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 August 2000 – 2009 December 2009 - Present APS Healthcare Administrative Services for Medicaid Behavioral Health O/P, MR/DD Waiver, APS Healthcare BCF Socially Necessary DHHR combined the APS & WVMI Services & BHHF Charity Contracts into one inclusive Contract, Care & Federal Block which was awarded to APS in late 2009: Grant Reporting 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 WVMI Necessary Services & Out of State Services BHHF Charity Care, Block Grant Reporting Utilization Management of Medicaid Medical Services and Select Administrative Services Behavioral Health Inpatient, All programs are fee-for-service, Aged & Disabled Waiver, and not risk based. Nursing Home Admission & Re-Evaluation Screenings
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 of 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
Recommend
More recommend
