health first colorado utilization reviewco.eqhs.com/portals/2/2020/new to eqsuite ppt/new... ·...
TRANSCRIPT
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Health First Colorado
Utilization Review
New to eQSuite®
Agenda
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• Overview of PAR process
• HealthFirst Colorado Rules
• eQSuite® Training
• 1st level and 2nd level determinations
• PAR numbers, PAR letters
• eQSuite® Reports
• Reconsideration and Peer-to-Peer Process
• Review Types
• Retroactive PARs
• PAR Revisions
Introduction to eQHealth Solutions
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• A non-profit population health management and technology
solutions company.
• Selected by the Colorado Department of Health Care Policy
and Financing to prior authorize services for Colorado Medicaid
clients effective September 1, 2015.
Current Scope of Services
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• Diagnostic Imaging
• Durable Medical Equipment
• Physical & Occupational Therapy
• Medical
Transplants
Surgical Procedures: such as Bariatric surgery
• Molecular Testing – BRCA1 and BRCA2
• Inpatient
• Pediatric Behavioral Therapy
• Speech Therapy
• Pediatric Long-Term Home Health
• Private Duty Nursing
• Out of State Non-emergency Inpatient
Stays
• Audiology
• Synagis®
• Vision
eQHealth Solutions Provides:
❑ 24-hour access for Utilization Review submissions
❑ Provider Communication and Support
❑ Provider Education and Outreach
❑ Comprehensive Utilization Management Program
❖ Prior Authorization Review (PAR)
❖ Retrospective Review
❖ PAR Reconsiderations & Peer-To-Peer Reviews
❖ PAR Revisions
❖ Real time access to provider reports
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Colorado Medicaid Rule
8.076.1.8 (All Services Except DME)
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Medical necessity means a Medical Assistance program good
or service that will, or is reasonably expected to prevent,
diagnose, cure, correct, reduce, or ameliorate the pain and
suffering, or the physical, mental, cognitive, or
developmental effects of an illness, injury, or disability. It
may also include a course of treatment that includes mere
observation or no treatment at all.
Colorado Medicaid Rule 8.590.2.A
(DME ONLY)
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Colorado Medicaid rule 10 CCR 2505-10, Section 8.590.2.A. under
states that, “DME, Supplies and Prosthetic or Orthotic Devices are a
benefit when Medically Necessary.”
•The item must be prescribed by a physician and, when
applicable; be recommended by an appropriately licensed
practitioner.
•The item must be reasonable, appropriate and effective method
for meeting the client’s medical need.
•Have an expected use that is in accordance with current medical
standards or practices.
Connectivity to eQSuite®
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Minimal Computer System Requirements
❖ Any one of the following browsers (please note it must be one of the two most
recent versions):
Internet Explorer
Google Chrome
Mozilla Firefox
Safari
❖ Broadband internet connection
❖ If you already have access to eQSuite® and experience connectivity issues, clear your
cache – Visit www.refreshyourcache.com
Select the browser you are using and follow the steps to clear your cache.
http://www.coloradopar.com/ProviderResources/ITRequirements.aspx
Getting Started
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Getting Started
Request for eQSuite® Users Form
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1.Complete the “Request for eQSuite® Users Form”. You can locate
this form by clicking on the link below or by visiting our website.
➢ Assign a System Administrator
➢ Sign and date
➢ Scan or fax
2. System Administrator
➢ Assign logons to staff
➢ Assign roles to staff based on job responsibilities
Getting StartedAccess Form
Must be an Active Biller and Provider Type in DXC
You can select multiple
services; however, access will
only be granted to
corresponding provider types
in DXC
Administrator for PARs
Most Direct Line
Getting Started
Obtaining an Authorization
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• Obtaining an authorization number is required when the item or service
code requires an authorization and to verify whether the service
requires prior authorization here before submitting a Utilization Review
via eQSuite®.
• VERIFY the Client’s eligibility for CO Medicaid (by contacting Colorado
Medicaid).
• Reminder: Authorization does not guarantee Medicaid payment for
services.
Timelines
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Submission Response
Prior to service Expedited – 2 business days
Standard – 4 business days
Untimely submission -
anytime after performance
of the test
Within 4 business days of
HCPF’s Retroactive PAR
exception decision.
Retrospective – client was
not eligible at the time of
service
4 business days
PAR Submission
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PAR request Receipt Dates:
❑ On business days:
• From 12:00 a.m. – 5:00 p.m.(MST) - it is considered received
that day.
❑ On holidays - it is considered received on the next business day.
❑ On days following state approved closures, i.e., natural disasters
- it is considered received on the next business day.
eQSuite® Login
Username and Password
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eQSuite® Menu Options
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Editing and Adding Users
eQSuite® User Administration
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New UserTrainer
eQSuite® Update my Profile
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NewUserTrainer
NewUser
Trainer
Creating a New Review
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Create New Review
Menu Options
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Creating a New Review Provider Information & Recipient Information
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Test Provider
Test Provider
Creating a New ReviewPhysician Information
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Ordering Physician Information
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Type of Request: Urgent v. Non-Urgent
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Creating a New Review
Check Key
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Creating a New ReviewStart Tab
• Checking Errors
Creating a New ReviewDX and Procedure Codes
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Creating a New ReviewDX Codes
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Creating a New ReviewProcedure Codes
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Creating a New ReviewProcedure Codes- DME Example
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Creating a New ReviewProcedure Codes- Therapy Example
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Creating a New ReviewSubmitting DX and Procedure Codes
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Clinical Tab
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Creating a New ReviewSubmit for Review
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Add any additional info pertinent to the request.
After Submission
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Supporting Documentation
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Submitting Supporting Documentation
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It will be necessary to provide supporting documentation with authorization requests. We offer two methods of submitting the documentation:
You may:
• Upload and directly link the information to the eQSuite® review record.
• Or fax the documents using eQSuite®’s Principal Barcoded coversheet that is specific to that request and enables automatic linking to the correct record.
• Additional supporting documentation may be requested as needed to complete the review.
Do NOT copy or reuse fax cover sheets!
Supporting DocumentationExamples
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• Order / Prescription
• Physician visit notes
• Price Quote or Invoice (Details and Itemized)
• Other documentation including but not limited to: laboratory
tests, radiology studies, or any other pertinent medical
information to support the request
Supporting DocumentationLinking Attachments
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• Before proceeding, make sure that all requested documents are saved to
your computer and available to upload in PDF, JPEG or TIF format.**
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Submitting Supporting Documentation
Attachments Tab
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eQSuite® “Attachments”
• The requestor will receive an email that the PAR is still Awaiting Required Attachments
• If the required attachment(s) is not received within 10 business days, you will receive a Lack of Information Denial, and either a new admission or a reconsideration request can be submitted.
• An algorithm driven review process to identify certain service requests that meet medical necessity criteria without further review.
• ALL applicable clinical questions must be answered.
• ALL documentation to support the review must STILL be uploaded even if an automatic approval occurs
Benefits of the SMART review is that Providers may receive Immediate medical necessity approval!
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SMART Review Process
Submitting Supporting Documentation for the
SMART Review Process
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Additional Documentation
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• Record status “Pended for Add’l Info” indicates that although you
have submitted a utilization review, either no documentation was
received at the time of submission or a nurse has reviewed the
request and needs additional documentation to make a medical
necessity determination.
• You will have 10 days (from the date the utilization review is set to
the status of “Pended for Add’l Info”) for outpatient settings and
1.5 days for Inpatient setting to upload the requested
documentation. If the requested documentation is not received
within the 10 business days for outpatient setting or 1.5 days for
Inpatient setting, your request will receive a technical denial and
both you and the Member will receive a denial notification.
Identifying What Additional Info is Needed
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You will receive email notification that your review has been
Pended For Add’l Info.
Locating What Additional Info is Needed
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To locate the information that is being requested
• Click on the Respond to Add’l info tab
• Select Cases Needing Add’l Info
• Locate your review.
• Scroll to the far right of the page and click on View Letter.
Identifying What Additional Info is Needed
Viewing Letters
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• A copy of the memo from the nurse will open which will state the
documentation that is being requested for this review.
• The following box will pop up and you should select View.
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• Click on the Respond to Add’l info tab and select
Cases Needing Add’l Info.
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• Locate your review. Click on open.
Responding to the Request
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• You may type your response in the additional info box or upload
additional documents
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If you have all the needed documentation ready to
upload, you may click on Submit Info.
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The following box will pop up and you should click Link Attachment.
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• After you click Link Attachment, the following box will open.
Viewing Supporting Documents
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You can verify that you have successfully uploaded or faxed the documentation
because this review will no longer be listed under the Respond to Addl info tab and
you will see the record status of this review change to “At Nurse Review.” You can
view the status of your request by clicking on the Attachments tab.
Intermediate Statuses
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The request is currently being reviewed by a first level clinical nurse reviewer.At Nurse Review
The request is currently being reviewed by a physician. At PR Review
If your request receives Pended For Add’l Info Status again, please review the steps listed above.
Pended for Add’lInfo
Clinical Review
Determinations
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First Level Clinical Review Determinations
First Level Clinical (Nurse) Reviewers may:
Approve the service as requested based on Department approved criteria.
Pend for Additional Information- when a PAR is pended back to the requesting provider for additional or clarifying information, the requesting provider will receive an eQSuite® email.
Refer the request to a physician reviewer for further review and determination (2nd level Clinical Review).
Deny the request for non-compliance with HCPF policy for Technical reasons, they can NOT deny for medical necessity.
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Second Level Clinical Review
Second Level Clinical (Physician) Reviewers may:
Approve the service(s) as requested.
Pend: the review for additional information
Request for a peer-to-peer consultation with the ordering Provider.
Render an adverse determination. An adverse determination may be a full or partial denial of the requested services or a reduction in services.
Technical Denials for Lack of Information
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Prior Authorization Requests (PARs) submitted without required
documentation may result in a Technical Denial.
This occurs when:
• PARs are missing appropriate attachments or documentation. The PAR will have
record Status of “Awaiting Required Attachments”
• PARs are pended because they require additional information to make a medical
necessity determination. The review will be located under the Respond to Add’l
info Tab in eQSuite®
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If information is not received within 10 business days for outpatient settings
and/or 1.5 business days for inpatient setting, the request will be denied due to
lack of Information and the requestor must:
•Submit a new PAR request with the necessary information; OR
•Complete a reconsideration request and include the necessary information. This
request and the documentation must be submitted in eQSuite® or by fax within ten
(10) calendar days from the denial date for outpatient settings and/or five (5)
business days from the denial date for inpatient setting.
• Once the required documentation has been received, your PAR as well as the documentation submitted will be reviewed. On average, it will take up to four (4) business days from the time your documentation is received to receive a determination.
Final Determinations:
• Approved: If your request is approved, your authorization number will be generated. You may log into eQSuite® or into the Colorado Medical Assistance Program Web Portal to view your authorization number.
• Partial or Full Medical Denial: If the request receives a medical denial, the provider and the member will receive a denial letter. If you disagree with this decision, you may request a reconsideration or schedule a peer to peer consultation. Please see the reconsideration and peer-to-peer provider guides located under the provider resources tab on the Colorado PAR website
• Technical Denial: If your request is technically denied, the provider and the member will receive a denial letter. If you disagree with this decision, you may request a reconsideration via fax or submit a new PAR through eQSuite®.
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What to Expect Next
PAR NumbersPrior Authorization Requests
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PAR Numbers
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eQHealth makes PAR determination
eQHealth transmits PAR determinations into
Medicaid Management Information System
(MMIS)
If the transmission into InterChange (IC) is
successful, a PAR number is generated, will be visible in eQSuite and determination letters
will be generated
If the information is verified in InterChange (IC), a final PAR Number will be assigned and can be found:
eQSuite®
eQHealth Solutions Customer Service
Colorado Medical Web Assistance Portal
Finding a PAR Number
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Viewing a PAR Number in eQSuite®
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PAR Reconsiderations
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PAR Reconsiderations
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Both the ordering and treating provider may submit a request for a PAR
reconsideration of an adverse determination within 10 calendar days for
outpatient setting or 5 business days for inpatient setting from the date
of the adverse determination .
PAR reconsideration requests may be submitted electronically (eQSuite®)
or by fax.
• eQHealth Solutions’ response time for Reconsiderations:
• Expedited - two business days
• Standard – ten business days for outpatient settings
• Standard – four business days for inpatient setting
Peer to Peer
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Peer to Peer Process
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The Peer-to-Peer (P2P) process offers the ordering or
treating physician an opportunity to discuss a medical
necessity denial with an eQHealth physician reviewer prior to
initiating a request for reconsideration.
▪The ordering/treating physician’s office may request a P2P
▪The request must be submitted within five (5) calendar days from
the date of the medical necessity denial
▪Submit the request via the online helpline, by calling customer
service, or by fax
Follow instructions in the Peer-to-Peer Guide at www.ColoradoPAR.com
Change of Provider
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Change of Provider
Form
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If a change of provider is required after a PAR is completed, please assist the client in completing
the “Change of Provider Form”. This form is located on the www.ColoradoPAR.com website, under
the provider resource tab, forms and instructions.
Review Types
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Definitions of Review Types
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1. Admission (Initial PAR request) – Select this review type for a new/initial PAR
request.
Please note: Admission is the terminology in eQSuite® for a new/initial PAR request
and does not indicate a hospital inpatient admission. The review type “admission”
should be used for most PARs submitted through eQSuite®.
2. Cont Stay – Select this review type to extend the date span for any previously
requested services. (applicable to PDN, LTHH and Therapy PARs)
3. Modify Authorization (PAR Revision) – Select this review type when there is a
clinical need to increase or decrease units in a currently approved PAR or to add a new
service code within the same “from” and “thru” dates to an existing eQHealth PAR.
PAR Revisions
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PAR RevisionsModifications
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If a client’s needs change after a PAR review has been completed, you would
submit a Modify Authorization Review Request. Examples:
• To add a new procedure code on an existing PAR within the same date span
o Only enter the date span needed. Enter the new code needed. Codes already
reviewed do NOT need to be entered. PAR Clinical documentation must be
attached/uploaded to this PAR to support medical necessity.
• To add units to a procedure code(s) on an existing PAR within the same date span
o Only enter the date span needed. Enter the code and additional units needed.
Units already reviewed do NOT need to be entered.
• To change or add modifiers for a procedure code on existing PAR Clinical
documentation must be attached/uploaded to this PAR to support medical necessity.
PAR RevisionsModification Request
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To enter a Modification Request,
click Create a New Review and then
select the admission type Modify Authorization. You
will then enter the PAR# of the original review and hit
Retrieve Data. You will then finish out request as
previously instructed.
PAR RevisionsContinued Stay Requests
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Select this review type to extend the date span for any
previously requested services. (applicable to PDN,
LTHH and Therapy PARs) or for a Concurrent Review for
Inpatient Hospital Utilization Review
To enter a Continued Stay Request,
click Create a New Review and then
select the admission type continued stay. You will then
enter the PAR# of the original review and hit Retrieve
Data. You will then finish out request as we previously
shown when entering an Admission. A Continued Stay
Review will generate a different Review ID than the
initial authorization.
Timeline for Retroactive PARs
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Review Type Retroactive PAR requests PAR date range
(calendar days)
Audiology Are not accepted* Up to 1 year (365 days)
Behavioral Therapy Are not accepted* Up to 180 days
Diagnostic Imaging Are allowed up to 90 calendar days Up to 90 days
DME Are not accepted* Up to 1 year (365 days)
Speech Therapy Are not accepted* Up to 180 days
LTHH Are allowed up to 10 business days Up to 1 year (365 days)
Inpatient N/A N/A
Molecular Testing Are allowed up to 7 business days Up to 1 year (365 days)
Private Duty Nursing Are allowed up to 10 business days Up to 1 year (365 days)
PT/ OT Are allowed up to 2 business days Up to 1 year (365 days)
Surgical Are not accepted* Up to 90 days
Transplants Are not accepted* Up to 1 year (365 days)
Vision Are not accepted* Up to 1 year (365 days)
eQSuite® Functions
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eQSuite® “Search”
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InpatientTrainer Inpatientxxxxxx xxxxxxxx
eQSuite® Reports
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Checking the Status of a PAR
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eQSuite® “Letters Search”
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Client ID
Respond to Denial
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eQSuite® Online Helpline
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Helpful Resources
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Helpful ResourcesColorado Department of Healthcare Policy and Financing
Helpful ResourcesColorado PAR Website
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Questions?
Contact Us
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Customer Service
Phone: 1-888-801-9355 (M-F, 8 a.m.-5 p.m., MST)
Or
Online Helpline via eQSuite®
For more information please visit
www.coloradoPAR.com – Provider Resources
Thank You!
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