Maryland Durable Medical Equipment (DME) Updates and Review January 2017

1. Maryland Durable Medical Equipment (DME) Updates and Review January 2017

2. Who Is Telligen • We are the Utilization Control Agent for Department of Health and Mental Hygiene (DHMH). We provide medical necessity Pre-authorization reviews for select Durable Medical Equipment. • We utilize the web application Qualitrac for our DME reviews

3. Agenda • Updates on Letters!!!! • New Features – Reconsideration Option!!!! • Review of DME request process via Qualitrac portal • Common Errors – Troubleshooting • Questions and Answer Period

4. Important Procedural Changes • Effective February 1, 2017, The pre- authorization number generated in Qualitrac will be used for billing to DHMH • This will replace the DHMH Authorization Number • Approval letters will not be generated any longer by DHMH • Providers can print out approval information in Qualitrac for their records

5. Provider Letters In Qualitrac • Denial letters-**NEW** • Effective February 1, 2017 Telligen will be issuing denial letters through Qualitrac • Additional Information • Letter attached in portal asking for additional documentation to evaluate medical necessity for the request. • No Review Required • Duplicate request • New request is needed(incorrect information entered) • HCPCS Codes not reviewed by Telligen

6. NEW FEATURES • When a case is denied providers now can request reconsideration with the push of a button!!! • Search for the request using the reference ID. If denied you will now see an option to REQUEST RECONSIDERATION.

7. Request Reconsideration • Your request has been denied or partially approved • You have 20 days to request a reconsideration on a case • Find the case

8. Press button

9. Attach additional information

10. Attest and electronically sign

11. Search for case again

12. Select case

13. Provider Portal Training Refresher

14. Telligen follows criteria established by DHMH for DME reviews and/or Medicare Local Care Determinations (LCD’S). COMAR 10.09.18 and 10.09.12 In the event medical necessity cannot be established by the nurse reviewer; it will be referred to a physician for review. Please ensure all supporting clinical documentation is provided so as not to delay the review process.

15. Our Website • http://www.telligenmd.qualitrac.com • Consists of : • Home page • Document Library- contains the Provider Portal application • Education and Training-recorded trainings/slides • Provider News • FAQs—this is a very big resource for DME • Contact Information There is also a link that will take you to the Qualitrac Portal Log in page

16. REMINDERS • When you upload a document to the Portal you will receive an email confirmation • When a determination is made on your request, you will receive an email notification • **Please note** - the person who enters the case receives the e-mail • When you access the portal, you can view the status of all requests by using the Qualitrac Reference ID number

17. Purchase vs Rental • The Maryland Medical Assistance fee schedule indicates whether an item can be rented or purchased. • It is at the discretion of the DME reviewer to approve a request for a rental or purchase • The reviewer may modify the request from a purchase to a rental • Examples include: • Osteogenesis bone stimulators -cough assist • bipap

18. Tips for Submission and Prompt Response Assist us to assist you • Do not group multiple equipment requests in one requisition. • Each piece of equipment AND its accompanying accessories warrant an individual request. • You can always check on the status of your request by returning to the portal and search using the Qualitrac Reference ID

19. Provider Portal: Start a New Request • To get started, navigate to the website: http://www.telligenmd.qualitrac.com • Utilize the “sign in” option in the top right hand corner to log-in to the Patient Portal. • To start a new request, select “Add Authorization” button

20. Select the Type of Request • Choose the type of review that you are requesting. • Select Durable Medical Equipment Review from the drop down box

21. Select the Review Timing • Select the Review Timing from the drop down box. • Prior Authorization is for a future request.

22. Provider Portal: Patient Information • Enter the member’s Medicaid ID and Date of Birth • The data entered MUST be an exact match to continue.

23. Group Selection Submitter will need to select the provider that this request is being submitted for.

24. Provider and Facility Search • Submitter will enter the Ordering Provider and the Treating Facility. Both are required fields. • Please use name, NPI and/or zip code to search

25. **Ordering provider** This is the physician who wrote the prescription for the equipment **Treating Facility**—This is the DME provider In the event this is not entered correctly the request will be returned to the provider and a new request will be needed. This will delay the processing of the request.

26. Service Information • Click on the blue edit box under equipment type. • Equipment type pop up box appears and submitter selects the type of equipment that this review is being submitted for. Select edit box icon to open equipment type selection box

27. Equipment Type Items that don’t meet a category • Wound Vac-at this time please enter as “specialty mattress” • Osteogenesis bone stimulator- at this time enter dynamic splint systems

28. Service Information Enter Principal Diagnosis Select Add Service to open pop up box for service information to be entered.

29. Add Service Submitter will need to enter: • Start Date • End Date • These are your requested dates of service

30. Add Service • Treatment Requested • This is the HCPCS Code • Treatment Description • Can be used if it is a recertification • For NOS codes

31. Add Service • Quantity • This is the number of items being requested for this particular HCPCS

32. Service Information Select if this will be a Rental or a Purchase

33. Rental For Rental: Enter required fields: -Quantity - Rental Cost - Frequency -How long does the member need this?

34. Purchase For a purchase: Enter required fields: - Quantity - Purchase cost

35. Procedure Code • Once all fields in the Requested Services pop up box are completed, the information will be displayed for your reference. • At this time, the submitter may select Add Service and add a second line to this submission. • 24 lines can be entered per request. If you need to request more items for a request a new case will need to be entered • Please note in the new request the Reference ID from the original request

36. Common Errors with Procedure Codes These can delay reviews • Entering HCPCS codes Telligen is not reviewing • Entering codes that do not require preauthorization • Entering an ICD-10 instead of a HCPCS code • Entering the wrong HCPCS for the request

37. Multiple Component Requests • Equipment with accessories • Must request each accessory separate from the main item • Each component is reviewed individually and will have its own outcome. • Denial Letters will follow for those components not approved . • Examples include: • Gait trainers -custom seat • Standers -custom back • Entering these items as one request will be returned to the provider and a new request will need to be entered. This can delay the review decision

38. Provider Portal: Supporting Documentation • Attach supporting documentation. • This is where the medical record will be attached to the file along with any other supporting documentation.

39. Trouble Shooting How to Minimize Errors When Uploading Documents • Do not upload documents that are password protected. • Do not upload documents directly from a secure drive. • If documents are larger than 300 Mb, split the document in to smaller files making them easier to process. • Please submit all documentation required to make an accurate determination, complete medical record. • Speed does affect the upload time of the document. Slower internet connections will result in extended upload times.

40. Summary and Attestation • The submitter will have the opportunity to review all information that was entered including support documentation that was uploaded. If there are any errors or items omitted, please hit the back button to correct the request • Once everything is correct, utilize the electronic signature and select done to submit the case. Under Review Under Review

41. Provider Portal: Summary and Attestation • Clicking the “Done” button is necessary to submit the case through the system for review. • An email will be sent to the User with the case number. This confirms that the case has been submitted. • The User will also receive an email when case review is complete. • A User may log in at any time to determine case status, view applicable correspondence, and attach additional information.

42. Patient Portal: Landing Page Use buttons to filter the cases in your queue. Use column headings to sort the data. Use search boxes to find specific information. Click on Case ID to get more details. Use to navigate through the pages Use this button to begin entering a new case.

43. Patient Portal: Case ID • After a case has been submitted, Users can look up the case and perform additional actions or view details. • A User can search for a case using the search fields or by navigating through the pages. Once the case has been located, click on the Case ID field to select it.

44. Patient Portal: Case Details • Clicking on the Case ID opens the Case Details page. Click the Reference ID to see a summary page and view correspondence

45. Patient Portal: Summary Page and Correspondence • When the User clicks on the Reference ID, a summary page opens where the case information, supporting documentation, and status can be reviewed. • This page contains any correspondence attached to the case. Clicking on the link(s) contained in the Letters section will open the correspondence for review.

46. For DME Questions We are here to help • please contact our Provider Help Desk by telephone at 888-276-7075 -pressing option number 2 will connect you with the DME Line. • or email marylanducsupport@telligen.com • When inquiring on a review request –please use your Qualitrac Case ID number(Reference ID) – please do not send PHI or PII in your email.

47. Questions Telligen will become your partner in serving Medicaid clients