DMAS and KePRO Your Key to PA

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DMAS and KePROYour Key to PA
August 31, 2006
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Presentation Outline

• Objectives
• PA Submission and Workflow Process
• Codes
• Receiving PA Numbers
• PA Specifics
• Next Steps

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Todays Objectives

• We understand that some providers have
  experienced delays and issues with the process
  and hope that these tips will assist with the
  transition
• We thank you for your patience and understanding
  as we improve the timeliness of this process
• Today, we hope to provide updates and
  clarification for the prior authorization (PA)
  process

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Presentation Outline

• Objectives
• PA Submission and Workflow Process
• Codes
• Receiving PA Numbers
• PA Specifics
• Next Steps

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Verifying Eligibility
Check eligibility before submitting the PA
request. Eligibility verification avoids
unnecessary delays associated with PA
submissions to an incorrect payer source
Submit PA requests for the dates that the
recipient is eligible. Requests that are
submitted for dates outside of the recipient's
eligibility coverage (except for future dates
where the recipient has on-going coverage) will
be rejected back to the provider for
correction How do providers verify recipient
eligibility? DMAS web-based ARS at
http//virginia.fhsc.com Medicall
(1-800-884-9730 or 1-800-772-9996)
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Submitting PA Requests

• Requests may be submitted via
• iEXCHANGE at http//dmas.kepro.org
• Telephone [phone] or 804-622-8900 (local)
• Fax [phone]
• or
• Mail to
• KePRO 2810 North Parham Road, Suite
  305 Richmond, VA  23294
• Do not send duplicate requests via multiple
  faxes, iEXCHANGE, etc. unless specifically
  instructed by KePRO to re-send. This only clogs
  up the system and slows the process

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PA Work Flow Process

• Customer service representative (CSR) retrieves
  information from provider via iEXCHANGE, phone,
  fax or mail
• CSR enters information into iExchange
• Case is created and given a case ID number for
  tracking
• CSR sends case to queue
• Nurse reviews case
• Clinical criteria reviewed

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PA Work Flow Process

• Case decision
• approved
• needs information needs peer
  review

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Submitting PA Requests via iEXCHANGE

• The preferred method of submission for most
  PA requests is through iEXCHANGE at
  http//dmas.kepro.org
• Providers can use iEXCHANGE to submit requests 24
  hours a day, seven days a week
• Registration is required and once completed,
  providers can expect to receive their iEXCHANGE
  user login and password by email within 10
  business days
• Include all relevant clinical information in the
  Severity of Illness (SI) and Intensity of Service
  (IS) boxes

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Submitting PA Requests via iEXCHANGE

• Need Help?
• A step-by-step iEXCHANGE user manual, an on-line
  pre-recorded training presentation with iEXCHANGE
  demo, and other helpful resources are available
  on the KePRO website at http//dmas.kepro.org/def
  ault.aspx?pageiexchange

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Submitting PA Requests via Fax

• Updated PA request fax forms are now posted
  on the DMAS and KePRO websites
• The forms have been updated based upon provider
  feedback, and are available in two formats
• (1) a PDF version that providers can download
  and complete manually and,
• (2) an editable Word version, that allows
  providers to save the form and input responses
  directly. Use of editable version of the PA
  request form will expedite processing

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Submitting PA Requests via FAX

• When submitting by fax and/or mail, providers
  should use the updated fax forms
• Be careful to select the correct service type on
  the fax forms
• Include all relevant clinical information in the
  Severity of Illness (SI) and Intensity of Service
  (IS) boxes
• Please do not state see attached or meets
  criteria, and do not send attachments with the
  fax forms, except as noted in fax form
  instructions
• Providers are responsible for providing accurate
  and correct information on their PA requests
• KePRO is unable to alter any information
  submitted on PA requests these requests will be
  rejected or pended for additional information

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Submitting PA Requests for Waivers

• The preferred method of submission for PA
  requests for waiver services is through
  fax however, requests may be submitted via
  iEXCHANGE, telephone, or mail
• Please note that PA requests for waiver
  enrollments must be submitted by fax or mail and
  must include a thoroughly completed copy of the
  individuals pre-admission screening form and
  assessments appropriate for the services
  requested upon enrollment
• A list of forms may be found in corresponding
  Provider Manuals for waiver services

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Submitting PA Requests for Waivers

• PA requested from and through service
  dates are required for all PA submissions
• However, for certain waiver services, an open
  through date (12/31/9999) is no longer acceptable
• Under KePRO, all dates entered must be valid
  and the new open through date format is equal to
  six (6) years beyond the from date of service
• The through date for open waiver PAs will be
  systematically auto-renewed by KePRO prior to the
  PA expiration date
• This new open end-date change applies to newly
  added and/or updated prior authorizations
• Providers do not need to change existing waiver
  prior authorizations (e.g., those on file with a
  12/31/9999 authorized through date)

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Submitting Additional Information

• To submit additional information on an open
  case
• iEXCHANGE
• Providers may submit additional information
  through iEXCHANGE by choosing "add to comments."
  (NOTE The "extend case" feature is to be used
  when requesting additional days of coverage).
  Whenever a provider adds to comments, this puts
  the case back in the nurse review queue
• FAX / PHONE
• Providers may receive a notice from KePRO
  requesting additional information. Providers
  should submit additional information by following
  the instructions received from KePRO on the
  "fax-back" notice

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Timely Filing

• DMAS has extended the relaxed requirement of
  timely submission for PA requests through
  December 31, 2006
• This applies for request dates beginning at the
  time of the KePRO implementation date of your
  specific service provision
• Starting January 1, 2007 timely submission for
  requests will again be applied and determinations
  will be made based on timeliness

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Presentation Outline

• Objectives
• PA Submission and Workflow Process
• Codes
• Receiving PA Numbers
• PA Specifics
• Next Steps

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ICD-9 Codes
ICD-9 Diagnosis Codes For ALL prior
authorization submissions, the primary ICD-9
diagnosis code (include all 5 digits, where
applicable) relative to the PA requested
service(s) is required For inpatient PA
requests, the admission or working diagnosis
ICD-9 code is sufficient. (The diagnosis code
provided with the inpatient PA request is not
required to match with the diagnosis code billed
on the inpatient claim) iEXCHANGE provides a
search feature for ICD-9 and procedure codes.
These codes are also available in an Excel format
on the KePRO website at http//dmas.kepro.org/def
ault.aspx?pagefaq and can be sorted by diagnosis
name
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Procedure Codes
Procedure Codes For inpatient admissions,
procedure codes are not required as part of the
PA submission. If the recipient is being admitted
for a planned, elective, surgical procedure, the
provider must specify the procedure to be
performed as part of the severity of illness or
intensity of service documentation For Outpatient
Psychiatric, Durable Medical Equipment, and
Orthotic Services, providers must identify the PA
requested service(s) using the most appropriate
procedure code (CPT, HCPCS, etc)
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Procedure Codes
Procedure Codes When entering a HCPCS
Procedure Code through iEXCHANGE, capitalize the
leading alpha character, such as "E1399"
Additionally, the maximum number of procedures
that can be submitted per PA is 18 (this is not a
change) Therefore, any PA request (i.e.,
specialized wheelchairs, etc.) having over 18
lines must be submitted via a separate PA request
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Procedure Codes
Procedure Codes For non-emergency outpatient
(NEOP) scans including MRI, PET, and CAT scans,
provide the CPT code(s) that most closely matches
with the physicians order, particularly with the
body part/location of scan While the CPT code
requested at the time of PA is not required to
match with the CPT code billed on the claim, it
should match the location (body part)
scanned Additionally, for those scans not yet
scheduled at the time of PA submission, submit
the PA request with a through date of service
up to 90 days beyond the requested service begin
date For scan claim submissions, the provider
must bill using the CPT code that matches the
scan service rendered. Claim payment is based
upon the CPT code billed
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Revenue Codes
Revenue Codes For Home Health and Outpatient
Rehabilitation providers, continue using the
existing revenue codes however, for PA
submissions, a prefix of R is needed, i.e.,
revenue code 0421 must be entered as R0421.
Please note that the R prefix is only required
for the PA submission continue to submit claims
without the R prefix The appropriate revenue
codes are listed in the DMAS Home Health Provider
Manual and Rehabilitation Provider Manual
(Chapter V)
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Presentation Outline

• Objectives
• PA Submission and Workflow Process
• Codes
• Receiving PA Numbers
• PA Specifics
• Next Steps

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Receiving a PA Number
Once your PA request has been submitted, a
case ID number will be generated The case ID
number is used to track this specific case
through KePROs system Please note that the
case ID number is not your PA number The PA
number will also be posted on iEXCHANGE (and sent
via fax for telephone and fax PA submissions)
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Receiving a PA Number from KePRO

• Providers may obtain the PA number from the
  following KePRO sources
• iEXCHANGE go to http//dmas.kepro.org
• Reading numbers in iEXCHANGE
• Medicaid ID numbers consists of 12 digits
• KePRO Case ID number is 9 digits with dashes
• PA Number generated by the VAMMIS is 11 digits
• PA Numbers for Waivers may be found under the
  Comments Section
• For requests faxed or phoned in, providers will
  receive a fax from KePRO

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Receiving a PA Number from First Health

• Providers may obtain the PA number from the
  following First Health (FH) sources
• PA notification letters
• Medicall (1-800-884-9730 or 1-800-772-9996)
• or
• Web-based ARS at http//virginia.fhsc.com

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Receiving a PA Number from First Health
Obtaining the PA number from the letters sent
by First Health PA notification letters are
sent to the provider mail to address on file
with the Provider Enrollment Unit Note If
there is no "Mail to" address, the letter goes to
the service address Providers who wish to change
their mail to address may do so by
contacting First Health Services Provider
Enrollment Unit (PEU) PO Box 26803 Richmond, VA
23261-6803 Phone [phone] (in state
toll-free) 1-804-270-5105 Fax [phone]
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Receiving a PA Number from First Health
Obtaining the PA number from the Medicall
System (1-800-884-9730 or 1-800-772-9996) A
valid provider number and a touch tone telephone
are required to access MediCall MediCall prompts
the caller throughout the inquiry, giving and
receiving only essential, pertinent information.
The data provided is the most up-to-date
information available, direct from the Medicaid
eligibility, claims and remittance
databases After dialing the MediCall number, the
system will ask for the provider number. Enter
the 9-digit number (using two leading zeros for 7
digit numbers). After the number is accepted, the
menu will present seven options Press 4 for
prior authorization information
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Receiving a PA Number from First Health
Obtaining the PA number from the web-based
ARS at http//virginia.fhsc.com The ARS system
is designed to be easy to use and is accessible
to anyone with an internet-connected PC and a web
browser New users must register for ARS online at
http//virginia.fhsc.com/. Within 72 hours of
registration, users will receive a phone call
from First Health Services Corporation with
further instructions on creating an account To
start, registered users select Secure Logon
from the Automated Response System (ARS) menu
to begin an inquiry The user enters the 9-digit
servicing providers Medicaid provider number
with the prefix VA, for example VA999999999.
For 7-digit provider numbers, users should enter
the prefix VA00, for example VA009999999 Once the
provider ID has been accepted, the main menu
screen will appear. Click on Prior Authorization
Log
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Presentation Outline

• Objectives
• PA Submission and Workflow Process
• Codes
• Receiving PA Numbers
• PA Specifics
• Next Steps

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Retro Reviews
PA requests for retroactively Medicaid
eligible recipients or retro-reviews
Requested start of care date should be entered
as the first day hands-on service was provided to
the individual once Medicaid eligibility was
effective These retro reviews can also be
submitted via iEXCHANGE, phone, or fax, and
should include only the same required clinical
documentation submitted for a regular admission
(i.e., do not submit the entire medical record
for inpatient acute hospital admissions)
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Overlapping Dates
Overlapping dates with the same provider For
on-going prior authorizations, check your files
and verify the dates that you already have
authorized before submitting your request Submit
your request using the correct begin and end
dates If your new PA request overlaps with an
approved PA that we already have on file (same
recipient, same provider, same service, same or
overlapping dates), your PA request will be
rejected back to you to correct the begin and/or
end dates
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Overlapping Dates
Overlapping dates with another provider If
your PA request overlaps with a PA from a
different provider (same recipient, same service,
same or overlapping dates), your PA request will
be delayed. Therefore, be sure to request the
correct begin and end dates Additionally, if your
client is transitioning to you from a different
provider, the recipient must inform the prior
provider to submit a PA change request before we
can authorize continuing services to you as the
new provider
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Anniversary Dates
Checking anniversary dates For waivers
anniversary date is applicable for DD waiver
only. Providers may contact DMAS' Health Care
Coordinators to obtain this information For
Outpatient Psych, the provider can check the
anniversary date by calling the DMAS
Helpline 804-786-6273 Richmond area and
out-of-state long distance 800-552-8627 All
other areas (in-state, toll-free long
distance)
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Presentation Outline

• Objectives
• PA Submission and Workflow Process
• Codes
• Receiving PA Numbers
• PA Specifics
• Next Steps

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Whats Next

• DMAS and KePRO are committed to providing
  helpful information to facilitate efficient PA
  processing
• Upcoming
• Medicaid Memos monthly until the end of this year
• WebEx trainings
• Establishment of a PA Advisory Group

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Program Changes and Updates

• Check out the Medicaid Memos and Manuals on
  line
• Its easy
• Go to the DMAS website at www.dmas.virginia.gov
  and click on the link to Providers Services
• or
• Go to the KePRO website at http//dmas.kepro.org

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Questions
Should you have any questions regarding the
prior authorization process, please send your
inquiries via e-mail to providerissues_at_kepro.org
or PAUR06_at_dmas.virginia.gov Remember, do not
send PHI by email unless it is sent via a secure
encrypted email transmission The most up-to-date
PA information is posted on the DMAS Website at
http//www.dmas.virginia.gov/pr-prior_authorizatio
n.htm and the KePRO website at http//dmas.kepro.o
rg A pre-recorded Web-Ex training that provides
an in-depth PA overview and an iEXCHANGE demo is
available on the KePRO website at
http//dmas.kepro.org/default.aspx?pageiexchange
Providers may view this web-cast training at
their convenience