WVPTA 2012 Spring Conference
IRG dba APS Healthcare, Inc. Update
Presented by: Denise Burton,
Utilization Management
Coordinator
Updates
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APS (UMC) Background/Introduction
Provider Registration with APS
Current System based on active Medicaid Manual Chapter
515 Occupational/Physical Therapy Services
Upcoming Changes when new Chapter 515 is released
(currently under comment)
Demonstration- PT portion of APS Medical
CareConnection®
Denials and Reconsiderations
Tips and tricks for Using APS Medical CareConnection®
(C3)
FAQ’s
Contact Information
APS Background/Introduction
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Utilization Management Contractor
for WV Medicaid Prior Authorizations
Developed direct data entry system
for prior authorization request
submissions, called
CareConnection®, or C3
Sub-contracts WVMI to review
requests
Provider Registration with APS
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Providers must register specifically with
APS Healthcare in order to access the
Medical CareConnection®
Providers must be WV Medicaid enrolled
in order to register with APS- providers
enroll in WV Medicaid through Molina
Providers who try to register with APS
and ARE NOT WV Medicaid enrolled will
be unable to submit prior authorization
requests
APS Registration Process
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There is a self-registration portal available
at https://c3wv.apshealthcare.com; on the
log-in page select self-enrollment
Brief instructions on registration are being
passed around- for more detailed
instructions go to http://apshealthcare.com
(WV program medical providers tab) or
contact us at:
wvmedicalservices@apshealthcare.com
Provider Eligibility Verification for Prior
Authorization Requests
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APS will check provider eligibility based on provider
enrollment information from Molina (daily file update).
The provider enrollment governs the provider’s ability
to create requests (access); ability to request certain
service types (limited to certain provider types); ability
for the prior authorization to be linked to the
appropriate Medicaid Provider ID or NPI in the Molina
system.
The organizations created upon registration with APS
are linked to provider enrollment in Molina (one
organization can be created in the APS system to link
to many Medicaid ID or NPI numbers OR many
organizations can be created in the APS system to link
to a single Medicaid ID or NPI number).
The REFERRING PROVIDER MUST be a WV Medicaid
enrolled provider.
Current System for PT Prior
Authorization Requests
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BOTH APS Medical
CareConnection® AND WVMI
Legacy system may be used at
present
Prior Authorization is presently
required after 20 PT/OT visits
If using the APS system select
clients as “established”
Registration with APS is required to
use the new system
Present Requirements Compared to upcoming
Requirements in Proposed Manual
Current Manual
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PA required after 20 visits of
PT/OT
Both APS and WVMI system
available
Existing fax forms available for
WVMI and new fax forms for APS
system mimic web
New Manual
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PA required from 1st serviceinitial authorization requires
minimal data for
autoadjudication-subsequent
visits require PA with current data
demand-initial number of visits is
not yet determined (WVPTA is
recommending 20 as with current
system
30 days post “go-live” (date TBA
after release of new manual)
ONLY APS system may be used
and WVMI legacy system is no
longer available
Only fax forms in use mimic APS
system once WVMI system is no
longer available
Retrospective Review Policy
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Retrospective review is available in the following instances:
 Weekends or holidays, or at times when APS/WVMI is closed.
Retrospective reviews must be initiated within 72 business
hours following the service;
 Member eligibility has been back-dated and must be initiated
within 12 months of the date of service;
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A procedure/service denied by the member’s primary payer
provided all requirements for the primary payer have been
followed including the appeals process (must submit EOB,
copy of denied payment).
 Turn around time for processing of retrospective requests is
72 hours (3 business days); reviews that require physician
review may require an additional 24 hours, depending upon
the nature of complexity of the case.
 If the retrospective request DOES NOT meet the criteria for
processing, it will not be reviewed for medical necessity
(policy denial).
 If the retrospective request meets the criteria for processing,
the normal review process will ensue.
Denials and Reconsiderations
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Status can be seen at the authorization record level OR
in reports. Denial letters are always found on the
Summary & Submit page of C3.
If you entered the prior authorization request in C3,
you will be messaged to your C3 inbox.
Reconsiderations are requested from the action menu
for requests that have been denied for medical
necessity.
Providers have 60 days to request reconsideration, so
make sure all appropriate information is provided at
the time of the reconsideration request.
If you mail your reconsideration chart, wait until it is
mailed prior to requesting in system and indicate in the
note that the record has been mailed (or faxed if you
do not attach at the time of reconsideration request).
Timeframes for Reconsideration
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Provider must request and submit
reconsideration with all pertinent
documentation within 60 calendar
days from member/provider
notification of the service denial.
APS/WVMI have 14 calendar days
to complete the review and notify
the provider and member of results.
C3 Tips
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Authorization Start
Date must be the
earliest Service Start
Date if multiple
services are requested.
You must be registered
as the provider type
indicated for the review
area. If you provide
many types of services
you must expand your
registration as each
review area is added to
be sure requests can be
made.
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Remember to save your
work- some areas (e.g. notes
require a save within the
page). If you hit save and
not save and continue the
record will be saved in your
work queue.
Please be patient. We know
the system is slow
sometimes, but IT believes
the cause of cases not going
to the WVMI work queue is
submit button being pushed
prior to all information being
loaded to the Summary &
Submit page-there are
multiple additional validations
at the time of submission so
this takes time!
Review Statuses
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Saved: in provider’s work queue/not submitted
Pending: in WVMI’s work queue, awaiting review
In Process: with nurse/physician reviewer
Closed: either duplicate, inappropriate recon
request, or TPL case
Complete: Case has been reviewed. The denial
reason and letter can be found at the record level
and the PA number is at the record level OR in
the daily report.
Submitted: User who worked case has only AUM
Provider role/not AUM Manager role so the case
has not been submitted to APS.
FAQs
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Who do I contact with questions and concerns?
A: Clinical inquiries will continue to be handled by WVMI, technical
inquiries (log-on, passwords, registration, C3 assistance, etc.), training
requests and questions about CareConnection® will be handled by APS.
Complaints should be directed to APS and will be routed to the appropriate
parties for follow-up.
APS- Medical Services: 1-800-346-8272; Email:
wvmedicalservices@apshealthcare.com
WVMI-PT/OT Review: 1-800-982-6334, Option 1, Fax #: 1.877.762.4338
Who do I contact if I have a question about a prior authorization?
A: If you are trying to determine if the case has been denied or approved,
first look in the C3 system. If you do not know how to do this, please call
APS and we will teach you how. If you have faxed a request to WVMI, are
registered with APS and do not see it in the C3 system, call WVMI. If you
are not registered with APS, call APS to get registered.
What do we do if we realize the date of service is wrong?
A: Contact APS either by phone or email explaining what the correct date
of service should be, the authorization request ID, and any other pertinent
information related to the case. APS will issue an IT ticket and within 72
hours, you will be able to re-submit your bill.
Where do I find what covered services are available to members?
A: BMS Manual Chapters are available on the BMS website at
www.dhhr.wv.gov/bms.
APS Contact Information
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Main Telephone:1-800-461-0655
Medical Services ONLY:1-800-346-8272
Local:
304-343-9663
Voicemail ONLY: ext. 6954
Fax:
1-866-209-9632
Web Address:
www.apshealthcare.com/wv
General Medical Services email:
wvmedicalservices@apshealthcare.com
Helen Snyder, Associate Director ~ hcsnyder@apshealthcare.com
ext. 6911
Heather Thompson, UM Nurse Reviewer ~ hthompson@apshealthcare.com
ext. 6907
Sherri Jackson, Office Manager ~ shjackson@apshealthcare.com
ext. 6902
Denise Burton, Utilization Review Coordinator ~ eburton@apshealthcare.com
ext. 6949
Alicia Perry, Eligibility Specialist ~ aperry@apshealthcare.com
ext. 6937
Jackie Harris, Eligibility Specialist ~ jharris@apshealthcare.com
ext. 6928
LeAnn Phillips, Eligibility Specialist ~ lphillips@apshealthcare.com
ext. 6906
Screenshots of Prior Authorization
Submission
Physical Therapy
Search Member Screen
Search Member Cont’d
Create New Request Screen
Member Demographics Screen
Provider Information Screen
Administrative Screen
Service Selection Screen
Search Provider Screen
Search Provider Screen Cont’d
Service Selection Cont’d
Service Selection Cont’d
Service Selection Completed
Diagnosis Screen
Diagnosis Screen Cont’d
Diagnosis Screen Cont’d
Evaluation Screen
Treatment Screen
Treatment Screen Cont’d
Treatment Screen Cont’d
Summary and Submit Screen
Summary and Submit Screen Cont’d