Qualis Health Wyoming Medicaid Home Health Services Program Prior - - PowerPoint PPT Presentation

Qualis Health Wyoming Medicaid Home Health Services Program 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 (PA)

• effective March 1, 2017- all Home Health services (HHS) will require

prior authorization

• Answer clinical and technical questions related to the HHS

program prior authorization and retrospective review

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

What We Don’t Do

We do not receive financial incentives to deny or limit services

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Presentation Objectives

• Provide instruction on how to submit a review

through the Qualis Health Provider Portal (QHPP)

• Describe the Wyoming Medicaid Home Health

Services (HHS) Program administered by Qualis Health

• Provide Qualis Health contacts and resources

available

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Providers

• Must be enrolled as a Wyoming Medicaid home

health provider, public health provider, prosthetic & orthotic provider, or medical supply provider

• Must obtain Prior Authorization (PA) before the

delivery of Home Health services (HHS)

• Must keep all client documents, physician
• rders, and authorization numbers on file

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Prior Authorization (PA) Requirements

• Clinical requirements for home health PAs follow the

guidelines in the Wyoming Medicaid Rules, Chapter 12 – Home Health services-available on the web site: https://rules.wyo.gov/Search.aspx?mode=1

• section 6 (Covered Services) & section 7 (Excluded Services)
• PA requests will be reviewed for compliance with

published policy in the provider manual, located on the web site: https://wymedicaid.acs- inc.com/manuals/Manual_Institutional_1_6_17.pdf on

• pg. 209 - 213

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Prior Authorization (PA) Requirements, cont.

• April 1, 2017- the updated manual will be

available with the new policy for PAs and regarding Medicare/Medicaid dual eligible clients

• Medicare/Medicaid dual eligible clients- the PA

request needs a statement from the physician that the client is not homebound and would not qualify under Medicare guidelines for HHS through Medicare

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Prior Authorization (PA) Requirements, cont.

• Effective March 1, 2017 and forward,

Wyoming Medicaid will no longer accept the Home Health Medicare Exemption Letter in place of a Medicare EOMB.

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Face to Face Requirement

• February 2, 2016- CMS published a final rule which

enacted changes to the federal regulations related to the coverage of Home Health services (HHS)

• This new policy mandates that when HHS are initially
• rdered, the client must have a face-to-face visit related

to the condition for which the services are being ordered within the previous ninety (90) days with the ordering or prescribing practitioner

• This final rule can be reviewed online:

https://www.federalregister.gov/documents/2016/02/02/2 016-01585/medicaid-program-face-to-face-requirements- for-home-health-services-policy-changes-and

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Face to Face Requirement, cont.

• Existing clients already receiving Home Health services

(HHS) will not require a new face-to-face visit

• This requirement will only apply to clients initiating

services with a Home Health provider starting March 1, 2017 or later

• PA requests will require documentation of the face-to-

face visit, including the date and practitioner, and a copy

• f the signed and dated plan of care or signed and dated

physician’s order

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Utilization Management

• Review for medical necessity of all Home Health

services (HHS)

• Assure appropriate use of healthcare resources

– Prior authorization review – Retrospective review

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Utilization Management Process

• Review submissions via the Qualis Health

Provider Portal (QHPP)

• Review utilizing InterQual or State of Wyoming

approved criteria/guidelines

• Approve or refer to physician reviewer
• Certification or non-certification
• Reconsideration and/or Doctor to Doctor offer
• Providers will be escalated to the State for

upheld denials- Appeal requests

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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) register

staff as Provider Portal User(s)

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www.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 enter can be found in Not Submitted, Processed Requests, and Outstanding Requests. All requests for your group can be found in Search Request.

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Not Submitted Tab

• The Not Submitted tab displays episodes

created by you that have not been submitted to Qualis

• QH-PP users may keep the episode in their Not

Submitted queue until they are ready to submit the request for review

• The status of the reviews in the Not Submitted

queue 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 Jiva.

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 Prior Authorization from the Episode Class drop-down list. Select non-urgent from the Urgency drop-down list. Select Home Health 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 HHS 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 A warning message appears when the Provider tab (#2) is incomplete

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Submitting a Request for Review

The Add Diagnosis tab allows you to add diagnoses. Only the primary diagnosis is required.

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Submitting a Request for Review

The UM Services tab allows you to request services for outpatient HHS. Codes only requiring prior authorization should be submitted. The Prior Authorization list is located on the Qualis Health website and under the Group Name hyperlink.

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Prior Authorization List

• The PA list is located under the Group Name

hyperlink

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Submitting a Request for Review

Click the Add Service button which displays the Service Request section. Select Code in the Code Type drop-down. Enter the codes in the Service Code field and include requested units/days

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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 clinical information
• Medicare 485 or form with similar content, signed and dated copy of the plan of

care, or signed and dated physician’s order

• Documentation of face to face visit for initial requests, including date and

practitioner

• Accepted formats include Word docs, PDFs, JPEGs and other picture formats
• Temporary image files (.tif) are not acceptable attachment formats

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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.

• 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- 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?

• Completed Medicare 485 or other form that contains the

same information

• Signed and dated copy of the plan of care or signed and

dated physician’s order

• Documentation of face to face visit for initial requests,

including date and practitioner

• Only list codes requiring prior authorization
• Include number of units and days requested
• Include any pertinent clinical documentation to support

medical necessity

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Prior Authorization (PA) Reviews

• PA approval must be requested prior to rendering

services

• Providers have 5 business days to submit additional

information if not submitted with original PA request

• Documentation not received within 5 business days of

the request will result in a Technical Denial.

• Providers have 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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The recommended browsers for Jiva are Internet Explorer 8 or 11, or Firefox 10.

If Jiva 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

• Submit completed forms, signed and dated plan of care
• r physician’s order that correspond to the PA request
• Submit only those codes requiring prior authorization–

the PA list is located on the Qualis Health website and under the Group Name hyperlink :Wyoming Medicaid Pre Auth List effective 01 01 2016

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Important Tips When Submitting Web Portal Requests, cont.

• Include requested units and dates
• When submitting additional clinical information,

do not change the episode type or class in Jiva

• When adding documents- Accepted formats

include Word docs, PDFs, JPEGs and other picture formats.

• Temporary (.tif) files are not accepted

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Qualis Health Contact Information

Wyoming Medicaid Home Health Services Program

Qualis Health

Phone (800) 783-8606 Fax (877) 840-9265 Teresa Kirn Manager, Clinical Care Management (206) 364-9700 x 5960 teresak@qualishealth.org Kate Moss Intake Specialist (206) 364-9700 x 2613 katem@qualishealth.org

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DEMO to follow