Virginia Medicaid

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Virginia Medicaid Prior Authorization Program
11/15/2009
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Welcome

• Scott Parker, KePRO
• Joined KePRO in February 2006
• More than 25 years of healthcare and healthcare
  related experience
• Expertise in healthcare operations, program
  development and implementation
• Trained clinician with an understanding of
  provider issues and concerns
• Experience working with DMAS on the Medicaid
  Managed Care Enrollment contract and the FAMIS
  CPU implementation and operation

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Overview of KePRO

• Healthcare Management Services Organization
• Established in 1985
• Wholly-owned subsidiary of the PA Medical Society
• Offices in six states FL, KY, MD, OH, PA and VA
• Approximately 250 employees
• ISO registered and URAC accredited
• 33 years of combined Medicaid experience
• Nations first automated Medicaid prior
  authorization processing system
• Medicare QIO experience

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Todays Objectives

• Introduce KePRO as new Prior Authorization
  Contractor for Virginia Medicaid Services
• Introduce whats new and what stays the same for
  providers
• Provide facilities/providers with a working
  knowledge of the process for submitting prior
  authorization requests

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Implementation Plan
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Whats New and Whats Not

• Whats New
• New Prior Authorization Contractor
• New phone/fax numbers and mailing address to
  submit requests
• Use of Internet technology
• Fax forms
• Reconsideration process automatic
• InterQual Criteria applied to some review types
• Shorter timeframes to receive PA numbers

• Whats the Same
• DMAS requirements for prior authorization of
  services
• Same review process for Initial review, appeals
  process
• DMAS criteria/guidelines

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Methods for Submitting Prior Authorization
Requests

• Telephonic
• 1-888-VAPAUTH (827-2884)
• 804 622-8900 (local)
• Via Fax
• 1-877-OKBYFAX (652-9329)
• Via U.S. Mail
• 2810 N. Parham Road, Suite 305
• Richmond, VA 23294
• Internet / iEXCHANGE
• http//dmas.kepro.org

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Prior Authorization Reviewer Qualifications

• Non-physician reviewers perform initial reviews
  using criteria
• VA Registered Nurses
• Behavioral Health Specialists
• Physician consultants review referrals from non-
  physician reviewers and make decisions based on
  clinical judgment within realms of DMAS policy
• VA licensed MDs and DOs
• Board-certified in specialty
• Actively practicing at least 20 hours/week

•   

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Inpatient Review Process
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Outpatient Review Process
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Prior Authorization Review Process- Criteria
Applied
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Prior Authorization Review Process- Criteria
Applied
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Prior Authorization Review Process- Criteria
Applied
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Prior Authorization Review Process- Criteria
Applied
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Prior AuthorizationTimeframes for Inpatient
Reviews

• Applies to Inpatient med/surg and Inpatient psych
• Timely receipt of request for prior authorization
  is defined as
• Planned/scheduled admissions within 24 hrs or
  the next business day after admission - obtaining
  prior authorization prior to the admission is
  encouraged
• Unplanned/urgent or emergency admissions within
  24 hours of admission or on next business day
  after admission
• Notes
• If received after timeframe, inpatient med/surg
  stays are paid on a DRG methodology, the
  admission should be denied as untimely.
• If received after this time frame, inpatient
  psych stays are reviewed from the receipt date
  forward.
• Retrospective reviews will be accepted if
  provider is notified of Medicaid eligibility
  after the fact or if Medicare denies the claim or
  if Medicare is exhausted.

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Prior AuthorizationTimeframes for Inpatient
Reviews

• Applies to Intensive Inpatient Rehabilitation
• Timely receipt of request for prior authorization
  is defined as
• Within 72 hours of admission
• Notes
• If received after timeframe, review from the
  receipt date forward.
• Retrospective reviews will be accepted if
  provider is notified of Medicaid eligibility
  after the fact or if Medicare denies the claim or
  if Medicare is exhausted.
• If the patient is readmitted back to the
  Intensive Rehab Unit from acute carelt 24 hours,
  no PA is required if admitted gt 24 hours, PA is
  required.

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Prior AuthorizationTimeframes for Outpatient
Reviews

• Applies to Outpatient Psych, Home Health,
  Outpatient Rehab and Non Emergent Outpatient
  MRI/PET/CAT Scans
• Timely receipt of request for prior authorization
  is defined as
• Prior to services being rendered
• Notes
• If received after timeframe, review from the
  receipt date forward.
• Retrospective reviews will be accepted if
  provider is notified of Medicaid eligibility
  after the fact or if Medicare denies the claim or
  if Medicare is exhausted.

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Prior AuthorizationTimeframes for Outpatient
Reviews

• Applies to DME
• Maximum time frame for claims is within a year
  from the date of service, therefore, the PA
  should follow that rule with same exceptions
  noted on all other services - i.e., except for
  retrospective eligibility issues.
• Request can be either prior to service or
  retrospective review

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Prior AuthorizationTimeframes for Outpatient
Reviews

• Applies to EPSDT
• Timeliness rules are applicable for the specific
  original requested service.
• Notes
• Any treatment service which is not otherwise
  covered under the States Plan for medical
  assistance can be covered for a child through
  EPSDT as long as the service is allowable and is
  determined to be medically necessary to correct
  or ameliorate the childs condition.

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Prior AuthorizationTimeframes for
Non-Traditional Services

• Applies to Treatment Foster Care Case Management,
  Residential Psych, and Intensive in-home services
• Timely receipt of request for prior authorization
  is defined as
• Residential Psych Within one business day of
  admission
• Treatment Foster Care within 10 days of
  admission
• Intensive in-home Only reviewed for on-going
  services
• Authorization for continued treatment beyond the
  initial certification must be requested prior to
  the expiration of the certification period
• Notes
• If received after timeframe, the review will be
  applied to day of receipt forward.
• Retrospective reviews will only be accepted if
  provider is notified of Medicaid eligibility
  after fact.

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Prior AuthorizationTimeframes for Waiver Services

• Applies to Elderly or Disabled with Consumer
  Direction Waiver (EDCD), HIV/AIDS Waiver,
  Individual and Family Developmental Disabilities
  (DD) Support Waiver Services, and Tech Waiver
• Timely receipt of request for prior authorization
  is defined as
• Must be submitted within 10 business days of
  start of care (SOC) OR
• Within 10 business days of providers receipt of
  verification of Medicaid eligibility
• Notes
• If received after timeframe, the approval will be
  applied to day of receipt forward.

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Prior AuthorizationReconsideration/Appeals
Process

• Reconsideration process now is built into the
  review process as a referral to physician after
  non-physician review
• Only peer/physician reviewers can deny services
• Providers can request an appeal to DMAS as per
  current process

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Next Steps

• KePRO will provide ongoing training sessions via
  Web-Ex
• Refer to handouts for instructions on how to
  log-into a web-ex
• Refer to http//dmas.kepro.org for provider
  training schedule
• KePRO will notify providers of upcoming training
  sessions via List-serve email notifications
• Toll-free number available on implementation date
  for assistance

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Reference Sites

• www.dmas.virginia.gov
• http//dmas.kepro.org
• Send Questions to PAUR06_at_dmas.virginia.gov

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iEXCHANGE Connectivity and Registration Process

• Providers need to register for user ID
• Providers will be provided a password
• Providers must maintain the number of users
  within their facility
• Refer to handout for specific instructions

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Questions? Send Questions to
PAUR06_at_dmas.virginia.gov