1. Qualis Health Care Management Services for South Carolina
Medicaid Barbara Excell, RN, MSHA, CPHQ, CPUR, PMC Director
Medicaid Services Central/East
2. Goals & Objectives
Provide a brief overview/background of Qualis Health including
the mission/vision and values
New additions to the Prior Authorization list and timeframe
changes for submission of retro charts as required by SC DHHS.
What these changes mean for providers
Prior authorization review form
Care Management Services and timeframes
Contact Information
3. Qualis Health Background
Qualis Health, headquartered in Seattle, WA is a private,
non-profit health care quality improvement organization (QIO).
Qualis Health has offices in Cayce, SC; Anchorage, AK; Boise,
ID; Tustin, CA and Lincoln NE.
Qualis Health has 30 years of experience providing health care
utilization/case management and quality assessment/improvement
services to public and private sector customers.
4. Care Management Is Our Core Business Vision: To be
recognized for leadership, innovation and excellence in improving
the health of individuals and populations Mission: To generate,
apply, and disseminate knowledge to improve the quality of
healthcare delivery and health outcomes Values: Integrity,
professionalism, collaboration, and stewardship
5. Qualis Health South Carolina Staff includes:
Director Medicaid Services
Registered Nurses
RHIA
Professional Intake and Administrative Staff
Medical Director
Associate Medical Director
Physician Specialty Consultants
6. Qualis Health SC Medicaid Services
Care Management
Utilization Review and Quality of Care Reviews
Retrospective reviews
DRG Analysis
Pre-authorization reviews
Support Documentation reviews
Sterilization reviews
Quality of care reviews utilizing CMS guidelines
HINN reviews
Therapeutic Foster Care onsite reviews
PRTF precert reviews
PRTF postcert reviews
PRTF annual reviews
ICF/MR reviews
IMD/RTF QOC reviews
7.
8. Qualis Health Supports the additional codes SC DHHS is
implementing for Prior Authorization Effective Beginning February
1, 2009 The changes include additions to the Prior Authorization
(PA) list and include mastectomy codes, back and spine codes. These
codes are in addition to all other codes requiring prior
authorization. The following slides will assist providers in
determining the best method for updating daily operations/processes
to comply with these new changes. Please refer to the SC DHHS
provider manual to reference all changes at: http
://www.dhhs.state.sc.us/dhhsnew/index.asp
9. Effective February 1, 2009 Additional Codes requiring Prior
Authorization Skin Tissue Rearrangement 86.89 85.99 Design Custom
Breast Implant 19396 85.21 Removal of Breast Capsule 19371 85
Surgery of Breast Capsule 19370 85.94 Removal of Implant Material
19330 85.43 Mastectomy, Modified Radical 19307 85.47 Mastectomy,
Radical, Urban Type 19306 85.45 Mastectomy, Radical 19305 85.34
Mastectomy, SQ 19304 85.41 Mastectomy, Simple Complete 19303 85.22
P-Mastectomy W/LN Removal 19302 85.22 Partial Mastectomy 19301
10. Prior Authorization Update Medicaid Bulletin The policy for
Mastectomy and Reconstructive Breast Surgery has not changed.
Reimbursement is allowed for reconstructive breast surgery
following a mastectomy when performed for the removal of cancer or
for prompt repair of an accidental injury. Breast reconstruction
done for cosmetic reasons is non-covered. Breast Augmentation is
non-covered under all circumstances. Program information can be
found in the provider and hospital manuals located at
www.scdhhs.gov .
12. 78.49 Spine Surgery Procedure 22899 84.51 Apply Spine
Prosth Device 22851 81.30 Reinsert Spinal Fixation 22849 Insert
Pelvic Fixation Device 22848 Insert Spine Fixation Device[8 or more
segments] 22847 Insert Spine Fixation Device[4-7 segments] 22846
Insert Spine Fixation Device[anterior with segments] 22845 Insert
Spine Fixation Device[13 or more segments] 22844 Insert Spine
Fixation Device[segments 7-12] 22843 Insert Spine Fixation
Device[posterior segmental] 22842 Insert Spine Fixation
Device[internal spinal fixation] 22841 Insert Spine Fixation
Device[posterior non-segmental] 22840 03.02 Exploration of Spinal
Fusion 22830 81.04 Fusion of Spine[8 or more vertebral segments]
22812 81.04 Fusion of Spine[4-7 vertebral segments] 22810 81.04
Fusion of Spine[arthrodesis, anterior] 22808 81.05 Fusion of
Spine[13 or more vertebral segments] 22804 81.05 Fusion of
Spine[7-12 vertebral segments] 22802 81.05 Fusion of
Spine[arthrodesis, posterior] 22800
13. 03.09 Decompress Spinal Cord 63055 78.49 C-Laminoplasty
With Graft/Plate 63051 03.09 Cervical Laminoplasty 63050 03.09
Remove Spinal Lamina Add On[each additional segment] 63048 03.09
Removal of Spinal Lamina[lumbar] 63047 03.09 Removal of Spinal
Lamina[thoracic] 63046 03.09 Removal of Spinal Lamina[laminectomy,
facetectomy and foraminotomy] 63045 03.02 Laminotomy, Additional
Lumbar 63044 03.02 Laminotomy, Additional Cervical 63043 03.02
Laminotomy, Single Lumbar 63042 03.02 Laminotomy, Single Cervical
63040 80.51 Spinal Disk Surgery Add On[each additional interspace]
63035 80.51 Low Back Disk Surgery[one interspace] 63030 80.51 Neck
Spine Disk Surgery[laminotomy] 63020 03.09 Removal of Spinal
Lamina[lumbar] 63017 03.09 Removal of Spinal Lamina[thoracic] 63016
03.09 Removal of Spinal Lamina[laminectomy with decompression
and/or exploration] 63015 03.09 Removal of Spinal
Lamina[laminectomy with removal of abnormal facets] 63012 03.09
Removal of Spinal Lamina[sacral] 63011 03.09 Removal of Spinal
Lamina[lumbar] 63005 03.09 Removal of Spinal Lamina[thoracic] 63003
03.09 Removal of Spinal Lamina[laminectomy with exploration]
63001
14. 80.49 Revise Spinal Cord Ligaments[mre than 2 segments]
63182 80.49 Revise Spinal Cord Ligaments[laminectomy and section of
dentate ligaments, w/wo graft segment] 63180 03.09 Drainage of
Spinal Cyst[to peritoneal or pleural space] 63173 03.09 Drainage of
Spinal Cyst[laminectomy with drainage of intramedullary cyst to
subarachnoid space] 63172 03.29 Incise Spinal Cord
Tract(s)[laminectomy with myelotomy] 63170 80.99 Removal of
Vertebral Body Add On[each additional segment] 63091 80.99 Removal
of Vertebral Body[transperitoneal or retroperitoneal approach]
63090 80.99 Removal of Vertebral Body Add On[each additional
segment] 63088 80.99 Removal of Vertebral Body[vertebral] 63087
80.99 Removal of Vertebral Body Add On[thoracic] 63086 80.99
Removal of Vertebral Body[vertebral-partial] 63085 80.99 Removal of
Vertebral Body Add On[cervical] 63082 80.99 Vertebral corpectomy
63081 80.51 Spine Disk Surgery, Thorax 63078 80.51 Spine Disk
Surgery, Thorax 63077 80.51 Neck Spine Disk Surgery[cervical] 63076
80.51 Neck Spine Disk Surgery[discectomy, anterior] 63075 03.09
Decompress Spinal Cord Add On[each additional segment] 63066 03.09
Decompress Spinal Cord[costovertrebral approach with decompression]
63064 03.09 Decompress Spinal Cord Add On[each additional segment]
63057 03.09 Decompress Spinal Cord[lumbar] 63056
15. 03.29 Incise Spinal Column & Cord[laminectomy with
release of tethered spinal cord, lumbar] 63200 03.29 Incise Spinal
Column & Cord[thoracic] 63199 03.29 Incise Spinal Column &
Cord[laminectomy with cordotomy, both tracts two stages cervical]
63198 03.29 Incise Spinal Column & Cord[thoracic] 63197 03.29
Incise Spinal Column & Cord[laminectomy with cordotomy, both
tracts one stage cervical] 63196 03.29 Incise Spinal Column &
Cord[thoracic] 63195 03.29 Incise Spinal Column &
Cord[laminectomy with cordotomy] 63194 04.03 Incise Spinal
Column/Nerves[laminectomy with section of spinal accessory nerve]
63191 03.1 Incise Spinal Column/Nerves[more than 2 segments] 63190
03.1 Incise Spinal Column/Nerves[laminectomy with rhizotomy, 1 or 2
segments] 63185
16. Effective February 1, 2009 Record receipt timeframe change
per the SC DHHS bulletin South Carolina Department of Health and
Human Services will no longer grant the additional 60 days in which
providers may submit medical records to Qualis Health for
retrospective reviews. Once Qualis Health has issued a technical
denial for records that have not been received within 30 days of
the request, that decision stands as final. To be sure Qualis has
the correct information you may contact Qualis Health at
1-877-717-8592 to confirm the correct mailing address and correct
hospital contact in order to ensure notifications are received and
records are submitted within the thirty-day time period. Qualis
will accept and encourages all providers to submit medical records
on CDs.
17. Qualis Health SC Medicaid Services Timeframes
Retrospective -Qualiss goal is to provide a decision to the
provider within 30 days from receipt of all requested information.
Effective February 1, 2009, providers will have 30 days to provide
the retrospective records to Qualis.
Pre-authorization- Qualiss goal is to provide a decision to the
provider within 15 days from receipt of all requested
information.
18. SC Medicaid Preauthorization Review Process
Review Request Received
Facsimile
Mail
Telephone
iEXCHANGE
Review completed by qualified reviewers Meets Criteria?
Notification to all parties Approval # given to providers
telephonically To physician reviewer with option of peer-to-peer
discussion offered when not approved Notification to facility,
provider and SC Medicaid via letter with reconsideration rights
included Yes No
19. Qualis Health Supports the SC Medicaid Review Process
Through formal training sessions
Working consistently with SC DHHS
During the utilization review process
With outreach to local provider associations
Through the local Qualis Health office. You may call us
anytime.
20.
As we continue to provide these QIO services, it is important
for us to hear from you regarding:
How the review process works for you
Any issues or concerns that may arise
Additional ways Qualis Health can assist you with education on
UM
Process improvement opportunities
Educational opportunities
21. Contact Information (803) 739-2766 (803) 739-2767 (877)
717-8594 Fax: (803) 739-2755 (877) 717-8592 Phone: Qualis Health
440 Knox Abbott Drive, Suite 220 Cayce, SC 29033 Address:
22. Contact Information (803) 739-2758 (803)-898-2665
(803)-898-2660 Barbara Excell, RN, MHSA, CPHQ, CPUR, PMC Director
Medicaid Services Central/East, Qualis Health
[email protected] SC DHHS Hospital Services Physician
Services http://www.dhhs.state.sc.us/dhhsnew/index.asp
