HUSKY Plus Program

Prior Authorization

Process

June 20, 2017

Introduction

The purpose of this webinar is to inform providers of the change in

process for requesting goods and services for members who are

enrolled in the HUSKY B program and eligible for supplemental

services under the HUSKY Plus program

This webinar will cover the following:

HUSKY Plus program overview

HUSKY Plus benefit categories

HUSKY Plus Prior Authorization (PA) process

Change in claims submission

1

HUSKY Plus History

Connecticut Children’s Medical Center (CCMC) has

been the HUSKY Plus program administrator since the

Children’s Health Insurance Program (CHIP) initiated

HUSKY Plus in the fall of 1997

As of June 30, 2017, CCMC will no longer administer

HUSKY Plus

Effective July 1, 2017, the HUSKY Plus program will be

administered by Community Health Network of

Connecticut, Inc. (CHNCT)

2

HUSKY Plus Transition Dates

Program Functions Prior to 6/30/17 On or after 7/1/17

Prior Authorization CCMC CHNCT

Reimbursement to

Providers

CCMC Connecticut Medical

Assistance Program

(CMAP) providers

enrolled

Case Coordination CCMC CHNCT

3

HUSKY Plus Overview

HUSKY Plus provides supplemental coverage of goods and

services beyond what is covered under HUSKY B for eligible

members:

Under the age of 19 years old

Enrolled in HUSKY B

Who have intensive physical health needs that have exhausted the

benefits or are not covered under HUSKY B

4

HUSKY Plus

Program Changes

5

Change to HUSKY Plus

In an effort to streamline the administration of services,

the Department of Social Services (DSS) will integrate

HUSKY Plus into the current prior authorization

processes performed for the HUSKY A, B, C, and D

programs

For dates of services on or after July 1, 2017 all

requests for HUSKY Plus services will be submitted to

CHNCT. Only providers will be permitted to submit PA

requests for clinical review.

6

Change to HUSKY Plus (Cont.)

CCMC will no longer:

Process any new PA requests

Accept claims or process reimbursement payments to medical

vendors for services performed after July 1, 2017

DXC Technology will process all HUSKY Plus claims

and reimbursement payments

7

HUSKY Plus

Benefit Coverage

8

HUSKY Plus Benefit Categories

For more information about which medical benefits are

covered under HUSKY Plus, go to: http://www.huskyhealthct.org/providers/benefits_authorizations.html#

Scroll down to “HUSKY Health Program Benefit Grids”

DME

Outpatient Hospital

Rehab Clinic

Therapy

9

Outpatient Therapy

Procedure Group Codes

The PA process for outpatient therapies will mirror the

current process for HUSKY A, B, C, and D

Rehabilitation clinics and independent therapists must

submit PA requests using a Procedure Code Group and

number of units

10

Therapy Clinic

HUSKY Plus Covered Codes

Code Group Benefit CPT Codes

HPOTC Occupational

Therapy -

Clinic

29125, 29126, 29131, 29260, 29280, 29540, 64550,

97165-97168, 97530, 97532, 97533, 97535, 97542,

97597, 97598, 97602, 97755, 97760-97762

HPPTC Physical

Therapy -

Clinic

29125, 29126, 29131, 29260, 29280, 29540, 64550,

97161-97164, 97010, 97012, 97014, 97016, 97018,

97022, 97026, 97032-97035, 97110, 97112, 97113,

97116, 97124, 97140, 97150, 97530, 97542, 97597,

97598, 97602, 97755, 97760-97762

HPSTC Speech

Therapy -

Clinic

92507, 92508, 92520-92524, 92526, 92537, 92538,

92540-92542, 92544-92547, 92550, 92553, 92555-

92557, 92565, 92567, 92568, 92570, 92577, 92579,

92582, 92583, 92585-92588, 92597, 92610, 94664,

96105, 96118-96120

11

Independent Therapy

HUSKY Plus Covered Codes

Code Group Benefit CPT Codes

HPOTI Occupational

Therapy -

Independent

97165-97168, 97504, 97520, 97530, 97542, 97760,

97761

HPPTI Physical

Therapy -

Independent

97161-97164, 97010, 97012, 97014, 97016, 97018,

97022, 97024, 97026, 97028, 97032-97036, 97039,

97110, 97112, 97113, 97116, 97124, 97139, 97140,

97150, 97530, 97542, 97760, 97761

HPSTI Speech/

Audiology

Therapy -

Independent

92507,92508, 92521, 92522-92524, 92531, 92533,

92534, 92537, 92538, 92540-92542, 92544, 92545,

92547, 92548, 92550-92553, 92555-92558, 92562-

92565, 92567, 92568, 92570-92572, 92575-92577,

92579, 92582, 92583, 92585-92588, 92592, 92593,

92596, 92601-92604, 92620, 92621, 92625-92627,

92630, 92633, 92640

12

Prior Authorization

Process

13

Updated PA Form

The current Outpatient PA

Form has been updated to

reflect services being

requested under HUSKY Plus

The PA Form can be found at

www.ct.gov/husky

Click “For Providers,” “Prior

Authorization,” then “Prior

Authorization Forms &

Manuals”

14

Clinical Review for HUSKY Plus

All requests for initial HUSKY Plus coverage and

ongoing goods and services will require clinical

documentation and undergo a person-centered medical

necessity review

All determinations must be in compliance with the

Definition of Medical Necessity, Regulation 17b-259b(a)

15

Definition of Medical Necessity

Section 17b-259b(a)

“Medical Necessity” (or “Medically Necessary”) means those health

services required to prevent, identify, diagnose, treat, rehabilitate or

ameliorate an individual’s medical condition; including mental illness, or

its effects, in order to attain or maintain the individual’s achievable

health and independent functioning provided such services are:

(1) Consistent with generally-accepted standards of medical

practice that are defined as standards based on:

(A) Credible scientific evidence published in peer-reviewed

medical literature that is generally recognized by the

relevant medical community

(B) Recommendations of a physician-specialty society

(C) The views of physicians practicing in relevant clinical

areas

(D) Any other relevant factors

16

Definition of Medical Necessity (cont.)

(2) Clinically appropriate in terms of type, frequency, timing,

site, extent and duration, and considered effective for the

individual’s illness, injury or disease

(3) Not primarily for the convenience of the individual, the

individual’s healthcare provider, or other healthcare providers

(4) Not more costly than an alternative service or sequence of

services at least as likely to produce equivalent therapeutic or

diagnostic results as to the diagnosis or treatment of the

individual’s illness, injury, or disease

(5) Based on an assessment of the individual and his/her

medical condition

All final determinations of medical necessity must

be based upon this statutory definition

17

Initial DME Requests

Goods that are excluded from HUSKY B coverage will

automatically be reviewed for medical necessity under

HUSKY Plus

Authorizations can be requested for up to a 90-day

period of time

18

Initial Therapy Requests

Services that have been exhausted from HUSKY B

coverage will be reviewed for medical necessity under

HUSKY Plus

Authorizations can be requested for up to a 90-day

period of time

19

Continuation of Services

Providers must submit an Outpatient PA request form

requesting services under HUSKY Plus, with updated

clinical documentation at least 14 days prior to the end

date of the current PA in order to avoid delays

PA requests lacking sufficient clinical information will be

pended for additional information for up to 20 business

days:

If requested documentation is not received, the request will be

denied for lack of information

20

DME Reauthorizations

Requests for ongoing goods will require PA under

HUSKY Plus

Box 16 must reflect HUSKY Plus

Authorizations can be requested for up to 90 days

Requests must include:

Valid prescription

Updated clinical notes

21

Therapy Reauthorizations

Requests for ongoing services will require PA under HUSKY

Plus

Box 16 must reflect HUSKY Plus

Authorizations can be requested for up to 90 days

Requests must include:

Valid prescription or signed treatment plan

Updated therapy progress note

Previous 4 treatment notes

22

Determination

Notifications

23

HUSKY B Denial Notifications

Determinations for medical necessity under HUSKY B

will remain the same

Denied Services:

Denial letters will be faxed within 3 business days of the

decision

Therapy/DME providers will continue to have 10 business days

to submit a written request for reevaluation

24

HUSKY B Approval Notifications

Determinations for HUSKY B coverage will remain the

same

Approved Services:

Approval letters will be faxed upon decision

25

HUSKY Plus Denial Notifications

If the requested good or service is not medically

necessary, the request will be denied or partially denied

The HUSKY Plus denial notification will follow the

current HUSKY B process

26

HUSKY B to HUSKY Plus Coverage:

DME

Requests for HUSKY B services will be reviewed for

medical necessity

If goods are considered medically necessary and the

requested goods are not covered under HUSKY B:

You will receive an approval for the requested goods under

HUSKY Plus

HUSKY B benefit non coverage determinations will no longer be

issued

27

HUSKY B to HUSKY Plus Coverage:

Outpatient Therapy

Requests for HUSKY B services will be reviewed for the

entire duration of the request

If services are considered medically necessary and

services have been exhausted under HUSKY B:

You will receive an approval under HUSKY B for services

covered within the benefit and

You will receive an approval under HUSKY Plus for services

covered under the supplemental program

28

HUSKY B to HUSKY Plus Coverage:

Outpatient Therapy (Cont.)

Denial and Partial Denial notifications will no longer be

given for medically necessary services that are

exhausted under HUSKY B

Prior authorization requests will be approved for the

entire duration:

The authorizations will be split into what is covered under

HUSKY B and the remaining services covered under HUSKY

Plus

29

Claims Processing

30

Claims Processing

Dates of Service prior to June 30, 2017:

Medical vendors can submit their claims to CCMC

For vendors that comply with timely billing with 60 calendar days

from the date of service payment will be remitted by CCMC

Billing that does not comply with this timely filing will not be

reimbursed per DSS guidance.

Dates of Service on or after July 1, 2017:

Claims should be submitted electronically to DXC Technology or

through the www.ctdssmap.com Secure Web Portal

31

Contact Information

32

Contact Information

CCMC

Ph: 1.877.743.5516

Fax: 1.860.837.6201

For questions about

PAs, claims

processing, and

payments for dates of

services prior to

June 30, 2017

DXC

1.800.842.8440

For questions about

provider enrollment,

claims processing, and

payments for dates of

service, July 1, 2017 and

forward

CHNCT

1.800.440.5071

8:00 a.m. – 6:00 p.m.

For questions about

PAs for dates of

service, July 1, 2017

and forward

33

Questions/Comments

34