Department of Medical Assistance Services Overview of New Prior Authorization Program for June 2006

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Department of Medical Assistance
ServicesOverview of New Prior Authorization
Program for June 2006

• PAUR Implementation Team
• APRIL 2006

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Presentation Outline

• Introduction/DMAS and Prior Authorization
• New Program Changes
• PA Submission Options
• Workflow Process
• Appeals
• Next Steps

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DMAS and Prior AuthorizationDMAS requires that
the following services are prior authorized for
Fee for Service Medicaid and FAMIS clients before
rendering the service

• Inpatient hospital admissions except for
  maternity
• Inpatient psychiatric rehabilitation stays
• Home health
• Certain DME orthotics
• Outpatient rehabilitation
• Certain non-emergent scans MRI, CAT, PET
• Outpatient psychiatric

• Home and Community Based Waivers
• Elderly or Disabled with Consumer Direction
• Developmental Disability
• Tech Assisted
• HIV/AIDS
• Specialized Behavioral Health (SBH)
• Treatment Foster Care
• Residential Psychiatric Treatment
• Intensive In-Home Care

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DMAS and Prior Authorization

• New Vision of DMAS
• Streamline PA process
• Have electronic capabilities available
• Review overall PA requirements
• Standardize criteria
• To be operational with new vendor June 5,
  2006

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Introduction of New Contractor

• Keystone Peer Review OrganizationKePRO
• Innovative healthcare management solution company
• Experience in Medicare, Medicaid, commercial
  health care
• Offices in Pennsylvania, Ohio, Florida, now
  Virginia
• Their office is located at 2810 N. Parham Road,
  Suite 305, Richmond VA 23294

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Prior Authorization Implementation Dates

• Phase I May 22 pilot - single service
• Phase II June 5 traditional services
• Phase III June 19 HCB waivers special
  behavioral health (SBH)

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Prior Authorization Implementation Dates

• This contract excludes PAs for
• Pharmacy
• Dental
• Transportation
• MR Day Support waivers
• MCOs
• These services will continue through the current
  vendors.
• DMAS will continue to PA for
• Organ transplants
• Gastric bypass
• Cosmetic procedures
• Prostheses (excluding orthotics)
• Out of state services
• Alzheimers waiver

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Presentation Outline

• Introduction/DMAS and Prior Authorization
• New Program Changes
• PA submission Options
• Workflow Process
• Appeals
• Next Steps

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Program/Contract Enhancements

• Innovative technical capabilities and systems
• User friendly
• Satisfaction surveys
• On-site dedicated medical director
• Professional clinical staff

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Program/Contract Enhancements

• Automatic reconsideration process
• Dedicated website http//dmas.kepro.org
• Longer service hours
• Monday-Friday 800 AM until 700 PM
• Web based technology

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Presentation Outline

• Introduction/DMAS and Prior Authorization
• New Program Changes
• PA submission Options
• Workflow Process
• Appeals
• Next Steps

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Use of the Web-based System

• PA Methods of Submission June 2006
• Internet/iExchange http//dmas.kepro.org
• Telephonic 1-888-827-2884
• 1-888-VAPAUTH
• Fax [phone]
• 1-877-OKBYFAX
• Mail

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New PAUR Submission Options and Work Flow Process
2006
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Use of Web-Based System iExchange
(http//dmas.kepro.org)

• Industry moving toward internet-based
  communications service requests
• Paperless process
• Automated PA system

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Use of Web-Based System iExchange
(http//dmas.kepro.org)

• Preferred method is KePROs iExchange
• Streamlines PA process
• User friendly system
• Internet access available 24/7

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Web-Based Submission iExchange (http//dmas.kepro.
org)

• KePro works with MEDecision in the development of
  the Virginia PA system
• There are two components
• The iExchange technology which is the base
  pathway for transacting authorizations
• and
• CarePlannerutilization management tool

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iExchange (http//dmas.kepro.org)

• Real time
• Compliments case management software
• Standard template
• Mandatory fields
• Clinical criteria
• Update to CarePlanner

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CarePlanner

• Utilization management
• Consistent application of review rules
• Paperless
• Integrated with InterQual

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iExchange Registration Process(http//dmas.kepro.
org)

• VA Medicaid providers required to register with
  KePRO
• System requirement is internet access
• Refer to DMAS and KePRO web sites and upcoming
  Medicaid memos

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iExchange Provider Registration(http//dmas.kepro
.org)

• Simple process
• Self explanatory
• Access the registration page
• Helpful guides built into the form

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iExchange Provider Registration(http//dmas.kepro
.org)

• To initiate the process you will need
• Tax ID Number
• Virginia Medicaid Number

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iExchange Provider Registration(http//dmas.kepro
.org)

• Application information
• Provider/facility information (required field)
• Provider/facility contact information (required
  field)
• Billing contact information
• Medical records contact information
• IT contact information
  

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KePRO Registration Process

• DMAS, through its partnership with KePRO, is
  offering providers a HIPAA compliant, secure
  web-based prior authorization processing system
  that will eliminate paperwork and provide quicker
  determinations
• Registration is easy! Just follow the steps
  below.

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KePRO Registration Process

• Complete the registration form (this will link to
  form) directly on line. You must complete each
  field for your registration to be valid.
• When you are finished, hit submit you will
  then receive notification that your registration
  has been received.
• If you are unclear about what is required in each
  field, just hold your mouse over the words and
  detailed instructions will appear.

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KePRO Registration Process

• On or about May 8, KePRO will contact you to
  provide you with each facility/provider unique
  user identification number and password.
• Generally, passwords will be processed within 48
  hours and forwarded to providers via email
• Please look for information in the coming weeks
  about training to use the iEXCHANGE system.

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Presentation Outline

• Introduction/DMAS and Prior Authorization
• New Program Changes
• PA submission Options
• Workflow Process
• Appeals
• Next Steps

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New PAUR Submission Options June 2006
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Presentation Outline

• Introduction/DMAS and Prior Authorization
• New Program Changes
• PA submission Options
• Workflow Process
• Appeals
• Next Steps

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PAUR Work Flow Process

• Customer service representative (CSR) retrieves
  information from source
• CSR enters in iExchange
• Eligibility is verified

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PAUR Work Flow Process

• Case is created
• CSR sends case to queue
• Auto decision or nurse review
• Clinical criteria system support

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PAUR Work Flow Process

• Case decision
• approved needs information

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PAUR Work Flow Process

• Or needs peer review

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PA Notification

• Online verification of PA number, tracking, or
  even denials and concerns
• Letters notification for approvals, denials,
  rejections, or for missing information (pend)

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KePRO Edits

• Criteria rules
• Verify eligibility
• Turn around time

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Presentation Outline

• Background
• New Program Changes
• PA submission Options
• Workflow Process
• Appeals
• Next Steps

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Appeals

• Providers have the right to challenge adverse
  decisions
• Review by medical director after nurse review
• Decision upheld by medical director
• Denial letter sent to provider client

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Appeals

• DMAS appeals division
• Basic function to be heard
• End result
• KePROs role

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Presentation Outline

• Steps Background
• New Program Changes
• PA submission Options
• Workflow Process
• Appeals
• Next steps

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Next Steps to June 5th

• DMAS is finalizing all manual changes and
  criteria
• Reviewing letters and forms
• Beginning testing with providers and KePRO
• iExchange registration is now available
  (http//dmas.kepro.org)
• Transitioning services from WVMI

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More Training Opportunities

• Several Medicaid memos and manual updates will be
  submitted by service type in May 2006
• Direct training to several health systems will be
  done on site in May 2006
• Specialized training for the outpatient
  psychiatric, home health and home and community
  based waiver providers will occur in May 2006
• WebEx training will be available the last week of
  May
• KePRO staff will be able to walk through the
  process in May 2006
• On-going training after June 6, 2006

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What Do I Do Next?

• Read Medicaid memos
• Register for iExchange (http//dmas.kepro.org)
• Continue to use WMVI until June 4, 2006
• Tell your office a change is coming
• Use WebEx or call KePRO last week of May to June
• Submit to KePRO in June 2006

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Resources

• KePRO http//dmas.kepro.org
• DMAS www.dmas.virginia.gov
• PAUR06_at_dmas.virginia.gov (questions)

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Questions/Comments
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The End