wyoming medicaid skilled nursing services review training · 2019-03-12 · • request for prior...
TRANSCRIPT
Advancing HealthcareImproving Health
Qualis Health Wyoming Medicaid Skilled Nursing
Services Review TrainingTeresa Kirn, RN IQCI
Clinical Nurse SpecialistLisa Layne
Non-Clinical ManagerMarch 12, 2019 and March 13, 2019
Advancing HealthcareImproving Health
One of the nation’s leading healthcare consulting organizations, partnering with our clients across the country to improve care for millions of Americans every day
www.qualishealth.org
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Qualis Health• A private nonprofit organization
established in 1974• Corporate Office located in
Seattle, Washington with regional offices in Alabama, Alaska, California, District of Columbia, Idaho, Kansas, and New Mexico
• Have provided care management to Medicaid and Private contracts since 1984
Qualis Health & HealthInsight have joined forces to do great things.
Together, we’re reimagining health care.
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What We Do
• Contract with Wyoming Medicaid to review for select outpatient services: – Durable Medical Equipment (DME), – Home Health Services (HHS)– Physical Therapy (PT), Occupational Therapy (OT) and Speech
Therapy (ST) and Behavioral Health visits. – Skilled Nursing (SN) reviews for waiver plans as of April 1, 2019
• We will use InterQual® (IQ) and organizational policies to conduct reviews
• Offer web-based and telephonic provider education
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What We Don’t Do
We do not receive financial incentives to deny or limit services
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Objectives• How to submit a request for services for Skilled
Nursing (SN) services for waiver plans
• How to add additional information when requested by Qualis Health
• How to check the status of a review
• Review upcoming trainings
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Qualis Health Provider Portal
http://www.qualishealth.org/sites/default/files/WY-Medicaid-QHPP-User-Guide.pdf
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Once you have your provider portal login information, launch the Qualis HealthProvider Portal (QHPP) from the Qualis Health website:
1. Enter your user/login ID in the User ID field2. Enter the password in the Password field3. Click Submit
The Forgot Password link will not work until you have created a
security question and answer in the Edit My Profile screen.
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QHPP User Acceptance Agreement
After reviewing the agreement, click on:• I Agree – allows you to fully log on to the QHPP• I Disagree –will navigate you back to the QHPP login page
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Let’s get Started1. Click on New Request2. Client - Select Wyoming Medicaid from dropdown list3. Insurance ID - Enter the participant’s Medicaid number4. Click Search
1.
2. 3.4.
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Adding a Request • Click Add Request ( ) under Actions and complete the required
fields:
1. Episode type: Outpatient
2. Episode class: Prior authorizations
3. Treatment type: • Community Choices Waiver• Comprehensive Waiver • Supports Waiver
4. Urgency: Non-Urgent
5. Diagnosis: Enter a code or description to search
6. Click Save
1.2.3.
4.
5.
6.
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Working Steps to Set Up a Review
• Please complete listed steps (excluding steps 3, 5 and 6)
• Click on each tab in the left navigational panel to complete the step
• Completing these steps will guide you to submitting a request
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Add Providers(Step 2 - QHPP)
• Start the search with the attach new button.
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Add Providers(Step 2 - QHPP)
• To search by a Provider:
1. Enter a minimum of the first 3 letters into the Provider Last Name search field
2. Do not select from dropdown list
3. Click Search
1.
3.2.
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Add Providers(Step 2 - QHPP)
• To search by a NPI number:
1. Enter full NPI number in the NPIN field
2. Click Search
Be sure to enter correct NPI number for the provider requesting services.
1.
2.
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Add Providers(Step 2 - QHPP)
• You will need to enter the provider type 3 times:1. Organization - Admitting
2. Facility/Vendor – Treating
3. Facility/Vendor - Requesting
You will need to repeat Search steps (slide 15) in order to add each provider role
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Add Providers(Step 2 - QHPP)
• Scroll down screen to Search Results
1. Find provider name with Organization as the type
2. Select Requesting from the Provider Role dropdown list
3. Click under Actions to attach
• This allows you to see the request in QHPP
1.2. 3.
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Add Providers(Step 2 - QHPP)
• Scroll down screen to Search Results
1. Find provider name with Facility\Vendor as the type
2. Select Treating from the Provider Role dropdown list
3. Click under Actions to add to the selected provider list
• The treating provider is the servicing provider
1.2.
3.
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Add Providers(Step 2 - QHPP)
• Scroll down screen to Search Results
1. Find provider name with Facility\Vendor as the type
2. Select Admitting from the Provider Role dropdown list
3. Click under Actions to add to the selected provider list
• The admitting provider is also the servicing provider.
1.2. 3.
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Add Providers(Step 2 - QHPP)
• Once you have added all 3 provider role types, scroll up to view the Selected Provider List
• Click Attach
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UM Services(Step 4 - QHPP)
• Select Add Services• Complete all fields except for the Service Type, Modifier
and UCR Cost in $• Use HCPC S9123 or T1002 only• Save
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UM Services(Step 4 - QHPP)
• Once saved you will not be able to edit a service line.• To delete:
– Click the icon under Action
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Add Notes(Step 7 - QHPP)
Examples:• Contact information • Responses for additional information requests• Clinical information - not included on the Prior Authorizations of
Skilled Nursing Services form
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Add documents(Step 8 - QHPP)
• Upload (PDF or Word only)– Required Prior Authorization of Skilled Nursing Services form– Physician’s orders
.tif files are not a compatible format to upload
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Submit Request(Step 9 - QHPP)
• Review request elements to ensure accuracy of data entered.
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Submit Request(Step 9 - QHPP)
• To make edits - click on the appropriate step to go back to that section
This icon will become a once review is submitted
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Submit Request(Step 9 - QHPP)
• Click Submit Request
• Confirmation of submission
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Dashboards and Alerts
The dashboard allows you to view your requests• OP - opens the request• Episode ID – abstract view
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Dashboards and Alerts
Monitor alerts for updates
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Community Choices Waiver Ages served 19 years and older
Eligibility Plan Code WLTCHCPC code S9123 (1 Hour)Required documentation:
Annually (all required): • Orders to include: reason for SN assessment and treatment, physician’s signature • Request for Prior Authorization of Skilled Nursing Services (new form coming soon)
Modifications (all required):• Request for Prior Authorization of Skilled Nursing Services (new form coming soon)
Review process: 1. Submit annual prior authorizations through the QHPP2. If you disagree with a decision (denied or reduced services), you may request a second
review through the QHPP within 30 days of the decision3. The provider will contact the case manager of denial or reductions , who notifies the
participant 4. A participant can request a reconsideration with the State of WY Medicaid5. A participant may request a Fair Hearing within 30 days of the case managers notification6. Modifications will be submitted as needed, second reviews are allowed and will follow the
process for annual reviews
Examples of technical denials:
• Missing required documentation (see required documentation above)• Incomplete required documentation• Lack of appropriate signatures on required documentation• Non-compliance of state and federal regulations
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Comprehensive Waiver Ages served 21 years and olderEligibility codes COAW: 21 years of age and olderHCPC code T1002 (15 minutes)Required documentation:
Annually (all required): • Orders to include: reason for SN assessment and treatment, physician’s signature • Request for Prior Authorization of Skilled Nursing Services (new form coming soon)
Modifications (all required):• Request for Prior Authorization of Skilled Nursing Services (new form coming soon)
Review process: 1. Submit annual prior authorizations through the QHPP2. If you disagree with a decision (denied or reduced services), you may request a second
review through the QHPP within 30 days of the decision3. The provider will contact the case manager of denial or reductions , who notifies the
participant 4. A participant can request a reconsideration with the State of WY Medicaid5. A participant may request a Fair Hearing within 30 days of the case managers notification6. Modifications will be submitted as needed, second reviews are allowed and will follow the
process for annual reviews
Examples of technical denials:
• Missing required documentation (see required documentation above)• Incomplete required documentation• Lack of appropriate signatures on required documentation• Non-compliance of state and federal regulations
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Supports Waiver Ages served 21 years and olderEligibility codes SUAW: 21 years of age and olderHCPC code T1002 (15 minutes)Required documentation:
Annually (all required): • Orders to include: reason for SN assessment and treatment, physician’s signature • Request for Prior Authorization of Skilled Nursing Services (new form coming soon)
Modifications (all required):• Request for Prior Authorization of Skilled Nursing Services (new form coming soon)
Review process: 1. Submit annual prior authorizations through the QHPP2. If you disagree with a decision (denied or reduced services), you may request a second
review through the QHPP within 30 days of the decision3. The provider will contact the case manager of denial or reductions , who notifies the
participant 4. A participant can request a reconsideration with the State of WY Medicaid5. A participant may request a Fair Hearing within 30 days of the case managers notification6. Modifications will be submitted as needed, second reviews are allowed and will follow the
process for annual reviews
Examples of technical denials:
• Missing required documentation (see required documentation above)• Incomplete required documentation• Lack of appropriate signatures on required documentation• Non-compliance of state and federal regulations
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Training WebEx ScheduleDate Time (MST) Training Topic
3/6/2019 Completed and
recorded
2-3pm How to register for the QHPP. All sessions will be recorded and available under WY Medicaid Resources at Qualishealth.org
3/7/2019Completed and
recorded
9:30-10:30am How to register for the QHPP (Repeat of 3/6/2019 afternoon session)
3/12/2019 3-4pm Provider Review Request for Skilled Nursing services for waiver plans
3/13/2019 9:30-10:30am Provider Review Request for Skilled Nursing for waiver plans(Repeat of 3/12/2019 afternoon session)
4/3/2019 2-3pm Question and Answer session after 4/1/2019go live
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Qualis Health Contact InformationQualis Health
Phone: (800) 783-8606Fax: (877) 810-9255
Teresa Kirn RN, IQCIClinical Nurse Specialist(208) [email protected]
Deon Westmorland RN BSN CCMAssociate Vice PresidentWyoming Medicaid Services(206) [email protected]
Lisa LayneNon-Clinical Manager(206) [email protected]
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Qualis Health Contact InformationUtilization Review Toll-free Phone: (800) 783-8606 Toll-free Fax: (877) 810-9265
Utilization Review Hours 8:30am to 7:00pm MST Monday through Friday
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Questions?