WVCHIP Transition to KEPRO

1. WVCHIP Transition to KEPRO For New Providers

2. WVCHIP Transition Beginning July 1, 2019 KEPRO will become the Utilization Management Contractor (UMC) for the West Virginia Children’s Health Insurance Program (WVCHIP) and HealthSmart will no longer be the vendor. • There will be a transition period – HealthSmart will process ALL prior authorization (PA) requests received through COB 06/24/2019. There will be a “blackout” on WVCHIP requests 06/25/2019-06/30/2019 where no WVCHIP requests will be processed by either HealthSmart OR KEPRO. • Any PA Requests submitted to HealthSmart after June 24th will not be accepted and all documents received by HealthSmart will be shredded. Provider will be contacted by phone or receive a return notice by fax. • KEPRO will begin processing requests on 07/01/2019. • Any PA issued by HealthSmart will be honored by DXC (claims payer) provided the date of the service is covered by the PA and there are sufficient units to cover the service. There is no need to get a new PA from KEPRO for a service already authorized. • Should a new service or additional service be needed after a PA expires, a prior authorization request must be submitted to KEPRO for medical necessity determination. • If a service is not conducted (e.g. rescheduled beyond valid dates of authorization), a prior authorization request must be submitted to KEPRO for medical necessity determination.

3. Who is KEPRO Currently? • KEPRO is a utilization management company contracted by the Bureau for Medical Services that serves the WV Medicaid fee-for-service population. • Fee-for-service population includes: • Foster care children • Medicaid waiver recipients • Nursing facility residents • The Elderly and/or disabled • And those who receive Medicare

4. Existing KEPRO Scope of Work Websites/Direct Data Entry Portals Medical Requests https://providerportal.kepro.com Health Homes https://providerportal.kepro.com Behavioral Health https://careconnectionwv.kepro.com Nursing Home PAS https://c3.kepro.com Personal Care https://wvltc.kepro.com Aged & Disabled Waiver https://wvltc.kepro.com IDD Waiver https://wvltc.kepro.com • Health Homes • IDD Waiver Services • AD Waiver Services • Personal Care Services • TBI Waiver Services • Nursing Home PAS Review • Behavioral Health Services • Medical Services • BCF-Socially Necessary Services • Substance Use Disorder Waiver

5. What Changes Will Occur July 1, 2019 for WVCHIP? • KEPRO’s business hours are 8AM-5PM Mon-Fri. • KEPRO has a direct-data-entry (DDE) system that is available 24/7 for prior authorization requestsubmission. • Registration is required with KEPRO to access the WV C3 Medical Provider Portal (C3). • WVCHIP prior authorization requests will now be submitted on KEPRO’s Provider Portal, DDE system or faxed utilizing request forms. • Fax forms for WVCHIP are available on the wvaso.kepro.com website in the WVCHIP providers section. These need to be completed entirely for staff to key requests- incomplete forms will be faxed back and may delay PA. • Telephonic requests will only be accepted for emergent situations. • Authorization letters will not be sent to the members or the providers. • Prior Authorization DOES NOT assure eligibility or payment of benefits under WVCHIP.

6. What Will Remain the Same? • WVCHIP Benefits • Covered services • Services requiring prior authorizations • Services with special instructions • Fee schedules • WVCHIP Member application and enrollment • PA requests will not be reviewed by KEPRO for providers who are not enrolled with WVCHIP • WVCHIP Provider enrollment • DXC will remain the claims payer • All claims billing issues and questions related to authorization numbers issued (HealthSmart or KEPRO authorizations) should be addressed to DXC.

7. New WVCHIP Master Code List • The WVCHIP Master Code List (MCL) provides a crosswalk of the WVCHIP benefit to the existing medical system and will direct you regarding how to submit requests (DDE or fax). • This list will include the codes that require prior authorization and codes with service limitations/special instructions. • There are some codes that are not eligible for direct-data-entry (DDE). These specific codes will need to be submitted via fax on the appropriate authorization request form. • It is recommended that codes available to be submitted via the DDE system are submitted in that manner. • This is recommended due to the DDE system’s validation features, tracking ability, efficiency, and timeliness. • The WVCHIP Master Code List (MCL) will be available on the www.wvaso.kepro.com website in the WVCHIP Section.

8. Example of WVCHIP MCL

9. Submitting Requests DDE v. Fax • Some codes in the WVCHIP benefit are not available in C3- the MCL indicates fax submission for these codes • Appropriate form must be selected and completed in its entirety and faxed to the number on the form-incomplete forms will be faxed back to provider requesting the necessary information • Requests will be keyed by KEPRO staff in the order received and sent to the clinical queue for review • When the MCL shows a code can be requested DDE you will be able to create and submit the request • This method provides guidance to ensure all required information for successful review is included • This method prefills provider information, member demographics and other information without keying • Goes directly to queue for review

10. Sample of PA Form

11. Telephonic Emergent Requests • KEPRO will only allow telephonic review for emergent requests. • Per WVCHIP, a medically urgent request is: • a delay could seriously jeopardize the life or health of the member or, • the ability of the member to regain maximum function or, • in the opinion of a physician with knowledge of the member’s medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the case. • Emergent requests can be submitted by DDE or fax, but are limited for phone review. Areas in which a request can be submitted by phone are: • Inpatient Services • Non-elective Outpatient Surgery • Emergent Lab/Imaging/Radiology requiring PA • NOTE: Some review areas do not recognize medically urgent requests. In these instances it is not a choice in the admission type dropdown. For those review areas that recognize medically urgent (e.g. inpatient) each admission type has a medically urgent choice (e.g. direct admission OR direct admission-medically urgent). Requests not meeting the medically urgent definition WILL NOT be clinically reviewed as medically urgent.

12. How to Enroll with KEPRO • To register go to https://c3wv.kepro.com. • On the login screen, select the Provider Self Enrollment (Providers Only) link. • A new screen will open and display the Organization Registration/Enrollment Request Form. • Note, there are two KEPRO websites: • https://c3wv.kepro.com – Organization Managers • https://providerportal.kepro.com – AUM Managers

13. Organization Registration/Enrollment Request Form • All fields in red are mandatory. • The Organization name should include WVCHIP. Example: WVCHIP Bugs Bunny Clinic. • Once you have filled out the mandatory information, click on the ‘terms and conditions’ and carefully review. • Check the box on the form stating that you have read and agree to the terms and conditions. • Review all the information entered and Click SUBMIT. • Note: If the Organization Admin Confirm Email that is entered does not match the original Organization Admin Email entered, the form cannot be submitted. • Notifications are sent to this email address when the request is completed. • Once the Organization Registration Request Form is submitted, the Organization Manager receives a confirmation pop-up message on screen. • The user will receive an e-mail message when the Organization has been reviewed by KEPRO. This email will contain your Username and Temporary password. • Please allow up to 2 business days.

14. Provider Portal Roles • (ORG) Organization Manager Role: Has permission to create Users under the organization(s) to which the person having the role belongs to. Each Organization must have at least one Organization Manager (preference is two). Please remember it is important to register for the correct role(s) to ensure the appropriate access is granted. Only Organization Managers can authorize and request the addition of NPI numbers to the Organization. • (AUM) Utilization Manager Role: Each Provider Organization must have at least one designated AUM Utilization Manager. A Utilization Manager will have the same rights and abilities as an-AUM Provider and additional supervisory abilities. The AUM Utilization Manager may also create and submit requests directly to KEPRO. The AUM Utilization Manager may search for any request submitted for the organization(s) to which they have access. Each Provider Organization may have as many AUM Utilization Managers as they wish. A User may only have one AUM Role assigned across all the organizations to which they belong OR an AUM User may also be an Organization Manager and have the same Username and Password for BOTH roles. • AUM Provider Role: AUM Provider role will have all the functionalities of Advanced Utilization Management (AUM) except that the User role will not have the accessibility to submit a request directly to KEPRO. The AUM Provider may only search and view those prior authorization requests they create. This role was designed primarily for Users who are orienting to the system and/or may need a supervisory approval for each submission. Please DO NOT CHOOSE this role if the user is expected to key and submit request into the DDE system. This user role will cause the authorization request to be in a SUBMITTED role which is like a limbo status. In the SUBMITTED role, the request does not go through the system.

15. Logging In to KEPRO Provider Portal • Once you receive your email, click on the link to login. • You will be directed to a page that requires you to logon. • Enter the Username and temporary password that was provided in the email and click ‘Log in’. • The screen will prompt you to create a new password. • Enter the old password. • Enter the new password. • Enter the new password again in the ‘Confirm Password’. • Click Confirm. • The password is successfully changed. The provider can use the new password to login to the system the next time he/she logs in. • Be sure you are using Internet Explorer to maximize the C3 Provider Portal.

16. Username and Passwords • Username and Password requirements: • All passwords must be changed by the User the first time the system is accessed. • Usernames may contain both alpha and numeric characters and are case sensitive • Passwords are case sensitive. • Passwords must be a minimum of eight characters and contain a capital alpha (a-z), a number (0-9) and a symbol (!,@,$). • When changing a Password, the new password must be different than the current/expiring password. • The current Password must always be supplied when creating a new password. • New Passwords must be entered into the system twice identically to ensure accuracy. • A new Password can be created by the User on demand and anytime by choosing Change Password from the menu given when logged on.

17. Password Management • When creating users do not utilize names such as “Front Desk” or “Doctors Office” for the First Name/Last Name. KEPRO staff will not reset the passwords unless assigned to ONE person. • Please do not share Usernames and Passwords. • Passwords automatically expire after 30 days, regardless of activity. • If this happens, the username will disappear from the Organization Manager’s list of users. The Organization Manager can call KEPRO to reactivate the user. Reactivation will bring the user back into the Organization Manager’s list of users. DO NOT CREATE A NEW USERNAME. • Once the user is active, the Organization Manager has the ability to go into the system and change the user’s password. • KEPRO can reactivate and change passwords but must give the password to the assigned user or Organization Manager directly whether by phone or e-mail. • Organization Managers are unable to reset their own password if they have expired.

18. What Can You Access on the Provider Portal? • Creating Prior Authorizations • Reconsideration Options • Copy for New Submissions • Copy for Corrections

19. Home Screen • This is the screen you will first see when you are logged in. • It will show your user roles, and organization. • You will click on AUM Manager. • From here you will be able to navigate the WV C3 Medical DDE system by clicking on the various tabs: • Search Member • Search Tx Episode • Search Authorization Request • Search PA Number • My Inbox • Queue • Reports

20. How to Submit a Prior Authorization Request • BE SURE YOU CHECK THE WVCHIP MCL BEFORE PROCEEDING! If the code is not located in C3 you will need to fax in the request. The WVCHIP MCL will indicate how the authorization request will need to be submitted. • Click on Search Member and enter the WVCHIP ID number and one of the following: • The member’s last name; • Hint: You can enter the first initial of the last name and click search • Member SSN; • Member’s Date of Birth • Note: with the C3 system less is more. Meaning the least amount of information will produce the most results. • Under “Coverage Details,” click on the subscriber code that matches the one you entered on the Search Member screen that has not termed or meets the timeframe of your request.

21. Treatment Episode • This will bring you to the Treatment Episode Screen which shows all the previous requests for the member that has been submitted by your organization. • You can check for duplications in this area. • Click on Add New Medical Request

22. Create New Request • Under provider, you will select whether you are the: • Referring Provider; • Servicing Provider; • Or both • Choose carefully! Ask yourself who will submit a claim for payment of requested service. The Servicing provider will be issued the authorization number. Therefore, the one to bill. • Next, enter the start date; the request category; the category of service; choose the requesting provider; and the request type. • There will only be a list available under the requesting provider if your registration is complete and your provider NPI numbers have been attached. • A Service preview will appear (you do not select your services here). • Scroll to the end of the screen and click “Create Request” • If a member has previous treatment episodes, it will ask you if you want to Attach. Choose “Do not Attach”. If the member has no previous episodes, click “Continue” Each review area will generate different choices for the category of service and request type. KEPRO has step by step instructions with screenshots available for providers to help guide this process.

23. Create New Request Cont.

24. Member Demographics • At this point go ahead and document the Authorization Request ID. • Please review all information of the member. • If the address is not correct, please change it. • Please note: Member address information comes from DXC. WVCHIP members must contact their county office to report address changes. Any provider edits made will not be saved for future requests. • If everything is correct, simply click Save and Continue.

25. Provider Information • If you chose that you are the referring provider, this will auto-populate. This information comes from DXC and edits will not be saved for future requests. Provider must contact DXC for assistance with address correction. • IT IS IMPERATIVE that you enter your contact information! • If the information is incorrect and the case is pended for additional information, the review nurse has no way to make contact. This will delay services to the member. • If the referring provider does not auto-populate you will need to select one. • You will start by clicking Search Provider. • Enter the physician’s name in the Name field and change Any Words to ALL WORDS and click Search or; • You can select NPI from the dropdown on the right side and enter the NPI number and click Search. • Searching by the NPI number will produce the most accurate results. • Once you have found the physician you are looking for, click the paper clip to attach. • Click Save and Continue.

26. Administrative • Answer all questions with the red asterisks(*) • Note: The date of referral is not needed. • Choose procedure type. • There are two choices for Authorization Type: • Prior Authorization • Retrospective • WVCHIP Policy for retrospective requests still applies.

27. Service Selection – Selecting a Provider • If you chose your organization as the servicing provider option, this will auto-populate. This information cannot be changed. • If you are the referring provider, you will need to attach the Servicing Provider’s information to the request. • To find the Servicing Provider: • Click on the Search • Enter the name of the provider/facility in the Name field and change Any Words to ALL WORDS and click Search or • You can select NPI from the dropdown on the right side and enter the NPI number and click Search. • Searching by the NPI number will produce the most accurate results. • Do not enter any other information in any other fields. Using name or NPI is sufficient. • Once you have located the provider you are searching for, click the paper clip to attach.

28. Service Selection • You are now ready to select your service code. • To find your service code, click the Search link beside the Service Code dropdown box and enter your CPT (procedure) code in the Service Code/Group Name field and click Search. • The service code that your CPT code falls under will appear. In the description, you can place your cursor over the DETAILS link to make sure that your code is actually in the group that appears. • If it is correct, click the paper clip to attach it. • Choose the place of service, and click Add Service under the Service Start Date. • Units and Service end dates are generally auto-populated (depending on the review area). • Continue answering any fields that are indicated with the red asterisks(*). • Click Save and Continue.

29. Diagnosis • Continue following the prompts and completing all areas with the red asterisks(*). • When you get to the Diagnosis screen click in the Diagnosis code box. • Start by typing the ICD-10 code into the box, wait for the dropdown list to appear, and click on the code from the list. • Enter the symptoms in the Symptoms Box and click the Add button. • Do this for as many diagnosis codes you may have. • Click Save and Continue • Complete pages as indicated by review area until you reach the Summary and Submit page.

30. Summary and Submit • The Summary and Submit page allows you to scroll the document from the beginning to the end. Review the information and make sure all things have been entered correctly, then click SUBMIT. • NOTE: It is recommended to Submit all cases from the TOP. As shown, there are times when Warning(s) appear. • You are able to ‘Continue’ through gray warnings. • Red warnings have to be resolved before the case can be submitted. • When the case is successfully submitted you will receive a pop up box stating“Request submitted successful” or “Request submitted successfully with warnings”. Click OK.

31. Status of Request • In Process – Reason: Requires Info from Provider • This requires the provider to check in on the request to see what additional information the nurse reviewer is requesting. • Complete – Reason: Review Complete • This is when you know that there is a determination in the system, whether it is an approval or a denial. • Closed – Reason: Closed – Administrative • Means the request never reached clinical review. This is usually due an issue with coverage eligibility. • Closed – Reason: Closed – Clinically • This occurs whenever a request has been pended for additional information and that information has not been received. • The case cannot be reviewed for medical necessity and the nurse reviewer ‘Closes’ the request. NOTE: Closed does not mean denied. • Saved – Reason: In Process • Means the request has not been submitted for UMC review and is still in the creator’s queue who started the authorization request. • The creator will have to enter the case and submit either by going into their queue or searching the authorization request. • Pending – Reason: Requires Care Manager Review • The case has been submitted and is ready to be picked up by a nurse reviewer. • Pending – Reason: Requires Eligibility Verification • The case has been submitted but requires the Eligibility staff to review for retrospective eligibility or member coverage. • In Process – Reason: Care Manager Review • The case has been picked up by a nurse reviewer and is waiting for review.

32. Finding Determinations – Search Authorization Request • This tab let’s you search for authorization requests by: • Authorization request ID • Request Category • Authorization start date • Authorization end date • Authorization submission date • Authorization request status • It is highly recommended to document the Authorization Request ID. • Once your case is located click on the Authorization Request ID to the left.

33. Finding Determinations • Click on the Expand/Collapse • You can view the authorization and date span from this page but it is always recommended to go in the case. • For authorization requests that are faxed in, you will have to go into the case to find the manual authorization. • Click on the second ‘Actions’ • Once the Action Item Details box appears, click on View Auth Request.

34. Finding Determinations • Once inside the authorization request use the navigational tree to go to the Summary and Submit page. • Scroll to the bottom to the last annotations box. • Here you will find: • Denial Letters • Which have been modified and formatted to meet WVCHIP requirements • Manual Authorizations • Documentation that is being requested by the nurse reviewer

35. About KEPRO Authorizations Issued • KEPRO does not notify members of approved prior authorization requests. It is the provider’s responsibility to notify and schedule the member for approved services. • Authorization numbers will be available on the DDE system ONLY. • If you have questions regarding claims or claim issues, please contact DXC. • When it is indicated that a code is fax only, C3 will generate an authorization number of all zero’s. • KEPRO staff will generate a manual authorization number (WXUTH#), and will post the manual authorization number in the last annotations box on the Summary and Submit screen. • Please do not use the all zero’s or use the authorization request ID on your claims. Your claim will be denied. • For PT/OT requests, once a member has reached their 20 visits and requires prior authorization to exceed the benefit ALWAYS choose Established request.

36. Example of all Zero Authorization Number

37. Reconsideration Options There are several types of reconsiderations offered to providers: • Expedited Reconsideration • Peer-to-Peer (Level 1) – This is a physician to physician discussion available to providers to present additional clinical information or medical necessity information following initial denial. The Level 2 reconsideration is STILL available after the Level 1 review. The provider can elect to go directly to Level 2 but cannot go back to Level 1 once a Level 2 review has been completed. • Reconsideration (Level 2) – In the KEPRO system this is the same as the Peer-to-Peer defined in the WVCHIP benefit.

38. Expedited Reconsideration Expedited reconsiderations are only to be requested if the authorization request is medically urgent. • Per WVCHIP, a medically urgent request is: • a delay could seriously jeopardize the life or health of the member or, • the ability of the member to regain maximum function or, • in the opinion of a physician with knowledge of the member’s medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the case. • These reconsiderations are completed by KEPRO within 24 hours of the request.

39. Peer-to-Peer Reconsideration (Level 1) A Peer to Peer may be requested by the member’s attending physician. A Peer-to-Peer review is requested in the C3 system. • When creating a Peer-to-Peer request, please include the attending physician’s name, contact information, and best dates/times to contact him/her. • The physician reviewer at KEPRO will contact the patient’s attending physician and discuss the case. The KEPRO reviewer will then determine if the additional information provided during the conversation alleviates his/her previous concerns, related to the medical necessity of the admission or procedure. A determination will be put into the C3 system with the denial letter or authorization number. • Peer-to-Peer reviews will be completed within 72 hours of request. Please note that if KEPRO is unable to reach the attending physician within this timeframe, a reconsideration will need to be requested, if the facility would like to pursue further. • Please note that Peer-to-Peer reconsiderations are considered a Level 1. It is not a requirement that the Peer-to-Peer needs to be requested first. If a Reconsideration Level 2 is requested before the Peer-to-Peer you cannot go back to the Peer-to-Peer Level 1 if the denial is upheld for the Reconsideration Level 2.

40. Reconsideration Level 2 Reconsideration reviews are requested in the C3 system. • Please attach additional information, or indicate that additional information is being faxed or mailed. • The provider may fax additional information and it will be attached to the record in C3 by KEPRO personnel. • It is important to know that if the provider chooses to mail or fax in medical records, it may delay the response as it will take more time for KEPRO staff to scan and attach it in the C3 system. • The most pertinent information to include is: • H&P, labs, D/C summary, Operative reports, diagnostic studies, & MAR. • When faxing additional information, the KEPRO fax coversheet must be used and completed in its entirety. If for any reason additional information must be mailed a cover letter indicating the Authorization request ID, Request for Reconsideration, and information indicating why the provider believes medical necessity is met should be included. • KEPRO has 14 calendar days to complete reconsideration requests. • Reconsiderations must be requested and submitted with all pertinent documentation by the provider within 60 calendar days from the member/provider notification of the service denial.

41. Notification of Determination • Denial and Reconsideration determination letters for Providers and Members are attached to the C3 record within 1 business day of the decision and are NOT mailed to providers. • KEPRO attaches the letters for the providers and members on the Summary and Submit screen in the last annotations box. • The user who created the request will also receive a copy of the Denial/Reconsideration letter in C3. This can be viewed by going to My Inbox. • KEPRO will mail a copy of the Denial/Reconsideration to the member via USPS.

42. Notification of Determination

43. Copy for Correction A copy for correction is a request to change or correct services previously authorized. Most corrections are: • To add services that were mistakenly left off the original request; • Request additional services that were performed along with already approved services; • Servicing provider changes; • For other permitted changes to an original request. There are some items that cannot be corrected using this feature. For example, if the previous authorization was for Inpatient, a copy for correction cannot be performed to change service to Outpatient.

44. Copy for New Submission A copy for New Submission is also requested when a copy for correction cannot be completed due to: • Closure of a previous authorization request and/or • Request is stuck in saved mode and won’t submit. • This feature also saves time and allows the provider to copy and edit a previous request to obtain authorization for a new service or a new authorization for continuation of an existing service.

45. Training and Technical Assistance • We offer training via webinar, phone, and various materials. • These are offered to make submitting online for Prior Authorization an easier process for providers. • There are also annual reviews/trainings available to providers. • Provider training is also offered for various provider groups. • Each PowerPoint presentation from the provider trainings are posted to the http://www.wvaso.kepro.com in the Manuals and Reference Materials section of our website.

46. All Trainings Available Before Transition • For WVCHIP ONLY (NEW) providers: • 6/18/2019 9AM-12PM • 6/20/2019 1PM-4PM • 6/26/2019 9AM-12PM • 6/27/2019 1PM-4PM • For Medicaid enrolled providers who are ALSO WVCHIP (EXISTING) providers: • 6/18/2019 2PM-3:30PM • 6/20/2019 9AM-10:30AM • 6/26/2019 2PM-3:30PM • 6/27/2019 9AM-10:30AM

47. New WVCHIP PA Contact Information Prior Authorization Request Fax Numbers (WVCHIP fax forms indicate the appropriate fax number) • 844.633.8426 - Bariatric/Inpatient/Inpatient Rehab Under 21/ Organ Transplants • 844.633.8427 - Outpatient Surgery • 844.633.8428 - Imaging/Radiology/Lab • 844.633.8429 - Cardiac & Pulmonary Rehab/DME/Orthotics & Prosthetics • 844.633.8430 - Home Health/Hospice/Private Duty Nursing • 844.633.8431 - Audiology/Speech/Chiropractic/ Dental/Orthodontic/Podiatry/PT/OT/ Vision • 866.209.9632 - Modification Requests/EPSDT/ Out of Network WVCHIP Phone: 1-888-571-0262 WVCHIP Fax: 1-866-438-1360 WVCHIP Email: WVCHIP@KEPRO.COM

48. KEPRO WVCHIP PA Contact Information