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Prior Authorizatio

n, Adjustments

, Appeals and DME

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UTILIZATION MANAGEMENT

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Utilization ManagementREFERRAL

A referral is a request (verbal, written, or telephonic communication) by a PMP for specialty care services.

PRIOR AUTHORIZATION

Prior Authorization is an approval from MHS to provide services designated as needing approval prior to treatment and/or payment.

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Utilization Management

• ALL referrals to participating specialists for office visits require communication between the PMP and the specialist.

• ALL referrals to non-participating specialists and/or for procedures that require authorization must be obtained by contacting MHS.

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Utilization Management

Self Referrals

• Podiatrist • Chiropractic• Family Planning• Routine Vision Care• Routine Dental Care• Mental Health by Type and Specialty• HIV/AIDS Case Management• Diabetes Self Management• Immunizations

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Utilization ManagementServices that require a prior authorization

regardless of contract status:• Assistant Surgeon• Blepharoplasty• Nuclear Cardiology/SPECT scans, PET, MRI, MRA• Circumcision• Transplant evaluation and request• Dental Surgery for members >5 years old and/or general

anesthesia is requested• Dialysis• Experimental or investigational treatment/services• Genetic testing or counseling

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Utilization ManagementServices that require a prior authorization

regardless of contract status:

• Hysteroscopy, infertility services• Implantable devices including cochlear implants• Mammoplasty• Nutritional counseling (non-diabetics only)• OB ultrasounds (2 per pregnancy without authorization)• Pain Management Programs including epidural, facet and

trigger point injections • Scar revision; cosmetic or plastic surgery; septoplasty;

rhinoplasty; spider and/or varicose vein treatment

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Utilization Management

HOSPITAL SERVICES

• All elective inpatient/outpatient services must be prior authorized with MHS at least 2 business days prior to the date of service.

• All urgent and emergent services must be called to MHS within 2 business days after the admit.

Failure to prior authorize services will result in claim denials.

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Utilization Management

TRANSFERS

• MHS requires notification and approval for all non-emergent transfers, at a minimum two (2) business days advance notice.

• MHS requires notification within two (2) business days following all emergent transfers. Transfers are inclusive of, but not limited to the following:• Facility to facility• Level of care changes

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Utilization Management

To initiate an authorization, referral staff will require the following information:

• Place of service: outpatient, observation or inpatient • Service type: elective, emergent or transfer • Service date• Name of admitting physician• CPT code for proposed services• Primary and any secondary diagnosis• Contact name and number to obtain clinical information

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Utilization Management• Prior Authorization (PA) should be initiated through the

MHS referral line at 1-877-MHS-4U4U (647-4848).

• The PA process begins at MHS by speaking with the MHS non-clinical referral staff.

• PAs can also be submitted online via our website at www.managedhealthservices.com. Additional documentation may be required to be sent via fax for approval of authorization.

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Utilization Management

MHS will:

• Provide a PA number at the time of the call unless clinical information is required.

• Provide the caller with the name and phone/fax number of the Case Manager (CM) assigned to the case if clinical information is required.

• The CM will correspond with the provider via the provider’s preferred method: phone or fax.

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Utilization Management• The MHS CM will review all available clinical

documentation; apply Milliman Care Guidelines, and seek Medical Director input as needed.

• PA for Observation Level of Care (up to 72 hours) is not required in contracted facilities.

• If the provider requests an inpatient level of care for a covered/eligible condition/procedure and documentation supports an outpatient/observation level of care, the case will be sent for a Medical Director review.

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Utilization Management

• If the provider requests inpatient level of care for a covered/eligible condition and documentation supports an inpatient level of care, the request will be approved.

• The CM may send any requests to a Medical Director for review/decision if he/she determines the individual clinical elements require the skills/knowledge of a physician or for which complete clinical information cannot be obtained.

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Utilization Management Examples of diagnoses potentially appropriatefor Observation Level of Care

Ambulatory DiagnosesAllergic Reaction (Generalized)AsthmaBronchitisEnteritis (Diarrhea)Epistaxis (Nose Bleed)Failure to ThriveFracture (Simple)HypertensionPre-term LaborRenal Colic / Calculus (Kidney Stone)SinusitisSprainsUrinary Tract Infection (UTI)Other not specifically listed

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Utilization Management Examples of diagnoses potentially appropriatefor Observation Level of Care

Symptomatic DiagnosesAbdominal PainAltered Mental Status (Confusion)Back PainChest PainDehydrationDelayed Recovery following Anesthesia/ ProcedureDizziness / WeaknessElectrolyte ImbalanceEpigastric PainFeverFlank Pain / TendernessHeadacheNausea / Vomiting Shortness of Breath (SOB)

Uncontrollable Vomiting/Pain after OutptSurg/ChemoAny “Rule Out” DiagnosisOther not specifically listed

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Utilization ManagementDenial of Request and Appeal Process

If MHS denies the requested service:

• The MHS CM will notify the provider verbally within one business day of the denial, provide the clinical rationale, and explain appeal rights.

• A formal letter of denial explaining denial rationale and appeals rights will be mailed within the next business day.

• If denial is based on Milliman Care Guidelines, provider has right to obtain a copy of the guidelines in which denial is based.

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Utilization ManagementDenial of Request and Appeal ProcessIf MHS denies the requested service:

• If member is still receiving services the provider has the right to an expedited appeal which must be requested by the attending physician.

• If the member has already discharged, an appeal must be submitted in writing from the attending physician within 60 days of the denial.

• The attending physician has the right to a peer-to-peer discussion.

• Peer-to-peer discussions and expedited appeals are initiated by calling MHS at 1-877-MHS-4U4U (647-4848) and asking for the Appeals Coordinator.

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Utilization Management

MEDICAL NECESSITY GRIEVANCE AND APPEALS

Managed Health ServicesAttn: Appeals Coordinator

1099 North Meridian Street, Suite 400Indianapolis, IN 46204

Determination will be communicated to the provider within 20 business days of receipt.

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DURABLE MEDICAL EQUIPMENT

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DME Policy• Before an item can be considered to be

durable medical equipment:

• It must be able to withstand repeated use.• It must be primarily and customarily used

to serve a medical purpose.• It is generally not useful to a person in the

absence of an illness or injury.• It is appropriate for use in the home.

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DME PolicyItems including, but not limited to, the following are examples of DME: Hospital beds Wheelchairs Canes Walkers Raised toilet seat Oxygen systems Ventilators Nebulizers Neuromuscular Stimulators Bone growth Stimulators Infusion Pump CPAP/BIPAP Wound Vacs

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DME Policy• DME with a purchase price of more than

$500.00 require prior authorization.

• Manually Priced DME – must be submitted with invoice.

• DME authorization requested by treating PMP or specialist.

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DME Policy

• All DME authorizations must be obtained prior to dispensing.

• Orthotics and prosthetics items with a purchase price above $250.00 require an MHS authorization.

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DME Policy• All DME items, regardless of purchase

price, must be medically necessary as defined by: 405 IAC 5-2-17 “Medically reasonable and necessary service”.

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DME PolicyIf the DME requires authorization, the authorization must be completed prior to dispensing the items, with the following exceptions:

• DME item necessary as part of discharge planning from the hospital.

• DME item necessary as part of the treatment plan for an urgent / emergent medical condition.

• DME item previously authorized by another MCO as a component of continuity of care during the 1st 30 days of transition.

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DME Policy• DME authorization decisions by MHS are based on

medical necessity.• The MHS Prior Authorization form should accompany all

clinical information submitted as part of the prior-authorization request.

• Authorization duration is based on medical necessity, anticipated outcomes, compliance with utilization, benefit limitations, and alternative treatment options available to meet the medical need of the member.

• Authorization requests to extend an existing authorization are required to be submitted prior to the expiration date of the current authorization.

• Authorization numbers and units are provided for approved DME items.

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Claims Adjustment and Appeals

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Resubmitted Claims• Clearly mark RESUBMISSION or CORRECTED

CLAIM at the top of the claim.

• Must attach EOP, documentation, and explanation of the resubmission reason.

• May use the Provider Claims Adjustment Request Form.

• Providers have 60 calendar days60 calendar days from the date they receive their EOP to file a resubmission.

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Adjusted Claims• If you need to make an adjustment to a paid claim,

you can do so by calling Provider Inquiry or you may submit on paper with the adjustment request form.

• Attach a Provider Adjustment Form along with documentation, including EOP (if available) explaining reason for resubmission.

• Claim adjustments must be submitted within 60 days of the date of the MHS EOP.

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Dispute ResolutionPROVIDERS HAVE 60 CALENDAR DAYS FROM THEDATE OF RECEIPT OF THE EOP TO FILE ANOFFICIAL DISPUTE OR APPEAL WITH MHS.

• Verbal inquiries can be made by calling the MHS Provider Inquiry Line at 1-877-MHS-4U4U (647-4848).

A verbal inquiry is not considered a dispute or appeal anddoes not stop the 60 calendar days from the date of receipt of

the EOP to file a dispute or appeal.

• Informal Claim Dispute - Level One Appeal• Formal Claim Dispute/Objection – Level Two Appeal

(Administrative)

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MHS – Need to know

www.managedhealthservices.com

&

1-877-MHS-4U4U (647-4848)

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Provider Inquiry ServicesCall us at 1-877-647-4848. We are ready to help you!

• Knowledgeable, friendly staff available 8:00-6:00 EST• Focused commitment to professional service• Claims address P.O. Box 3002 Farmington, MO 63640• Dispute & appeal processes (60 days from receipt of EOP)• Appeal address P.O. Box 3000 Farmington, MO 63640• Filing limits dependent upon contract status• Follow IHCP requirements

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MHS WEBSITE• www.managedhealthservices.com • Enhanced website – Access for both contracted/non-

contracted groups• On-line Registration – Multiple Users• Provider Directory Search Functionality• Enhanced Claim Detail• Direct Claim Submission (Professional Claims only)• Prior Authorization• Claim Auditing Software Tool• Downloadable Eligibility Listing• Printable, Current Forms and Manual

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Questions and Answers