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Policy and Procedures Updates for the QIO

Policy and Procedures Updates for the QIO. KePRO. On February 24, 2012, the award was reinstated with a 90-day implementation plan to begin operation June 1, 2012. Scope of Services . KePRO’s contract includes a number of new services requiring Prior Authorization

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Policy and Procedures Updates for the QIO

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  1. Policy and Procedures Updates for the QIO

  2. KePRO • On February 24, 2012, the award was reinstated with a 90-day implementation plan to begin operation June 1, 2012

  3. Scope of Services • KePRO’s contract includes a number of new services requiring Prior Authorization • Inpatient Hospital Admissions • Exception: Births/Deliveries • Emergencies – Require PA w/ 2 Business Days of Admission • Physical, Occupational, Speech Therapy • Adults >21 years • Outpatient Hospital

  4. Scope of Services cont. • DME • Power/Manual Wheelchairs and Accessories • Cranial Molding Bands • Organ Transplants • Authorization includes evaluation. • Approval to be treated oos when applicable.

  5. Scope of Services cont. • Mental Health Counseling Services • Select Surgical Procedures

  6. Retrospective Reviews • Review of medical support documentation • Sterilization Forms • Unlisted Procedures • Quality of Care reviews for IP Psychiatric facilities and PRTFs • Quality of Care and Utilization Reviews of Intermediate Care Facilities

  7. Transition Plan • Alliant will continue to perform prior authorization reviews until May 31, 2012. • Prior authorization reviews currently performed by SCDHHS will continue until May 31, 2012.

  8. Provider Bulletins • April 11, 2012, bulletin that announced the contract award. • April 16, 2012 - training opportunities. • May, 16, 2012 – Policy Changes and contact information. • https://www.scdhhs.gov

  9. Claims Processing • June 1, 2012 – Contact KePRO for Prior authorizations. • Warning message on remits/web-tool (June) to allow for transitioning. • July 1, 2012 claims or services prior authorization from the QIO will automatically reject if auth number is not present or not valid. • Claims DOS Prior to June 15 will continue to reject with old edits.

  10. Claims Processing Cont. • Edit 837 – Service requires PA from KePRO – no PA on claim. • Edit 838 – Service requires PA from KePRO – PA is not valid. • Edit 839 – IP admission requires PA from KePRO.

  11. Reminders • Provider Manual updated each month. Change Control Log shows what’s changed. • Bulletins – sign-up for e-bulletins • http://www.scdhhs.gov

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