Authorization Review Processfl.eqhs.com/Portals/1/Authorization Review Process...• Local office/operations in Tampa Bay area 5802 Benjamin Center Drive, Suite 105 Tampa, FL 33634

Authorization Review Process Chiropractic, Hearing, Optometric, Vision and Physician Services

Transition to eQHealth Solutions

November 2012

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Introduction to eQHealth

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Mission Statement:

“To Improve the Quality of Health and Health Care by Using Information and Collaborative Relationships to Enable Change”

Vision:

“To be an Effective Leader in Improving the Quality and Value of Health Care in Diverse and Global Markets”

Mission and Vision

3

• eQHealth is the Agency for Health Care

Administration’s contracted quality

improvement organization (QIO), responsible

for the Comprehensive Medicaid Utilization

Management Program for the state of Florida

• Local office/operations in Tampa Bay area

5802 Benjamin Center Drive, Suite 105

Tampa, FL 33634

• Branch office in Miami/Dade area

Partnership: Agency for Health Care

Administration and eQHealth

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http://fl.eqhs.org

Website demonstration

Dedicated Florida Website

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http://fl.eqhs.org/

Scope of Services

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Service Requirements

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Recipients must be:

• Enrolled in a Medicaid benefit program that covers

the service requested:

• Fee for service

• MediPass

• Medically Needy

• Dually eligible (Medicare/Medicaid &

Commercial/Medicaid)

• Waiver Recipients

• Eligible at the time services are rendered

Not Subject to Prior Authorization

by eQHealth

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Recipients who are:

• Members of a Medicaid HMO

• Members of a Medicaid Provider Service

Network (PSN)

• Members of Children’s Medical Services (CMS)

• Residents of ICF/DD: vision services

Retrospective Review Requests

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Retrospective authorization may only be requested if

the recipient is granted retroactive Medicaid eligibility

that covers the date(s) services were provided.

Exceptions:

• Hearing evaluation beyond the maximum service limits

• Certain hearing aid fitting and dispensing

• Hearing aids that meet the requirement for immediate need

• Repair or replacement of cochlear implant internal parts

outside of the manufacturer’s warranty

• Emergency outpatient surgeries (evidence of “emergency”

required)

Medicaid reimburses services that do not duplicate

another provider’s service and are medically

necessary for the treatment of a specific documented

medical disorder, disease or impairment.

The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, goods or services medically necessary or a medical necessity or a covered service.

Medical Necessity

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Multi-Specialty Services

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Physician Services (includes Ambulatory Surgery, Oral and Maxillofacial Surgery)

Chiropractic

Hearing Services

Optometric & Vision Services

Special Services

Intrathecal Baclofen Therapy (ITB) Pump

Authorization Requirements

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Prior Authorization (PA) is required for all services that

have a “PA” marked on the AHCA fee schedule or as

indicated by the applicable handbook.

Prior Authorization numbers are valid for 120 days; if

an extension is needed, contact eQHealth Customer

Service.


Chiropractic

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Codes that ONLY require PA if the maximum number of visits

(24 visits per year) are exceeded

• 98940 - Chiropractic Manipulative Treatment (CMT); Spinal,

One To Two Regions


Three To Four Regions


Five Regions


Hearing Services

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Codes that ALWAYS require PA • L7510 - Repair Of Prosthetic Device, Repair or Replace Minor Parts

• L8615 - Headset / Headpiece for use with Cochlear Implant Device, Replacement

• L8616 - Microphone for use with Cochlear Implant Device, Replacement

• L8617 - Transmitter Coil for use with Cochlear Implant Device, Replacement

• L8618 - Transmitter Cable for use with Cochlear Implant Device, Replacement

• L8619 - Cochlear Implant External Speech Processor And Controller, Integrated System, Replacement

• L8623 - Lithium Ion Battery for use with Cochlear Implant Device Speech Processor, Other than Ear

Level, Replacement, Each

• L8624 - Lithium Ion Battery for use with Cochlear Implant Device Speech Processor, Ear Level,

Replacement, Each

• L8627 - Cochlear Implant, External Speech Processor, Component, Replacement

• L8628 - Cochlear Implant, External Controller Component, Replacement

• L8629 - Transmitting Coil And Cable, Integrated, for use with Cochlear Implant Device, Replacement

• L8691 - Auditory Osseointegrated Device, External Sound Processor, Replacement

• L8692 - Auditory Osseointegrated Device, External Sound Processor, used without Osseointegration,

Body Worn, Includes Headband or other means of External Attachment

• V5299 - Hearing Service, Miscellaneous


Hearing Services

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Codes that ONLY require PA if the limits are exceeded

• V5014 - Repair/Modification of a Hearing Aid (Use for Factory Repair)

• V5050 - Hearing Aid; (Use for Category 1 Hearing Aids)

• V5090 - Dispensing Fee, Unspecified Hearing Aid

• V5200 - Dispensing Fee, Cros

• V5240 - Dispensing Fee, Bicros

• V5264 - Earmold/Insert, Not Disposable, Any Type

• V5267 - Hearing Aid Supplies / Accessories


Vision/Optometric Services

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Codes that ALWAYS require PA

• S0590 - Integral Lens Service, Miscellaneous Services Reported Separately

• V2199 - Not Otherwise Classified, Single Vision Lens

• V2299 - Specialty Bifocal

• V2399 - Specialty Trifocal

• V2500 - Contact Lens, Pmma, Spherical, Per Lens

• V2501 - Contact Lens, Pmma, Toric or Prism Ballast, Per Lens

• V2511 - Contact Lens, Gas Permeable, Toric or Prism Ballast, Per Lens

• V2513 - Contact Lens, Gas Permeable, Extended Wear, Per Lens

• V2520 - Contact Lens Hydrophilic, Spherical, Per Lens

• V2521 - Contact Lens Hydrophilic, Toric or Prism Ballast, Per Lens

• V2523 - Contact Lens Hydrophilic, Extended Wear, Per Lens

• V2599 - Contact Lens, Other Type

• V2730 - Special Base Curve, Glass or Plastic, Per Lens

• V2799 - Vision Service, Miscellaneous



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Codes that ONLY require PA when the maximum is exceeded

• 92340 - Fitting Of Spectacles, Except For Aphakia; Monofocal

• 92341 - Fitting Of Spectacles, Except For Aphakia; Bifocal

• 92342 - Fitting Of Spectacles, Except For Aphakia; Multifocal, Other than

Bifocal

• 92352 - Fitting Of Spectacle Prosthesis For Aphakia; Monofocal

• 92353 - Fitting Of Spectacle Prosthesis For Aphakia; Multifocal

• V2020 - Frames, Regular, Office Repair, Plastic

• V2025 - Deluxe Frame (New Or Replacement; Metal)

• V2115 - Lenticular, (Myodisc), Per Lens, Single Vision

• V2121 - Lenticular Lens, Per Lens, Single

• V2315 - Lenticular, (Myodisc), Per Lens, Trifocal

Codes that ONLY require PA when the maximum is exceeded

• V2319 - Trifocal Seg Width Over 28 Mm

• V2320 - Trifocal Add Over 3.25D

• V2410 - Variable Asphericity Lens, Single Vision, Full Field, Glass or Plastic, Per Lens

• V2430 - Variable Asphericity Lens, Bifocal, Full Field, Glass or Plastic, Per Lens

• V2510 - Contact Lens, Gas Permeable, Spherical, Per Lens

• V2710 - Slab Off Prism, Glass or Plastic. Per Lens

• V2715 - Prism, Per Lens

• V2745 - Addition To Lens; Tint, Any Color, Solid, Gradient or Equal, Excludes Photochromatic, Any Lens Material, Per Lens

• V2755 - U-V Lens, Per Lens

• V2780 - Oversize Lens, Per Lens



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Physician Services

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• 15781 - Dermabrasion, chemical peel

• 15820 - Blepharoplasty and Brow Pitosis repair

• 15822 - Blepharoplasty of upper lids

• 15823 – Blepharoplasty

• 15830 – Excision of excessive skin

• 15847 – Abdominoplasty

• 19318 - Breast Reduction Surgery

• 19324 - Breast Repair and Reconstruction

• 19325 – Mammoplasty, augmentation

• 36468 - Single or multiple injections of sclerosing solutions

• 36470 - Sclerotherapy injection, single vein

• 56805 - Ligation or transaction of fallopian tubes

• 67901 - Repair of blepharoptosis; frontalis muscle technique with suture or other

• 67902 - Eyelid Reconstruction, pitosis surgery

• 67903 – Repair of Blepharoptosis; (Tarso) Levator Resection


Physician Services

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• 67904 - Bilateral levator resection for upper lid ptosis

• 67906 – Repair of blepharoptosis, superior rectus technique

• 67908 - Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator res

• 67909 - Reduction of overcorrect of pitosis

• 67911 – Upper or lower eyelid retraction

• 69300 - Otoplasty – unilateral or bilateral

• 69710 - Implantation or replacement of electromagnetic bone conduction anchored

hearing aids

• 69711 – Remove/Repair Hearing Aid

• 69714 - Implantation, osseointegrated implant, temporal bone, with percutaneous

attachment to external speech processor/cochlear stimulator without mastoidectomy

• 69715 - Implantation, osseointegrated implant, temporal bone, with percutaneous

attachment to external speech processor/cochlear with mastoidectomy

• 69717 - Replacement (including removal of existing device), osseointegrated implant,

temporal bone, with percutaneous attachment to external speech processor/cochlear

stimulator; without mastoidectomy

• 69930 - Cochlear device implantation, with or without mastoidectomy

• S2411 - Fetoscopic laser therapy for treatment of twin to twin transfusion syndrome


• E0783 - Infusion Pump System, Implantable, Programmable

• E0786 - Implantable Programmable Infusion Pump, Replacement

Note: Insertion of the pump does not require authorization.



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Oral/Maxillofacial Surgery

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• 21208 - Osteoplasty, facial bones augmentation

• 21230 – Graft, rib cartilage autogenous to face, chin, nose, or ear

• 21235 - Graft, ear cartilage, autogenous to nose or ear

• 21248 – Reconstruction of mandible or maxilla

• 21249 - Reconstruction of mandible, mancilla, endosteel implant,

complete

• At this time, NO podiatry services require prior

authorization.

• For chiropractic services, prior authorization

should only be obtained for the 25th visit within

a specific calendar year.

Multi-Specialty Services – Exceptions

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Review Requests

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Please submit all review requests to:

eQHealth Solutions

Attn: Multi-Specialty Department

5802 Benjamin Center Drive, Suite 105

Tampa, FL 33634

Submission of Review Requests

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• Prior to submitting a review, verify that the:

• Recipient is Medicaid eligible

• Requested service is:

– A covered Medicaid benefit

– Required to be prior authorized by eQHealth

• Required supporting documentation is:

– Complete

– Legible

• Multi-Specialty Services Prior Authorization request form is complete and appropriately signed and dated

Review Requests

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Types of Review Requests:

• Initial Authorization

• Retrospective

– applicable only for recipients who are retroactively eligible for Medicaid

• Reconsideration review

– response to an adverse determination

Review Requests

27

Prior authorization must be obtained prior to

providing services

Exception:

• Retrospective Medicaid eligibility

– Authorization must be obtained prior to billing

– Claims must be billed within 12 months of

determination of eligibility

Review Requests

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SERVICE TYPE SUBMISSION REVIEW COMPLETION

Physician Services

At least 10 days prior

to initiation of services

1st Level – 2 business days

2nd Level – 1additional business day

Vision / Optometry 1st Level – 3 business days

2nd Level – 2 additional business days

Hearing Services 1st Level – 3 business days


ITB Pump (Intrathecal

Baclofen Therapy

Pump)

1st Level – 3 business days


Special Services 21 business days

Request Submission & Response

Initial Request

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Physician Services

As soon as the recipient

receives Medicaid

Eligibility.

20 business days

Vision / Optometry

Hearing Services

ITB Pump

(Intrathecal

Baclofen Pump)


Retrospective

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Note: Claims must be submitted within 12 months of the date of service


Physician Services

Within 30 calendar days

of the notification date.

3 business days

receipt of request

Vision / Optometry

Hearing Services

ITB Pump (Intrathecal

Baclofen Therapy Pump)

Special Services


Reconsideration Request

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Verification that there are no review exclusions:

• Recipient is not eligible for the service

• Duplication of service

• Request does not meet the replacement time

span requirement; (ITB Pump or Cochlear

Implant)

• Requested service is not covered by Medicaid*

*Exception: Special Services

First Level Review

Screening

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Review Determination Process

• 1st Level Clinician Review:

– Administrative Screening

– Clinical Screening

• 2nd Level Peer Review

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First Level Clinical Reviewers may:

• Approve the request

• Issue a technical denial of the request, if

appropriate, for example

– Duplicative service

– Noncompliant with Medicaid policy

• Pend the request back to the provider for:

– Additional or clarifying information

– Supporting documentation

• Refer the request to a second level Peer Reviewer

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Pended Requests (Administrative/Clinical)

• An advisory letter is mailed to the requesting

provider.

• The provider accesses the review record to

determine what additional information is needed.

• The information should be submitted within five

(5) business days.

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• Multi-Specialty Peer Reviewers base their determination on generally accepted professional standards of care, their clinical experience and judgment, Medicaid’s medical necessity criteria, and peer-to-peer consultation with the requesting provider when necessary.

• Peer Reviewers may render an approval or an adverse determination.

• An adverse determination may be a full denial of the requested services or a partial denial of the requested services.

Second Level Review

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Determination notifications are issued to providers, and

recipients within one (1) business day of the determination.

• The requesting provider will receive a written notification of

the determination via mail.

• The recipient, or legal guardian, also receives written,

mailed notification of the determination via mail.

Review Determination Notification

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Notifications include:

• Services approved or denied

• Reason for an adverse determination

• Rights to a reconsideration and how to

request one

• Recipient’s right to a fair hearing and how

the recipient may request one

Review Determination Notification

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A peer reviewer, not involved in the original adverse determination, will:

• Uphold the original adverse determination; • Modify the original determination, approving a

portion of the services requested; or • Reverse the original determination, approving all

the services requested.

Reconsideration reviews are completed within three (3) business days of receipt of a complete and valid request.

Please Note: When requesting a reconsideration, new and/or additional clinical information must be submitted.

Reconsiderations

Any party involved in the case may request a

reconsideration of an adverse determination:

• Requesting Provider

• Recipient or Legal Guardian

Methods to request a reconsideration:

• Phone

• Mail

• Fax

Reconsiderations

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Recipients or their legal representatives may appeal

an adverse determination by requesting a fair hearing.

The request must be submitted within 90 days from

the date of the adverse notification letter by calling or

writing:

• The local Medicaid area office; or

• Department of Children Families Office of Appeals

and Hearings

Fair Hearings

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Supporting documentation is determined by AHCA policy and is required to substantiate the necessity of items or services.

All supporting documentation must be submitted with the request for authorization for Multi-Specialty Services.

ALL authorizations must be requested using the Multi-Specialty Services Prior Authorization Request form.

Required Supporting Documentation

42

.

Additional Supporting Documentation Requirements

Physician Services

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SERVICE TYPE DOCUMENTATION

(As appropriate for service type)

Physician Services – Includes

Ambulatory Surgery, Oral and

Maxillofacial Surgery

•Current medical records (within the past 6

months)

•Treating physician referral to specialty

provider

•Radiographs, MRI, laboratory results,

•Photographs

•Diagnostic studies

•Medical clearance letter

Oral and Maxillofacial Surgery

Additional to above

Prior dental records & treatment records as

applicable

.


Physician Services

44


Blepharoplasties • Current medical records (last 6 months)

• Documentation of need for procedure

• Visual field study

• Eyelid photography with and without tape

• Optical exam

.


Optometric/Visual Services

45


Visual Services - Eyeglasses • Eyeglass Prescription

• Documentation of recipient’s condition that

meets the criteria for provision of specific

eyeglasses or lens types,

• Optical / refraction examination,

• Itemized invoice for eyeglasses provided

Visual Services – Contact Lens • Recipient’s eligibility for contact lenses

• Contact lens prescription

• All appropriate procedure codes

• Substantiation for special fitting

• Itemized invoice for lenses provided

• Documentation the type of lens to be provided

• Completed contact lens request form

.


Hearing Services

46


Hearing Services – Hearing

Aids and related items

• Current audiogram (last 6 months)

• Current medical records (last 6 months)

• Physician’s order

• Medical clearance letter

• Documentation of medical necessity

• All procedure codes and related fees

Hearing Services – Cochlear

Implant Repair / Replacement

• Current medical records (last 6 months)

• Examination report


• Documentation indicating need /nature of

repair and replacement

• Itemized documentation of repair cost

.



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ITB Pump • Current medical records (last 12 months)

• Documentation of successful Baclofen trial

with intrathecal injection

• Physical therapy assessment for the Baclofen

pump trial

• Referral letter from primary physician

• Documentation of trial of PO Baclofen


.


Special Services

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Special Services • Attestation and documentation of need of

special service from treating provider

• Referral information from referring provider

• Current medical record (last 6 months)

• All procedure code information (if applicable)

eQHealth’s peer reviewers reserve the right to

request additional information or clarifying

information to substantiate the medical necessity

of the service(s) requested.

Supporting Documentation

Additional Information

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• Submit all supporting documentation along

with the Multi-Specialty Services Prior

Authorization Request form via mail for the

initial request.

• Additional supporting information requested

after the initial request may be submitted via

mail or by fax to 855-677-3747.

Submitting Supporting

Documentation

50

• 11/22/12: Last date to submit authorization

requests to AHCA

• 11/27/12: First date to submit requests to

eQHealth

• 12/1/12: eQHealth begins reviewing

authorization requests

Transition Timeline

51

– Customer Service: 885-444-3747

Monday-Friday, from 8 a.m.–5 p.m.

Eastern Time

– Dedicated Florida Provider Website

http://fl.eqhs.org

– Blast emails

Nancy Calvert, Provider Education and

Outreach Manager [email protected]

Provider Communications

and Resources

52

http://fl.eqhs.org/

mailto:[email protected]

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Documents

Authorization Review Processfl.eqhs.com/Portals/1/Authorization Review Process...• Local office/operations in Tampa Bay area 5802 Benjamin Center Drive, Suite 105 Tampa, FL 33634