request Form and the MHSLate Notification of Services Submission form with clinicalinformation supporting the medical necessity for the admission.It is presumed that the facility would become aware of themember’s eligibility within one week of visibility on the StatePortal.22
NICUScenario 1:Mother delivers healthy infant.Mom and infant are discharged and go home together.No prior-authorization is required.Claim is submitted and processed.23
NICUScenario 2:Mother delivers infant.Newborn admits to special care nursery.Hospital notifies MHS within two business days after the admissiondate. No PA is required.Claim is submitted and processed.24
NICUScenario 3:Mother delivers infant.Mother is discharged from hospital.Infant remains hospitalized after mother is discharged.Ordering physician contacts MHS within two business days to obtainauthorization.Claim is submitted and processed.25
Turning Point26
Turning PointTurning Point Healthcare Solutions manages priorauthorizations for medical necessity and appropriate length ofstay (when applicable) for services listed on the next threeslides through MHS’ existing contractual relationships.27
Orthopedic and Spinal SurgicalProceduresOrthopedic Surgical ProceduresKnee ArthroplastyUnicompartmental/Bicompartmental KneeReplacementHip ArthroplastyShoulder ArthroplastyElbow ArthroplastyAnkle ArthroplastyWrist ArthroplastyAcromioplasty and Rotator Cuff RepairAnterior CruciateLigament RepairHip ResurfacingMeniscal RepairHip ArthroscopyFemoroacetabularArthroscopyAnkle FusionShoulder FusionWrist FusionOsteochondral DefectRepair28
Orthopedic and SpinalSurgical ProceduresSpinal Surgical ProceduresSpinal Fusion Surgeries Cervical Lumbar Thoracic Sacral ScoliosisDisc broplastySacroiliac Joint FusionImplantable Pain PumpsSpinal Cord NeurostimulatorSpinal Decompression29
Cardiac ProceduresAutomated Implantable Cardioverter DefibrillatorLeadless PacemakerPacemakerRevision or Replacement of Implanted Cardiac DeviceCoronary Artery Bypass Grafting (Non-Emergent)Coronary Angioplasty and StentingNon-Coronary Angioplasty and Stenting30
Turning PointWeb Portal Intake: http://www.myturningpoint-healthcare.comTelephonic Intake: 1-574-784-1005 1-855-415-7482Facsimile Intake: 1-463-207-5864Informational webinars are available! Please register 9485390131
Turning PointIt is the responsibility of the ordering physician to obtainauthorization.Facilities should not render services without obtaining thePA number from the ordering physician.Failure to ensure the referring provider has obtained thePA may result in a claim denial.It is recommended the facility verify the CPT code thatwas authorized as well as the date of service requested.32
Turning PointIf the anticipated CPT billing code changes and a differentprocedure is done, the rendering provider has up to 30 calendardays, following service, to contact the MHS Turning Point team toupdate the code that was approved on the PA.If services change from out-patient to inpatient, contact MHS at877-647-4848 for a new authorization. A new authorization mustbe initiated for the in-patient stay.Medical Director handles all Turning Point appeals.33
Turning PointScenario 1:Ordering physician obtains authorization for total shoulderarthroplasty (TSA), CPT code 23472.Surgeon starts surgery.No change in surgery.Claim is billed with CPT code 23472.Claim is submitted and processed.34
Turning PointScenario 2:Ordering physician obtains authorization for total shoulder arthroplasty(TSA), CPT code 23472.Surgeon starts surgery.Surgery changes from TSA to shoulder fusion, CPT code 23800.Rendering provider contacts MHS Turning Point team within 30 days ofthe service and before claim is submitted to update the code.Claim is submitted and processed.35
Turning PointScenario 3:Ordering physician obtains authorization for out-patient total shoulderarthroplasty (TSA), CPT code 23472.Surgeon starts surgery.Place of service changes from out patient to inpatient. MHS iscontacted to initiate an authorization for the inpatient stay.Claim is submitted and processed.36
National Imaging Associates(NIA)37
National Imaging Associates(NIA)Physical, Occupational and Speech TherapyUtilization management of these services is managed by NIAPrior Authorization for PT, OT and ST services is required todetermine whether services are medically necessary andappropriate.All MHS approved training/education materials are posted onthe NIA website. RADMD.com For new users to access theseweb-based documents, a RadMD account ID and passwordmust be created.38
NIAOutpatient Radiology PA RequestMHS partners with NIA for outpatient radiology PA process.PA request must be submitted via: NIA website at RadMD.com 1-866-904-5096*Not applicable for ER and Observation requests.39
Durable & Home MedicalEquipmentMHS utilizes a tiered provider network for DurableMedical Equipment.All DME request should be faxed directly to MHS.Fax Number: 866-912-424540
Prior AuthorizationAppeals41
Prior Authorization AppealsDenied Authorizations must follow the authorization appeal process,not the claims appeal process.A prior authorization appeal is different than a claim appeal.Claim appeals can not change the status of a denied authorization.Written member or provider appeals can be delivered by email toappeals@mhsindiana.com, by fax to 1-866-714-7993, or by mail toMHS AppealsPO Box 441567Indianapolis, IN 46244.Medicaid prior authorization/medical necessity denial appeals can besubmitted to MHS through the Secure Provider Portal.42
Prior Authorization AppealsAll member or provider appeals of an MHS decision as to medicalnecessity must include a statement from the provider supportingthe appeal and the need for the service.The appeal must be received by MHS within 60 calendar days ofthe date listed on the denial determination letter. The monitoring ofthe appeal timeline will begin the day MHS receives and receiptstamps the appeal. Verbal appeals are accepted but must befollowed with a written, signed appeal.If the appeal is received outside of the allotted time frame, MHSwill send a letter stating the appeal was received past the 60calendar day time frame and will not be considered.43
Behavioral Health PA Denialand Appeal ProcessMedical Necessity appeals must be received by MHS within60 calendar days of the date listed on the denialdetermination letter. The monitoring of the appeal timelinewill begin the day MHS receives and receipt-stamps theappeal. Medical necessity behavioral health appeals shouldbe mailed or faxed to:MHS Behavioral HealthATTN: Appeals Coordinator12515 Research Blvd, Suite 400Austin, TX 78701FAX: 1-866-714-799144
Prior AuthorizationDetermination GuidelinesDeterminations are made within 20 business days of the date ofreceipt of the appeal request.MHS may request more time to review, in writing on or beforethe 20th business day or the appeal will be approved.45
PA/Medical Necessity Appealson the Provider Secure PortalMedicaid prior authorization/medical necessity denial appealscan be submitted to Managed Health Services (MHS) and willallow tracking of the appeal from submission through decisionon the Secure Provider Portal.46
Prior Authorization DeterminationGuidelinesOnce determination is made MHS will attempt to notify themember by phone.The appealing party will receive written notification within 25business days, signed by the MHS physician reviewed or his orher designee, mailed within 5 business days of the appealdetermination to: The attending or managing physician/facility The member’s PMP The member and/or member designated personalrepresentative In the case of an adverse determination, the letter willinclude information on the availability of any additional levelof appeal47
Prior Authorization Peer-toPeer ReviewPeer-to-Peer requests must be done within 10-calendar days ofthe denial.Provider must contact MHS Appeals and provide three availabledates and times to schedule a personal discussion with theMHS Medical Director.Providers may contact MHS Appeals at 1-877-647-4848,extension 87058 to leave a voice mail with their availability.48
Authorization Tips49
Authorization TipsAlways check the member’s eligibility before submitting anauthorization requestA web authorization cannot be submitted on an ineligible memberUp to five (5) separate documents can be attached to a webauthorization request Each file can be up to 5MBFile names cannot contain spaces, special characters, or exceed 25 charactersIt is highly recommended to include clinical / medical documentation with allauthorization requestsComplete the Medical Review (i.e., InterQual Connect) to reduceprocessing time/delaysSuccessfully submitted web authorizations, generally load inprocessing system within seconds of submissionTo track the status of web authorization requests, check theAuthorizations main page (i.e. Authorization Summary) for updates50
Resources51
ResourcesPrior /prior-authorization.htmlClinical & Payment Policies: Clinical & Payment Policies MHS IndianaProvider Manuals and Quick Reference l52
ResourcesIHCP Prior Authorization Request 2021.pdfLate Notification of Services Submission e/mhsindiana/medicaid/pdfs/Late Notification of Services Submission Form.pdfProvider Education & urces/providertraining.html53
MHS Team54
MHS Provider Network TerritoriesNORTHEAST REGIONFor claims issues, email:MHS ProviderRelations NE@mhsindiana.comChad Pratt. Provider Partnership Associate1-877-647-4848, ext. 20454NORTHWEST REGIONFor claims issues, email:MHS ProviderRelations NW@mhsindiana.comCandace Ervin, Provider Partnership Associate1-877-647-4848, ext. 20187NORTH CENTRAL REGIONFor claims issues. email:MHS ProviderRelations NC@mhsindiana.comNatalie Smith.ProviderP a r t n e r s h i pAssociate1-877-647-4848, ext. 20127CENTRAL REGIONFor claims issues, email:MHS ProviderRelations C@mhsindiana.comMona Green. Provider Partnership Associate1-877-647-4848, ext. 20080SOUTH CENTRAL REGIONFor claims issues, email:MHS ProviderRelations SC@mhsindiana.comDalesia Dennrig, Provider Partnerhip Associate1-877-647-4848, ext. 20026SOUTHWEST REGIONFor claims issuss, email:MHS ProviderRelations SW@mhsindiana.comDawn McCarty, Provider Partnership Associate1-877-647-4848, ext. 20117SOUTHEAST REGIONAvailable ene/mhsindiana/medicaid/pdfs/ProviderTerritory map 2021.pdfFor claims issues,email:MHS ProviderRelations SE@mhsindiana.comCarolyn Valachovic MonroeProvider Partnership Associate1-877-647-4848, ext. 20114
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Network Leadership57
Questions?Thank you for being our partner in care.Ambetter from MHS I Hoosier Healthwise I Healthy Indiana Plan I Hoosier Care Connect I Wellcare by Allwell58
Agenda 1012 MHS Prior Authorization 101 InterQual Connect Overview Prior Authorization (PA) Job Functions Behavioral Health Prior Authorization NICU
Metrics reported by Time and Volume: Overall Prior Authorizations First Pass Status Touchless Authorizations Authorizations with Additional Clinical Information needed Authorizations with Peer -to Peer Today's Webinar: Timeframe: October 14, 2021 Note: Issue Brief to follow Part I Part II C
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