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Advancing Healthcare Improving Health
Advancing Healthcare Improving Health
WY Medicaid Behavioral Health Provider Outreach Teresa Kirn, RN - - PowerPoint PPT Presentation
WY Medicaid Behavioral Health Provider Outreach Teresa Kirn, RN - - PowerPoint PPT Presentation
WY Medicaid Behavioral Health Provider Outreach Teresa Kirn, RN IQCI Manager, Care Management Department July 23, 26, and 27, 2018 Advancing Healthcare Improving Health One of the nations leading healthcare consulting organizations,
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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
- Providing 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), Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) and Behavioral Health visits.
- We use InterQual and organizational policies to conduct our
review
- Offer telephonic provider consultation
- 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
- Details of the behavioral health review
guidelines
- How Qualis Health uses the guidelines
- Everything you need to submit with your review
request
- How to get your reviews approved
- What you can do if you disagree with Qualis
Health’s decision
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New WY BH guidelines
- New as of 6/21/2018
- Located at Qualishealth.org
- How we apply these guidelines
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Getting Started
- Submit all required documentation
- Initial Behavioral Health intake form
- Updated Behavioral Health intake form (required at
least annually as of 4/1/2018)
- The last 5 clinical notes for each service/code
requested & occurring just prior to the authorization start date
- Signed and dated treatment plan with frequency and
duration for each service/code requested clearly
- utlined
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Getting Started, cont.
- Date of the 20th visit
- Start and end date for the requested
authorization
- Number of visits/units being requested
per code(s)
- Submit all requests for a patient (as
- utlined by the treatment plan) at the
same time
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Comprehensive Qualis Health Reviews
- All documentation must be submitted to Qualis
Health for review of each client.
- For example, the client receiving case management,
individual therapy and group therapy: all information will need to be submitted through the Qualis Health Provider Portal for each service request per provider with required documentation for a comprehensive review.
- No reviews will be completed if past timely filing
(DOS over 1 year old).
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UM Review Process
- Cases reviewed for required documents and
services
- Clinical reviewers use the WY BH guidelines
and InterQual criteria
- Clinical Reviewers will approve per the guidelines and IQ
criteria
- Clinical Reviewer will forwarded to a physician when 1st
level determination cannot be made
- Physician Reviewer will make all denial
determinations
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UM Review Process, cont.
- Request a reconsideration for decisions
that you disagree with within 30 days of the decision
- All appeals are sent to Provider Services
Program Manager
- Fair Hearing requests can be made by the
client or their legal representative
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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 have
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
- Send to Andrea Bailey at andrea.bailey@wyo.gov
- For more information visit:
http://wyomingthr.wyo.gov/ccd-viewer
− Provider Names − Provider email Addresses − Primary Contact
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Training WebEx Schedule
Date Time (MST) Training Topic 07/23/2018 10am -12pm WY Behavioral Health Provider outreach 07/26/2018 11am – 1pm WY Behavioral Health Provider outreach 07/27/2018 1 – 3PM WY Behavioral Health Provider outreach
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Qualis Health Contact Information
Phone: (800) 783-8606 Fax: (877) 810-9255
Teresa Kirn RN IQCI Manager, Clinical Care Management (208) 383-5960 teresak@qualishealth.org Lisa Layne Manager, Non clinical Care (206) 288-2385 lisal@qualishealth.org Deon Westmorland RN BSN CCM Associate Vice President, Care Management (206) 288-2347 deonw@qualishealth.org
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Utilization Review 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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