Qualis Health Provider Review Request Process for Outpatient - - PowerPoint PPT Presentation

Advancing Healthcare Improving Health

Qualis Health Provider Review Request Process for Outpatient Therapy (PT, OT and ST)

Teresa Kirn, RN Manager, Care Management Department Oct 3rd, 2017 and Oct 10th, 2017

Advancing Healthcare Improving Health

One of the nation’s leading healthcare consulting organizations, partnering with our clients across the country to improve care for millions of Americans every day www.qualishealth.org

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Qualis Health

• A private nonprofit organization

established in 1974

• Corporate Office located in

Seattle, Washington with regional

• ffices in Alabama, Alaska,

California, District of Columbia, Idaho, Kansas, and New Mexico

• Have provided care management

to Medicaid and Private contracts since 1984

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What We Do

• Contract with Wyoming Medicaid to review for select
• utpatient services:

– Durable Medical Equipment (DME), – Home Health Services (HHS) and now adding Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) and Behavioral Health visits.

• We will use InterQual and organizational policies to conduct
• ur review
• Offer telephonic provider education
• Provider review support resource accessibility on our webpage

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What We Don’t Do

We do not receive financial incentives to deny or limit services

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Objectives

• How to submit a request for services for outpatient

PT, OT and ST

• How to add additional information when requested

by Qualis Health

• How to check the status of a review
• Review upcoming trainings

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To Launch the QHPP

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Let’s get Started

Enter the patient’s Medicaid number, WY Medicaid for the client, and then Search.

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Adding a Request

• Click the Add Service button and complete the

required fields

• Episode class: Prior authorizations
• Episode type: outpatient
• Treatment type: Physical or occupational or

speech therapy.

• Diagnosis: enter a code or description to search
• Click Save

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Starting a Request

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Working Steps to Set Up a Review

• Please complete all the steps

prior to submitting.

• Click on each tab in the left

navigational panel to complete the step.

• Completing theses steps will

guide you to submitting a request.

• Not all steps are required prior to

submitting.

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Step 2: Add Providers

• Start the search with the attach new button.
• Enter the providers name with a minimum of 3 letters and SEARCH.
• Enter a provider type of Organizational is the Requesting Provider
• Role. This allows you to see the request.
• Enter a provider type of Individual is the Treating Provider Role.

This is the Provider/Practitioner.

• Enter a provider role of Facility/Vendor is the Admitting Provider
• Role. This is the facility where services are rendered. This is the

Pay to Provider.

• Click the icon to add all 3. Then Attach button.
• It is important to add all 3 types. This allows you to view the

requests and properly submit claims.

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Step 3: Add Diagnosis

• You added the initial diagnosis on the set up page.
• If you have more, please add them here.
• Select Add New Diagnosis button.
• Add a code or description to select new or additional

diagnosis.

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Step 4: UM services

• Select Add services. Complete the required areas
• Use CPT codes only
• Start date is the day request entered. Correct the end date

to your requested date. Start dates can be back dated.

• Save

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Step 5: Add Assessments

• This is not currently being used for this

type of request.

• Please skip this step.

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Step 6: Add Contact Info

• Great place to leave your contact information.
• Select add new contact. Enter key information

and Save

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Step 7: Add Notes

• This is the place to add notes to Qualis Health!
• This can be a variety of information to service

questions, clinical and changes to the request.

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Step 8: Add documents

• Upload required documents here. No .tif records.

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Step 9: Submit Request

• You are able to preview the request prior

to submitting.

• To edit, go to step 1 to make corrections.
• Click submit when your request is complete.

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Important Information for Adults

• For ages 21 years and over
• Must be for restorative or rehabilitative in

nature

• Can be for exacerbations of a chronic

condition

• Prior authorizations are needed after the

initial 20 visits per year

• Not for maintenance or weight loss

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Important Information for Children

• For ages 20 years and younger
• Can be for restorative or rehabilitative in

nature or maintenance care

• PA needed after the initial 20 visits per year

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Required documentation

• Orders with frequency and duration of therapy type
• Orders/Prescriptions are only valid for 180 days
• Patients acute condition or maintenance needs
• Maximum therapeutic benefit to be expected for

acute conditions

• Include therapy notes to substantiate progress with

progress towards goals

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Maximum Approvals

Adults:

• Acute conditions with a max 8 visits per PA.

Children:

• Acute conditions with a max of 8 visits.
• Maintenance therapies will be for 180 days.

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Dashboards and Alerts

• Your dashboard will allow you to view

your patients.

• To open a request, click on the ‘OP’.
• The episode number will give you an

abstract of the request in a view only.

• Monitor your alerts for updates to the

case.

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QHPP User Guide

• The Qualis Health Provider Portal user guide

is located on our home page just below the download of the registration packet.

(http://www.qualishealth.org/sites/default/files/WY-Medicaid-QHPP-User-Guide.pdf)

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Community of Care Document

• CCD Viewer
• CCD viewer allows authorized users to

search & retrieve Patient Summary CCD for current Medicaid recipients.

• This will show how many visits/services

has been billed to Medicaid and if patients are being seen by other therapy providers.

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CCD Access

• Please send an email containing:

– Clinic Name – Address – Phone number – Provider Names – Provider email Addresses – Primary Contact

• Send to Andrea Bailey at andrea.bailey@wyo.gov
• For more information visit: http://wyomingthr.wyo.gov/ccd-viewer

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Training WebEx Schedule

Date Time (MST) Training Topic 9/18/2017 11am-12pm How to register for the QHPP. This was recorded and is under resources at Qualishealth.org. 10/3/2017 10-11am Provider Review Request for Therapy (PT,OT & ST) 10/5/2017 10-11am Provider Review Request for Behavioral Health 10/10/2017 2-3pm Provider Review Request for Therapy (PT,OT & ST - repeat of 10/3/17 morning session) 10/12/2017 2-3pm Provider Review Request for Behavioral Health (repeat of 10/5/17 morning session) 11/2/2017 1-2pm Question and Answer session after 11/1/2017 go live

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Qualis Health Contact Information

Phone: (800) 783-8606 Fax: (877) 810-9255 Teresa Kirn RN

Manager, Clinical Care Management (208) 383-5960 teresak@qualishealth.org

Deon Westmorland RN BSN CCM

Director, Wyoming Medicaid Services (206) 288-2347 deonw@qualishealth.org

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Qualis Health Contact Information

Utilization Review

• Toll-free Phone: (800) 783-8606
• Toll-free Fax: (877) 810-9265

Utilization Review Hours

• 8:30am to 7:00pm MST
• Monday through Friday

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Qualis Health Provider Portal

Questions?