Qualis Health Wyoming Medicaid DME Prior Authorization and - - PowerPoint PPT Presentation

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Qualis Health Wyoming Medicaid DME Prior Authorization and - - PowerPoint PPT Presentation

Oct 22, 2023 622 likes •1.13k views

Qualis Health Wyoming Medicaid DME Prior Authorization and Provider Portal Training December 2015 One of the nations leading healthcare consulting organizations, partnering with our clients across the country to improve care for millions

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Qualis Health Wyoming Medicaid DME Prior Authorization and Provider Portal Training

December 2015

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One of the nation’s leading healthcare consulting

  • rganizations, partnering with our

clients across the country to improve care for millions of Americans every day

www.qualishealth.org

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Who We Are

  • We are clinicians.
  • We respect your

clinical judgment.

  • We want your clients

to receive the necessary and appropriate services.

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What We Do

  • Contract with Wyoming Medicaid to review select medical

services and supplies requiring prior authorization effective January 1, 2016

  • Answer clinical and technical questions related to DME

prior authorization and retrospective review

  • Offer telephonic and electronic provider education
  • Provide review support resource accessibility on
  • ur 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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Presentation Objectives

  • Describe the Wyoming Medicaid DME program

administered by Qualis Health

  • Provide instruction on how to submit a review

through the Qualis Health Provider Portal (QHPP)

  • Provide Qualis Health contacts and

resources available

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Care Management Services

  • Utilization management
  • Retrospective reviews
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Utilization Management

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Utilization Management

  • Review for medical necessity of select DME

supplies and services

  • Assure appropriate use of healthcare resource

Prior authorization review Retrospective review

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Utilization Management Process

  • Review submission via the

Qualis Health Provider Portal (QHPP)

  • Clinical review utilizing InterQual or

State of Wyoming approved criteria/guidelines

  • Approval or referral to physician reviewer
  • Certification or non-certification
  • Reconsideration and/or Doctor to Doctor offer
  • Appeals process for non-certified cases
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Web-Based Utilization Review Submission

  • Secure access
  • Review the status of your request online
  • Improved turnaround time for completion
  • Enhanced communication
  • Provider Portal is member centric
  • Provider Portal is based on Episodes of care
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Introduction to Qualis Health’s Provider Portal

  • Registration Process
  • Provider Portal Training
  • Accessing the Provider Portal
  • Logging In
  • The Dashboard
  • Submitting a request for review
  • Provider Portal User Support
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Registration Process

  • Locate online Registration Packet
  • Healthcare Organization Executive

appoints Provider Portal Administrator(s)

  • Provider Portal Administrator(s) registers

Provider Portal User(s)

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www.qualishealth.org

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Provider Portal Training

The Qualis Health Provider Portal Training Manual walks you through entering a request through the portal, searching for existing requests, adding patients and more. Find it on our Wyoming Medicaid Provider Resources page at: http://www.qualishealth.org/healthcare-professionals/ wyoming-medicaid/provider-resources Training webinars can also be arranged by email request to: ProviderPortalHelp@qualishealth.org

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Accessing The Provider Portal Logging In

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Accessing The Provider Portal: The Dashboard

Requests that you entered can be found in Actions Required, Processed Requests and Outstanding Requests. All requests for your group can be found in Search Request.

Dashboard can always be opened from here.

Find the requests you entered into the Provider Portal under the My Tasks bar.

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Actions Required

  • The Actions Required tab displays episodes created by

you that have not been submitted to Qualis Health.

  • QH-PP users may keep the episode in their Actions

Required tab until they are ready to submit the request for review.

  • The status of these reviews are Pending for Submission

and will not be visible to Qualis Health until they are submitted for review.

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Search Request

The Search Request allows you to search by client name, client Medicaid ID (Insurance ID), Episode ID and more…

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Submitting a Request for Review

Go to the New Request tab and in Member Search look for the client using their Medicaid ID.

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Submitting a Request for Review

When the client record comes up, you can use the plus icon to add a new request. If the client is not found in our database, you will have to call Qualis Health to speak with a representative, who can search MMIS for the client information and add it to the Qualis Health Provider Portal.

Add Request

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Select Outpatient from the Episode Type drop-down list . The Add New Request screen will display and allow you to enter the basic information to create the shell of your request. Select Retrospective or Prior Authorization from the Episode Class drop-down list. Select non-urgent from the Urgency drop-down list. Select DME from the Treatment Type drop-down list.

Submitting a Request for Review

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Submitting a Request for Review

Once you have saved the shell of your request, the Left Navigation Panel will show tabs with the steps to complete your request. The Edit Request tab allows you to edit anything on your request shell.

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Submitting a Request for Review

The Add Providers tab allows you to add the DME provider. Your group will already be listed as the requesting provider. Episodes submitted via the QHPP must have 3 provider Types attached to the Episode. Organization/Requesting – this is how your agency is registered with the Qualis Health Provider Portal. Admitting/Facility and Treating/Individual - your agency will be listed as both the Admitting and Treating Provider

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Submitting a Request for Review

The Add Diagnosis tab allows you to add diagnoses. Your primary diagnosis will already be listed. Only the primary diagnosis is needed.

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Submitting a Request for Review

The UM Services tab allows you to request services for outpatient DME. HCPCS only requiring prior authorization should be submitted. The Prior Authorization list is located on the Qualis Health website.

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Submitting a Request for Review

Click the Add Service button which then displays the Service Request section. Select Code in the Code Type drop-down. For DMEPOS, enter the HCPCS in the Service Code field. Click in the Modifier text field to search for a modifier, enter RR for Rental (DME).

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Submitting a Request for Review

The Add Contacts tab allows you to add your name and phone to your request.

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Submitting a Request for Review

The Add Notes tab allows you to enter details about your request. This area is where you enter your review & clinical information.

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Submitting a Request for Review

The Documents tab allows you to enter information about your request. This area is where you attach your PA request form, CMN & clinicals.

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Submitting a Request for Review

  • Add Document and Enter the Document Title.
  • Select the type of document from the Document Type drop-down list

(if applicable).

  • Enter a brief description in the Document Description text box.
  • Click Browse to navigate to the location of the saved document and

select it.

  • Click Upload Document, this displays the uploaded document in

the Documents screen.

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Submitting a Request for Review

When your request is complete, the Submit Request tab allows you to review and, if needed, print your request before submitting. If any required elements are missing, an alert will pop up.

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Checking the Status of a Review

To find your request, you can go to the Processed Requests in your Dashboard, or you can use the Search Request tab and enter search criteria to pull up and open your request.

Look in Processed Requests

  • r Use the Search Request

tab

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Additional Information Requests

– You will receive an alert on your dashboard under the ALERTS tab

*click on Episode type to open*

– Requested additional information will be found in the NOTES tab

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Additional Information Requests

This feature is applicable to Additional Information requests only!

The Add Documents tab allows you to attach requested documents. Accepted formats include Word docs, PDFs, JPEGs and other picture formats.

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Provider Administrator Tasks

The Provider Portal Administrator has an extra tab at the top of their

  • screen. Under Manage Staff, use the User Search Form to search for

existing user accounts or add new users. You can also modify a user account or reset their password.

Modify an account Reset a password

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Submitting a Request for Review

Review Process

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Submitting a Request for Review

What to submit for a review?

  • 1. Completed prior authorization (PA) form
  • 2. Signed Certificate of Medical Necessity (CMN)
  • 3. Only HCPCS for requested equipment and/or

supplies requiring prior authorization

  • 3. Include number of units/days or months

requested

  • 4. Include any pertinent clinical documentation to

support PA request

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Prior Authorization (PA) Reviews

  • PA approval must be requested prior to rendering

services

  • Providers must submit PA form, CMN and relevant

clinical documentation as noted in the DME manual

  • Provider has 5 business days to submit additional

information if not received with original PA request

  • Documentation not received within 5 business days of

the request will result in a Technical Denial.

  • Provider has 30 calendar days to request

Reconsideration for denials

  • Documentation received after 30 days from the date
  • f a denial will be considered a new PA request
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Frequently Asked Question

What browser to use with the Qualis Health Provider Portal?

  • Issues that have sometimes been noted when using
  • ther browsers or browser versions include:
  • Not being able to enter your time in an activity
  • Not being able to lock a fax
  • Not being able to attach an existing provider record to

an episode

  • Not being able to select a procedure code
  • Internet Explorer 8 or Firefox 10 are the recommended

browsers

  • Internet Explorer 11 is also compatible
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The recommended browsers for the Qualis Health Provider Portal are Internet Explorer 8 or Firefox 10.

If the Qualis Health Provider Portal is not working the way it should for you, the first thing to check is the version of your browser. In your browser, find your Help menu and choose “About name of program” or the equivalent. This should tell you what version of the program you have.

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Important Tips When Submitting Web Portal Requests

  • Please ensure all alerts are addressed/corrected when

submitting the portal request to prevent delays

  • Please enter providers-treating, admitting, & requesting
  • Submit completed PA form, signed CMN and clinical

documentation that corresponds to the PA request

  • Submit only HCPCs requiring prior authorization–the PA

list will be located on the Qualis Health website.

  • Include requested units/days or months
  • When submitting additional clinical information, do not

change the episode type or class in the QHPP

  • When adding documents- Accepted formats include

Word docs, PDFs, JPEGs and other picture formats

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Qualis Health Contact Information

Wyoming Medicaid DME/Prosthesis/Orthotics Program

Qualis Health

Phone (800) 783-8606 Fax (877) 840-9265

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Provider Portal User Support

Send an email message to: ProviderPortalHelp@qualishealth.org

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DEMO to follow