Welcome to the Indiana Health Coverage Program Seminar:
MDwise Care Select Prior Authorization
Presented by
MDwise Provider Relations
October 6 – 8, 2008
PCS0050 (09/08)
Agenda
 Welcome
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Eligibility Review – The Key to Success
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MDwise 101
 The Prior Authorization (PA) Process
 Questions/Answers
Care Select Eligibility
Always verify the Care Select member’s eligibility
Review the entire eligibility record to determine the member’s
Care Management Organization (CMO)
The member’s CMO affiliation determined on the date of
eligibility verification determines everything:
1. Which CMO receives a PA request
2. Member’s Care Manager
3. CMO who processes restricted card information
4. Where members can change primary medical providers
(PMP)
Care Select Eligibility
Reminders:
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Know the member’s assigned PMP and contact information
Providers rendering services that require the PMP’s two character
certification code must obtain that certification code prior to
rendering the service (see BT200804 for a list of services requiring the
certification code)
Services where the PMP declines to provide the certification code are
non – covered by the Indiana Health Coverage Programs (IHCP)
A patient waiver as described in Chapter Four, Section 5 of the IHCP
Provider Manual can be used if the member insists on receiving the
service not authorized by the assigned PMP
MDwise 101
MDwise, Inc.
Hoosier Healthwise
Program
(MCOs)
Care Select
Program
(CMOs)
Healthy Indiana
Plan
MDwise w/AmeriChoice
Delivery Systems:
9 Delivery Systems
1 Mental Health Benefits
Manager
No Delivery System
Administration
4 Delivery Systems
1 Mental Health Benefits
Manager
Claims, Medical Mgt, ROQ
Checks/RAs
Network Development
Utilization Mgt, and PBM
Care Mgt, PA, Disease
Mgt, Provider Relations,
Member Services, Utilization
Mgt, and Hearings/Appeals
Claims, Medical Mgt,
POWER Account Mgt,
Member Services, Utilization
Mgt, and Provider Relations
MDwise Prior Authorization Process
Procedures:
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Submit the PA request to the CMO the member is affiliated with on the date
of request
Reminder: ADVANTAGE Health Solutions processes PA requests for
Traditional Medicaid members
Services which require PA due to State regulations are discussed in the IHCP
Provider Manual Chapter 6 (Also refer to handout)
Reminder: Care Select PA rules are not the same as Hoosier Healthwise PA
requirements – don’t get them confused
Services which require PA are processed according to the guidelines specified
in the IHCP Provider Manual Chapter 6
Reminder: Do not submit PA requests to a MDwise HHW Delivery System
MDwise Prior Authorization Process
Procedures:
 Providers have 30 days to submit additional information for a PA that is
suspended
Reminder: Submit this documentation to the CMO you originally sent the PA
request to
 Suspended PA requests are denied in 30 days
Reminder: Respond to suspended PA requests timely and if that PA request is
denied for timeliness, submit a new PA request
 The preferred method to submit PA requests is via fax or Web interChange
Reminder: Submit PA requests in writing or via web and not via phone
MDwise Prior Authorization Process
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Does the service require PA?
Services the State requires PA for:
1. Transplants
2. Outpatient surgeries
3. Home Health - No inpatient discharge
4. Durable Medical Equipment and Home Medical Equipment
5. Inpatient psychiatric admissions, inpatient surgeries, rehabilitation, burn and
substance abuse
6. Therapies (Physical, Speech, and Occupational) – No inpatient discharge
7. Transportation (>20 one way trips or >50 miles one way)
8. Outpatient Mental Health (>20 visits)
9. PRTF
Check the fee schedule at www.indianamedicaid.com to determine if a code requires
PA
MDwise Prior Authorization Process
Select a method to submit your PA to MDwise:
1. Fax PA Forms: (877-822-7186 or 317-822-7515)
Note: Preferred method to receive PA requests
2. Web interChange (www.indianamedicaid.com)
Note: Select provider specialties only
3. Mail PA requests to:
MDwise Care Select Prior Authorization
P.O. Box 44214
Indianapolis, Indiana 46244-0214
Note: Providers can follow a PA request’s status using Web interChange regardless of the
method of submission
MDwise Prior Authorization Process
General Institutional PA Guidelines
 Criteria used to process PA requests for institutional services
are located in 405 IAC 5
 Inpatient services that require PA are substance abuse, inpatient
psychiatric, surgical procedures, rehabilitation, and certain burn
cases
 Days that are not approved by PA are non – covered by the
IHCP
 The PA Request Form is always required when submitting a PA
(located at www.indianamedicaid.com)
MDwise Prior Authorization Process
Supporting Documents Necessary for Institutional PA Requests
Note: Free-Standing Inpatient Psychiatric Hospitals or Acute Care Hospital
Psychiatric Units
 Pre-certification must be phoned in for all emergent and nonemergent requests
 The Division of Family Resources 1261A must be submitted within 10
days of a non-emergent request and 14 days of an emergent request
 Recertification as specified by the State for continued inpatient psych
admissions
 Reimbursement is not allowed if pre-certification and the Form 1261
A are not completed within the time frames specified
MDwise Prior Authorization Process
Psychiatric Residential Treatment Facility (PRTF)
 Supporting Documentation Requirements:
 Intake Assessment
 Form 1261A
 Physician History
 Physical
 Current Inpatient Treatment Plan
 Physician Progress Notes
 Inpatient Nursing Notes
 Physician Recommendation Letter
MDwise Prior Authorization Process
Inpatient emergency admissions requiring PA
 Reported to MDwise within 48 hours of admission
 See Chapter 8 of the IHCP Provider Manual for a list of
applicable emergency diagnosis codes.
 Complete the PA Request form if applicable
 Report emergency services to member’s PMP within 48 hours
MDwise Prior Authorization Process
Non-Institutional PA Requirements
Criteria used to process PA requests for institutional services are located
in 405 IAC 5
Practitioners:
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Doctor of Chiropractic Medicine
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Medical Doctor
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Doctor of Osteopathy
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Doctor of Podiatric Medicine
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Health Services Provider in Psychology
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Optometrist
MDwise PA Process
Physician PA requirements found in 405 IAC 5-25
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Bariatric surgery
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Blepharoplasties
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Bone marrow or stem cell transplants
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Brand name medically necessary drugs
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Genetic testing for detection of cancer
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Home health services
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Intersex surgeries
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Long-term acute care hospitalization
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Mastectomies for gynecomastia
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Maxillo-facial surgeries related to diseases of the jaw and contiguous structures
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Organ transplants
MDwise PA Process
Physician Services:
PA required for Evaluation and Management (E&M) services that exceed 30 visits
per member per rolling calendar year:
99201 – 99205
99381 - 99387
E&M Codes subject to PA after 30 visits:
99211 - 99215
99241 - 99245
99391 - 99387
99401 – 99429
Please note: Physician services rendered during an inpatient stay that do not receive PA
are not reimbursable
MDwise PA Process
PA requirements for podiatry services are found in 405 IAC 5-26
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Podiatry services rendered during inpatient or outpatient stays that were not
require PA
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PA requirements for chiropractic services are found in 405 IAC 5-12
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Chiropractic services rendered without PA are subject to denial
MDwise PA Process – Home Health
PA criteria for home health services located at 405 IAC 5-16
Note: PA is required for home health services except for those services ordered in writing
by a physician before the patient’s discharge from a inpatient stay that do not
exceed 120 hours within 30 days of discharge provided by:
 Registered nurse
 Licensed practical nurse
 Home health aide
 PA requests submitted must include the following:
 Appropriate home visit nursing level code – 99600 TD-Unlisted home visit,
service, or procedure-registered nurse
MDwise PA Process – Home Health
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Copy of written plan of treatment signed by attending physician, current
through date of request that documents effectiveness of treatment
Estimate of costs for the required services ordered by the physician and
signed by the physician reflected in plan of treatment
Number and availability of non-paid caregivers that assist in member care
(even if none available)
Number of members in household receiving home health services to
coordinate care efficiently
Number of hours of service per day, number of visits per day, and number of
days per week the service is to be provided
MDwise PA Process – Home Health
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Home health visits greater than three per day provided to the same
household or member
Other non-IHCP home health services provided to the member including
Medicare, CHOICE, Waiver, private insurance, private pay, school system, and
other paid caregivers (include number of hours per day and number of days
per week for each service)
Encounter – direct personal contact between patient and authorized person
to furnish services to patient
Frequency of visits is the number of encounters in a given period between
patient and person authorized to furnish services (specific number of range)
MDwise PA Process – Home Health
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Prescribed in writing by physician (medically confined to home)
Medically necessary and reasonable
Less expensive than alternative modes of care
Progress notes detailing patient evaluation and physical
involvement by physician to document acute needs
MDwise PA Process – Home Health
Medical plan of care must be developed with home health agency
and in consideration of all pertinent diagnoses, includes the
following:
 Mental status
 Types of services/equipment
 Frequency of visits
 Prognosis
 Rehabilitation potential
 Functional limitations
 Activities permitted
MDwise PA Process – Home Health
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Nutritional requirements
Medications and treatments
Safety measures to protect against injury
Instructions for timely discharge or referral
Specific procedures/modalities to be used along with frequency,
amount, and duration of each
Note:The medical plan of care must be reviewed by the practitioner at least
every two months
Note: A written summary by the agency must be sent to the practitioner every
two months
MDwise PA Process – Home Health
New authorization requests for home health services must include:
 The clinical summary of PA form must be updated to reflect any
change in patient’s status (as documented in the patient plan of
care)
 Non-covered services under home health benefit:
 Homemaker
 Chore services
 Sitter/companion services
MDwise PA Process - Therapy
Criteria for therapy services is located in 405-IAC 5-22-6 through
405-IAC-5-22-11
Note:Therapy service PA requests may be submitted by home health agencies or
individual therapy providers (See BR200831) for limitations
PA is not required for:
 Initial evaluations
 Emergency respiratory therapy
 Therapy services ordered in writing by a physician at inpatient
discharge, up to 30 hours, sessions or visits in 30 calendar days
MDwise PA Process - Therapy
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Deductible or co-payment for services covered by Medicare
Therapy services provided by a nursing facility of ICF/MR which are
included in the facility’s per diem rate
PA criteria for occupational, physical, respiratory, or speech therapy
 Written evidence of physician involvement and patient evaluation
needed to document acute needs
 Current plan of treatment
 Physician order
MDwise PA Process - Therapy
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Current plan of treatment and progress notes documenting necessity
and effectiveness of therapy
Qualified therapist or qualified assistant under supervision of therapist
must provide therapy
Therapy must be of a level of complexity and sophistication and the
condition of the member must be such that judgment, knowledge, and
skills of a qualified therapist are required
Medically necessary
Rehabilitative service covered for a member no longer than two years
from initiation of therapy unless a significant change in medical
condition is noted
MDwise PA Process - Therapy
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Maintenance therapy not covered
Progress evaluations not separately reimbursable and are covered as
part of the therapy program
One hour of therapy must include minimum of 45 minutes of direct
patient care with balance spent in patient related services
Therapy services not approved for more than one hour per day per
type of therapy
Duplicate therapy services are not covered
MDwise PA Process – Mental Health
Mental health PA criteria are listed in 405 IAC 5-20-8
PA required for mental health services provided in an outpatient or office
setting that exceed 20 units per member, per provider, per rolling 12month period
Criteria reviewed:
 PA request form
 Current treatment plan
 Progress notes – necessity and effectiveness of therapy
MDwise PA Process – Mental Health
Note: PA required for neuropsychological and psychological testing and includes
96101 – psychological testing, 96111 – developmental test extended, and
96118 – neuropsychological testing battery
PA not required:
 2 units of psychiatric diagnostic interview allowed per 12 months per
member, per provider if a physician or HSPP and a mid level
practitioner separately evaluate the member (90801)
 Medicaid Rehabilitation Option (MRO) services are not subject to PA
as outlined in 405 IAC 5-21
MDwise PA Process – Mental Health
Assertive Community Treatment (ACT)
PA is required for ACT services covered by the IHCP per 440 IAC 5.2-2-3
and PA requirements in 405 IAC 5-21-8(d)
Required Documents:
 Assessment of current medical status
 Psychiatric history
 Status at time of review for ACT
 Treatment goals reviewed by ACT team psychiatrist
MDwise PA Process – Mental Health
Note: Care Select members can self refer to any IHCP enrolled mental
health provider. However, mental health services furnished to
members by providers enrolled with specialties other than mental
health must contact the member’s assigned MDwise Care Select PMP
to obtain that PMP’s two character certification code
All services billed to EDS as fee for service
MDwise PA Process – DME/HME
Medical Supplies and Equipment
Criteria for medical supplies, durable medical equipment, and home medical
equipment can be found in 405 IAC 5-19
PA is not required for the following items:
 Cervical collars
 Back supportive devices
 Hernia trusses
 Oxygen, supplies, and equipment for its delivery for nursing facility residents
 Parenteral infusion pumps used with parenteral hyperalimentation
 Eyeglasses
MDwise PA Process – DME/HME
Chapter 6, section 5 details other DME and HME which does not require PA. Also,
see the IHCP fee schedule at www.indianamedicaid.com
Oxygen:
 All oxygen equipment and supplies require PA for members in a home setting
Physician order required
Note: DME/HME that is purchased and require repair also require PA
MDwise PA Process – DME/HME
A Medical Clearance Form is required for certain types of DME, HME or medical
supplies and must accompany the PA request form
Note:The medical clearance form is used to justify the medical necessity of certain DME,
HME, or medical supplies:
 Augmentative communication systems – Augmentative Communication
System Selection form
 Certificate of Medical Necessity (CMN) for home oxygen therapy –
Certificate of Medical Necessity: Oxygen form
 CMN parenteral or enteral nutrition – Certificate of Medical Necessity:
Parenteral or Enteral form
MDwise PA Process – DME/HME
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Audiometric tests for hearing aid fitting – Medicaid Medical Clearance
and Audiometric Test form
Hearing Aids – IHCP Medical Clearance and Audiometric Test form
Hospital beds – Medical Clearance Form: Hospital and Specialty beds
Motorized wheelchairs or other power-operated vehicles – IHCP
Medical Clearance for Motorized Wheelchair Purchase form
Negative pressure wound therapy – IHCP Medical Clearance form for
Negative Pressure Wound Therapy
MDwise PA Process – DME/HME
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Non-motorized wheelchairs – IHCP Medical Clearance form for
Non-motorized Wheelchair Purchase
Standing equipment – Medical Clearance Form: Physical Assessment
for Standing Equipment
Transcutaneous electrical nerve stimulator (TENS) – Medical
Clearance form for TENS Unit
Note: All forms are available in the IHCP Provider Manual or by contacting EDS
Customer Service at 1-800-577-1278 or at www.indianamedicaid.com
MDwise PA Process – DME/HME
PA request for DME and HME are reviewed on a case-by case basis based
on the following:
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The item must be medically necessary for the treatment of an illness
or injury or to improve the function of a body part
The item must be adequate for the medical need; however, items with
unnecessary convenience or luxury features are not allowed
The anticipated period of need, plus the cost of the item is considered
in determining whether the item is rented or purchased
MDwise PA Process – DME/HME
Note:The IHCP case mix rate for long term care facilities includes costs for the
following and cannot be separately authorized or billed to the IHCP:
 Medical and non-medical supplies
 Mental health service
 Nursing care
 Room and board
 Therapy services
 Transportation
 Habilitation
MDwise PA Process - Transportation
PA criteria for transportation services are found in 405 IAC 5-30
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PA is required for transportation trips exceeding 20 one – way trips per
member, per rolling 12-month period (exception: emergency ambulance,
transport to or from a hospital admission or discharge, patients on dialysis,
and patients in nursing homes)
Trips 50 or more miles one way
Out – of – state or non – designated trips
Airline or air ambulance by a provider located out-of-state or in a non –
designated area
In state bus or train services
Family member transportation (authorized by the county office of the DFR)
MDwise PA Process - Transportation
Submit the following information:
 PA form
 Proper procedure codes
 Member’s age, diagnosis, and condition
 Level of service needed
 Reason for and destination of service
 Frequency of service
 Duration of service
 Total mileage for each trip
 Total wait time for each trip
Note: PA not required for accompanying parent or attendant unless the trip exceeds 50
miles one - way
MDwise PA Process – Genetic Tests
Genetic testing for breast and ovarian cancer
 Documentation required:
 PA request form
 Appropriate procedure codes
 Medical necessity documentation
MDwise PA Process – Reminders
 Verify member eligibility
 Verify member’s CMO affiliation (No Delivery Systems in Care
Select)
 Verify if the service requires PA
 Complete the PA request form
 Complete with appropriate CPT/HCPCS codes
 Fax PA form and supporting documentation to MDwise
877-8227186 or 317-822-7515
 Verify PA status using web interChange
 Finalize all PA requests (including suspended PAs) with CMO
receiving original PA request
MDwise PA Process
Questions?
Thanks for attending!