INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT

1. INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT South Carolina KePRO QIO Request Submission Requirements New 6/14/2012

2. Topics • Service Type(s) • KePRO SCDHHS Website • Service Type Requirements • Contact Information

3. Prior Authorization Service Types • Therapies – (PT, OT, SP) • Home Health • Hospice

4. South Carolina Web Site

5. Forms Navigate to Form Tab to obtain Documents such as: Fax and Justification forms

6. Therapies – PT, OT , and SP • 21 years and Older - OP Hospital • Under 21–OP Hospital and Private setting • Medicare Primary –   Medicare claim denied or benefits exhausted – Then Medicaid PA could be obtained • Medicare Hospice- Therapy is not related to the illness. • Provider Manual - Hospital Services provider manual, not the Private Rehab  provider manual • Evaluation = 1 • Follow up session(s) - 1 unit = 15minutes • See Hospital Provider Manual - Section 4-74 to 76 for Codes requiring PA and appropriate Unit designation

7. Therapies-PT,OT,SP • Therapy codes: • 92506 • 92507 • 92508 • 92607 • 92608 • 92609 • 92610 • 97001 • 97002 • 97003 • 97004 • 97012 • 97016 • 97018 • 97022 • 97024 • 97026 • 97028 • 97032 • 97033 • 97034 • 97035 • 97036 • Therapy codes: • 97110 • 97112 • 97113 • 97116 • 97124 • 97140 • 97150 • 97530 • 97532 • 97533 • 97535 • 97537 • 97542 • 97597 • 97598 • 97605 • 97606 • 97750 • 97755 • 97760 • 97761 • 97762

8. Home Health Home Health covered services: • Nursing services • Home health aide • PT, OT, SP

9. Home Health KePRO will review for the following procedure codes: • T1030- Nursing care in home by Registered nurse • T1031- Nursing care by a Licensed Practical nurse • T1021- Home Health Aide Visit • T1028- Assessment Visit DME Evaluation • A9900- Supplies • S9127- Social Work visit, in the home • S9128- Speech Therapy • S9129- Occupational Therapy • S9131-Physical Therapy

10. Home Health • Recipients may receive up to 50 home health skilled nursing, PT, OT, SP visits per fiscal year without prior authorization. • Prior authorization is required for services beyond the first 50 visits • 1 unit = 1 visit

11. Home Health • Request for extended service beyond the initial authorization period must be submitted to KePRO prior to the last authorized day in the certification period • Provider has two business days to respond to additional information pend notices. • If no response received to pend, the request will be forwarded for Higher level review or administratively denied • Providers have two business days to respond to Insufficient information request • If no response received to pend, the request will be closed requiring re-submission for Prior authorization

12. Hospice • Effective October 1, 2012, all requests for Hospice Services for Medicaid-only Recipients will need to be submitted to KePRO for Prior Authorization

13. Hospice Hospice Procedure codes • T1015- GIP General Inpatient Care • S9126- Routine home Care • S9123- Continuous home Care • S9125- Inpatient Respite Care

14. Hospice • Required Documentation: • KePRO Outpatient Fax Form • DHHS 149 (Election Form) • DHHS 151 (Physician Certification Form) • Plan of Care (POC) • DHHS 153 (Revocation Form)- If applicable • DHHS 154 (Discharge Form)- If applicable • DHHS 152 (Change Request Form)- If applicable • Clinical documentation to support request

15. Hospice • KePRO Outpatient Fax Form • Please make sure that all necessary information has been filled out on the KePRO fax form • Include all 3 procedure codes (GIP should also be included if that is the status of the client upon submission) • Requests for GIP should be submitted at the time of inpatient admission, and if approved, will be approved for a 30 day time span

16. Hospice • DHHS 149 Form (Medicaid Hospice Election): • To be eligible to elect Hospice under Medicaid: • Person must be certified as being terminally ill. • Person is considered terminally ill if he or she has a medical prognosis that his or her life expectancy is 6 months or less, if the disease runs its normal course • Hospice coverage is available for an unspecified number of days. • The days are subdivided into election periods • Two 90-day periods each • An unlimited number of subsequent periods of 60 days each

17. Hospice • DHHS 149 Form (Medicaid Hospice Election): • Designate an effective date for the election period to begin • The request must be submitted to KePRO within 15 business days of election of benefits • If not received within 15 business days, the request will be approved effective the date the request was received by KePRO

18. Hospice DHHS 149 Form

19. Hospice • DHHS Form 151- Medicare Hospice Physician Certification and Recertification • Hospice must ensure the following conditions are met: • Written certification statements must be obtained within 2 calendar days after hospice care has been initiated • Signed by the Medical Director of the Hospice or the physician member of the Hospice interdisciplinary group • Signed by the person’s attending physician (if the individual has an attending physician)

20. Hospice • DHHS Form 151- Medicare Hospice Physician Certification and Recertification • Hospice must ensure the following conditions are met: • If written certification if not obtained within 2 days after the initiation of Hospice care: • A verbal certification may be obtained within these 2 days • A written certification must be obtained prior to submission of a request for prior authorization

21. Hospice • DHHS Form 151- Medicare Hospice Physician Certification and Recertification • Hospice must ensure the following conditions are met for recertification: • The Hospice must obtain (no later than 2 calendar days after the beginning of that period): • A written certification statement completed by the medical director of the hospice or the physician member of the Hospice’s interdisciplinary group • Must include the physician’s signature • A statement that the individual’s medical prognosis is of a life expectancy of 6 months or less, if the terminal illness runs its normal course

22. Hospice DHHS Form 151- Medicare Hospice Physician Certification and Recertification

23. Hospice • Revocation • A beneficiary may revoke the election of Hospice care at any time • The individual loses any remaining days in the Hospice benefit period and regular Medicaid benefits are reinstated effective the date of the revocation • The individual may at any time elect to receive Hospice coverage for any other Hospice election period for which he or she is eligible.

24. Hospice • DHHS Form 153- Medicaid Hospice Revocation • To revoke Hospice, the individual must: • Complete DHHS form 153 • Designate an effective date to revoke Hospice • Submit Form 153 to KePRO within 5 business days of revocation of benefits • Mail a copy of the form to the nursing facility or ICF/MR

25. Hospice DHHS Form 153- Medicaid Hospice Revocation

26. Hospice • Discharge: • Discharge of an individual may occur for the following reasons: • The individual expires • The individual is noncompliant • The individual is determined to have a prognosis greater than 6 months • The individual moves out of the Hospice’s geographically defined service area • If discharging for reasons other than death, the Hospice provider must send a copy of the Medicaid Hospice Discharge Statement to the beneficiary or responsible party upon discharge

27. Hospice • DHHS Form 154- Medicaid Hospice Discharge: • Form 154 must be completed • Designate an effective date to discontinue Hospice • Submit form to KePRO within 5 working days of the effective date of discharge

28. Hospice DHHS Form 154- Medicaid Hospice Discharge

29. Hospice • DHHS Form 152- Medicaid Hospice Provider Change Request Form • Form 152 is to be used when an individual chooses to change the designation of the particular Hospice from which he or she elects to receive Hospice Care in each election period • To change the designation of Hospice providers, the individual must notify their current Hospice provider that they which to change Hospices

30. Hospice • DHHS Form 152- Medicaid Hospice Provider Change Request Form • The Hospice provider that is releasing the beneficiary must: • Complete all appropriate portions of Form 152 • Submit a copy of Form 152 to KePRO within 5 business days • Send a copy to the receiving Hospice Provider

31. Hospice • The receiving Hospice Provider must: • Receive a copy of Form 152 within 2 business days of the effective date of change • Forward a completed copy to the SCDHHS Hospice Program Manager within 5 business days of the effective date of receiving Hospice’s first day of service to be included for billing • Mail a copy of the form to the nursing facility or ICF/MR • For Medicaid only beneficiaries, Form 152 can be faxed to KePRO

32. Hospice DHHS Form 152- Medicaid Hospice Provider Change Request Form

33. DME Effective October 1,2012 the following two codes will require prior authorization request from KePRO: • S8189- Tracheostomy Supply, not otherwise classified • L0638- Lumbar-sacral orthotic (SLO) • Providers must attach pricing information on claims for procedure codes that are manually priced

34. Outpatient Fax Form

35. KePRO Outpatient Fax Form cont.

36. KePRO Contacts

37. Thank You! 37