Presentation for Molina Provider Enrollment Seminars June 2011 - - PowerPoint PPT Presentation

Innovative Resource Group, Inc. d/b/a

Presentation for Molina Provider Enrollment Seminars June 2011

Innovative Resource Group, Inc. d/b/a

• “Improving the health of those we serve.”
• We are a specialty health services company that focuses on communication, technology, and

linking people to the health services they need.

• We work in conjunction with the Bureau for Medical Services, the Bureau for Children &

Families, and the Bureau for Behavioral Health & Health Facilities

• The APS-West Virginia office is located in Charleston, West Virginia with field staff working

throughout the state.

CONTRACT HISTORY

WVMI

Utilization Management

• f Medicaid Medical Services

Behavioral Health Inpatient, Aged & Disabled Waiver, and Nursing Home Admission & Re-Evaluation Screenings

August 2000 – 2009 December 2009 - Present

APS Healthcare

DHHR combined the APS & WVMI Contracts into one inclusive Contract, which was awarded to APS in late 2009:

• Medicaid Medical & Dental Services
• Medicaid Behavioral Health In/Outpatient
• Medicaid MR/DD Waiver Program
• Medicaid Aged & Disabled Waiver Program
• Medicaid & Non-Medicaid Nursing Home
• Bureau for Children & Families: Socially

Necessary Services & Out of State Services

• BHHF Charity Care, Block Grant Reporting

and Select Administrative Services All programs are fee-for-service, not risk based.

APS Healthcare

Administrative Services for Medicaid Behavioral Health O/P, MR/DD Waiver, BCF Socially Necessary Services & BHHF Charity Care & Federal Block Grant Reporting

MEDICAL NECESSITY REVIEWS

Medical Necessity Reviews will be conducted by the UMC in the following areas:

• Inpatient Services
• Cardiac Rehab
• Pulmonary Rehab
• Chiropractic
• Dental
• Durable Medical Equipment (DME)
• Home Health
• Hospice
• Lab
• Radiology
• Imaging
• Occupational Therapy
• Physical Therapy
• Speech Therapy
• Outpatient Surgery
• Podiatry
• Audiology
• Vision
• Out-of-Network Services

UTILIZATION MANAGEMENT CONTRACTOR(UMC) FUNCTIONS

• Prior Authorization of services specified in BMS Provider Chapters
• Will be performed by WVMI
• Developing a Direct Data Entry (DDE) system for all review areas to facilitate completeness and

speed of prior authorization requests

• UMC forms will be modified to mimic DDE format for easy use
• Developing a flexible method of informing providers of authorization that can be utilized by billing

departments to import authorizations into existing systems

– Providers can view on website or receive daily file with status of all reviews

• Providing training and technical assistance to providers on utilization and requirements of the APS

prior authorization request system

– Providers will need to register with APS

• Utilizing existing clinical review protocols, criteria, and manual requirements to prevent disruption

to the service delivery system

– We will publish a Master Code List for providers

WHAT DOES THIS MEAN FOR ME?

What stays the same….

• WVMI will continue to review all medical necessity cases

– They will perform reviews and answer case-specific questions

• InterQual criteria is still being used

– Annual updates to existing criteria sets – There will be new criteria sets added to reflect new areas of review (ex. HHA, PT) – Smart sheets still available – If InterQual criteria is not available for a review area, criteria approved by BMS will be utilized

• All UMC procedures and protocols are based on the

relevant BMS Chapters

– Refresher courses regarding policies will be held periodically by APS

WHAT DOES THIS MEAN TO ME? Upcoming changes……

• Prior authorization (PA) requests now made by DDE

– DDE system makes PA requests easier by automatically validating information – Prior authorization requests by fax will be accepted but DDE is highly encouraged

• UMC forms in Chapters to be modified

– These will mimic the DDE format approved by BMS and will be published on the APS and WVMI websites

• Prior authorization results per web or file only

– No faxed authorization results will be sent to providers – Will be seen in Web view or received as daily file

• Registration with APS is required to access DDE and authorization

files

• System training

– Education on inputting data & navigating the system

• Code changes

– APS will provide a published Master Code List of CPT and HCPCS codes requiring prior authorization

• Ongoing support

– For questions/concerns and technical support

TRAINING AND COMMUNICATION

• APS will be providing trainings by way of seminars

and webinars

• APS will communicate changes and updates by way
• f publications, the website and email

announcements

• Electronic communication is our first choice due to efficiency
• However, publications will be provided
• Provider contact information needed; sign-up sheets

coming around now

• Please tell us the best way to communicate with you on the sign-up

sheet or by calling us.

QUESTIONS ?

Contact Us.

APS Healthcare Telephone: 1-800-461-0655 Medical Services: 1-800-346-8272 ext. 6954 Web Address: www.apshealthcare.com/wv General e-mail Medical Services:wvmedicalservices@apshealthcare.com

• Helen Snyder, Associate Director ~ hcsnyder@apshealthcare.com
• ext. 6911
• Heather Thompson, UM Nurse Reviewer ~ hthompson@apshealthcare.com
• ext. 6907
• Diab Thomas, Technical Liaison ~ dothomas@apshealthcare.com
• ext. 6910
• Sherri Jackson, Office Manager~ shjackson@apshealthcare.com
• ext. 6902

WVMI Telephone: Management 1-800-642-8686 Web Address: www.wvmi.org click on the link under Medicaid Information

• John Marks, Director of State Services, jmarks@wvmi.org
• ext. 2271
• Stacy Holstine, RN, BA, CPUM, Project Manager, sholstine@wvmi.org
• ext. 3279
• Melissa Nichols, Support Staff Supervisor, mnichols@wvmi.org
• ext. 3233