Overview of Durable Medical Equipment Prior Authorization Process

April 28, 2016

Objectives

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n  Improve understanding of the HUSKY Health Program’s Prior Authorization process for Durable Medical Equipment (DME)

n  Describe and use the Department of Social Services (DSS) Fee Schedule

n  Review the MEDS Pricing Policy n  Reduce administrative burden associated with the prior

authorization process n  Improve provider satisfaction with the prior authorization

process

Overview

n  All HUSKY Health members are eligible to receive healthcare goods or services from Connecticut Medical Assistance Program (CMAP) enrolled providers

n  Only CMAP enrolled providers will be reimbursed for goods or services provided to HUSKY Health members

n  All ordering, prescribing, or referring providers must be enrolled as either an ordering/prescribing/referring (OPR) or CMAP provider

n  Determinations are made on a case-by-case person-centered clinical assessment of members and their clinical needs

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Person-Centeredness

n  Providing the member with needed information, education and support required to make fully informed decisions about his or her care options and to actively participate in his or her self-care and care planning

n  Supporting the member, and their designated representative(s) in working together with his or her non-medical, behavioral health and medical providers and Care Manager(s) to obtain necessary supports and services

n  Reflecting care coordination under the direction of and in partnership with the member and his/her representative(s) that is consistent with his or her personal preferences, choices and strengths and that is implemented in the most integrated setting

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Prior Authorization Requirements

n  Required for the rental and/or purchase of select DME §  Requests are reviewed in accordance with clinical criteria,

guidelines or medical policies

§  Coverage determination is based upon a clinical review of submitted case-specific information with consideration for a person-centered approach

n  Payment based on the member having active coverage, benefits, and policies in effect at the time of service

n  All determinations are made on the basis of medical necessity and must be in compliance with the Definition of Medical Necessity, Regulation 17b-259b(a)

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Definition of Medical Necessity

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§  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

Definition of Medical Necessity (cont.)

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(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

DSS Fee Schedule

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Locating the DSS Fee Schedule n  Go to www.ctdssmap.com n  Click on “Provider”

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Locating the DSS Fee Schedule (cont.)

n  Click on “Provider Fee Schedule Download”

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Locating the DSS Fee Schedule (cont.)

n  Click on the “I Accept” button at the bottom of the License Agreement

n  Choose the desired Provider Fee Schedule

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Navigating the DSS Fee Schedule

n  The columns on the Fee Schedule are as follows:

n  If there is a “Y” in the “PA” column, then Prior Authorization is required for that item

n  If a member needs a larger quantity than what is listed under the “Qty” column (even if there is no “Y” listed), then prior authorization is required for that item

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Procedure Code Proc Description Mod1 Mod1 Desc Rate Type Max Fee Effective Date End Date PA Qty

Required Documentation Prior Authorization Requests

n  Completed Outpatient Prior Authorization Request Form n  Prescription for the goods/services signed by the

ordering physician n  Clinical documentation from the ordering physician

supporting the medical necessity of the requested goods/services

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Outpatient Prior Authorization Request Form Instructions

n Download Outpatient Prior Authorization Request Forms from the HUSKY Health website: www.ct.gov/husky, click “For Providers”

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Outpatient Prior Authorization Request Form Instructions (cont.)

n  Click on the “Providers” tab

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Outpatient Prior Authorization Request Form Instructions (cont.)

n  Click on “Provider Bulletins & Forms”

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Outpatient Prior Authorization Request Form Instructions (cont.)

n  Click on “Outpatient Prior Authorization Request Form”

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Outpatient Prior Authorization Request Form

n  Full instructions on Page 2 of form

n  All boxes must be completed in order for your request to be considered for coverage

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Clinical Information Required n  Reference “Clinical Policies” on the “Policies, Procedures

& Guidelines” web page for information on specific goods:

http://www.huskyhealthct.org/providers/policies_procedures.html

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Manually Priced Goods Overview

n  Actual Acquisition Cost (AAC): §  When the manufacturer is not the provider: AAC is the price paid by

the provider to the manufacturer, or any other supplier for orthotic or prosthetic devices, equipment, or supplies

§  When the manufacturer is the provider: AAC is the actual cost of manufacturing such orthotic or prosthetic devices, equipment or supplies

n  Manufacturer’s Suggested Retail Price (MSRP): §  Manufacturer’s suggested retail price or list price is the selling price that

the manufacturer recommends that the seller or retailer receive for goods or services

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Required Pricing Documents

n  The DSS Pricing Policy for MEDS Items is found on the “Policies, Procedures & Guidelines” web page under the “Clinical Policies” section

If an item requires manual pricing, an AAC and MSRP MUST be submitted along with the Prior Authorization request 20

Submit a Prior Authorization Request

n  Providers may submit a Prior Authorization request by either of the following methods:

§  Clear Coverage Portal Clinical/pricing information

§  Fax: 203.265.3994 Completed form and clinical/pricing information

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After a Prior Authorization Request is Submitted

n  A pending authorization number is generated n  If more information is needed, the clinical reviewer will contact

the provider via fax, phone, and/or email or through their Clear Coverage account; if additional information is required, the provider is given additional time to submit the requested information

n  All requests for DME are reviewed within 14 calendar days from the date of receipt

n  A decision must be made by the 20th business day from the date of receipt

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Request Approvals

n  Approval letters are generated within 48 hours after request approval

n  Approval letters are distributed by: §  Fax to DME Providers

§  Mail to referring physicians and members

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Request Denials

n  Verbal notifications provided to DME providers and referring physicians within 24 hours after a decision has been made

n  The verbal notification includes an outline of the appeal process

n  Letters are mailed to DME providers, referring physicians and members within 3 business days from the decision date

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Questions?

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