Indiana Care Select ProgramPrior Authorization

Presented byADVANTAGE Health Solutions, Inc.

and MDwise, Inc.

Mitchell E. Daniels, Jr., GovernorState of Indiana

Indiana Family and Social Services Administration

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Today’s Agenda

• Prior Authorization (PA) Overview• What Requires PA and Supporting Documentation• Common Reasons for PA Suspensions or Denials• How to Complete the Indiana Prior Review and Authorization

Request Form• How to Complete the Indiana Dental Prior Review and

Authorization Request Form• How to Complete a PA Request Using Web interChange• Questions & Answers

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PA Overview

There are two Care Management Organizations (CMOs):– ADVANTAGE Health Solutions, Inc.sm

– MDwise, Inc.Note: ADVANTAGE adjudicates all Traditional Medicaid and

Medicaid Rehabilitation Option (MRO) PA requests

By contract, the CMOs are responsible for:• Processing PA requests• Making medical necessity determinations• Notifying providers and members of the determination• Basing PA decisions on OMPP approved guidelines

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PA Overview

PA decisions can be appealed by the member and/or provider• Follow IHCP guidelines – IHCP Provider Manual Ch. 6, Section 7

– PA decision letters are mailed to the provider and member• Provider letters sent to “mail to” address in IndianaAIM or PA request

form

Required forms located at www.indianamedicaid.com in forms• Indiana Prior Review and Authorization Request (IPRAR) Form

– Medical and Behavioral Health• Indiana Prior Review and Authorization Dental Request (IPRADR) Form• System Update Form

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What Requires PA?

Determine if a service or item requires PA in Traditional Medicaid and Care Select (CS):

• Use the IHCP fee schedule: www.indianamedicaid.com• More information found in the IHCP Provider Manual Ch. 6,

Indiana Administrative Code (IAC), bulletins, banner pages, and newsletters

Check PA status using PA inquiry function in Web interChange

Providers must submit PA request/supporting documentation via fax, web interChange, or mail

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PA must be submitted on the appropriate PA request form and be supported by appropriate medical necessity documentation:

• medical clearance form • treatment plan/plan of care• physician order • physician notes• Other documentation supporting medical necessity

Types of Supporting Documentation

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PA Suspension/Denial Reasons

Top 5 PA Suspension/Denial Reasons• Certificate of medical necessity missing/incomplete• Home health plan of care missing/incomplete• Incomplete PA form • Missing physician orders• Clinical documentation missing• Incorrect form submitted

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Helpful Hints to Get Started for all PA:• Always verify eligibility on PA submision date • Submit PA to the member’s health plan • PA decisions made within five (5) business days for CS and ten

(10) business days for FFS• Suspended PA requests must be completed within 30 days by

the provider• Fax the PA form along with supporting documents together • Web interChange allows providers to submit non-pharmacy

PA requests • Mail – Submit PA request form along with supporting

documents

How to Complete PA Forms

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How to Complete the Paper IPRAR Form

How to access the form•Go to www.indianamedicaid.com•Select Forms from the right side of the web page•Scroll down to Prior Authorization •Select either the Word version or Adobe Acrobat version of the Prior Review and Authorization Form or the PA System Update Form

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How to Complete the IPRAR Form

Note: Information found in the IHCP Provider Manual Ch 6, Section 2, p. 6-18

PA Form Field:• Requesting provider NPI

– Enter requesting or rendering provider’s National Provider Identifier (NPI)

• Phone – Enter the phone number of the requesting or rendering provider’s NPI

• Mail to Provider – Enter the address of the requesting or rendering provider

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How to Complete the IPRAR Form

• Mailing provider ID and Service Location – – If this field is completed and the address is valid, the mailing provider

ID and service location address receives the PA Decision Letter• Rendering provider NPI/Name, Address, City, State, and Zip

– Enter the information for the provider rendering the service• Managed Care Organization (MCO)/590/Fee-for-Service

(FFS)/Care Select (CS) – – Enter the program the member is eligible for on the date of service

• RID No/Date of Birth/Name, Address, City, State, and Zip – Enter the information for the member who receives the service

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How to Complete the IPRAR Form

• Medical Diagnosis – Enter the primary and secondary ICD-9-CM diagnosis codes for the

member receiving the service• Is this a request for a continuing service?

– Check “yes” if this is a continuing service request or “no” if this is not a continuing service request

Note: “Continuing Service” Defined as:• No break between two certification periods• (i.e. weekly or monthly)

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How to Complete the IPRAR Form

• Will DME be: Purchased/Rented/Repaired – Determine/Enter the transaction type and include any medical

clearance forms• Length of time DME required

– Regardless of transaction type, enter duration of need• Has Service or Medical Supply Previously been Provided? -

Enter “Yes”, Date, or “No”• Dates of Service Start – Enter requested start date• Dates of Service Stop – Enter requested stop date

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How to Complete the IPRAR Form

• Service Code – – Enter the requested code (i.e. CPTs, HCPCs, Revenue, or NDC…Please note

these codes are required and must be furnished by the service provider)• Modifier – Enter service modifier(s)

– Please note when required, these must be furnished by the service provider• Requested Services

– Enter a short description (or include an attachment) of the requested service• Taxonomy

– Enter any applicable taxonomy codes• Place of Service (POS)

– Enter the place of service (POS) where the service will be rendered (i.e. clinic, home, etc)

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How to Complete the IPRAR Form

• Units – Enter the number of units (i.e. days, months, or items depending on the

service request)• Dollars

– Enter the estimated or known IHCP cost of the item or service (Note: required for home health, DME, and pharmacy)

• Clinical Summary – Enter clinical information pertinent to the service being requested– Note: treatment plan and progress notes and the dates of service should

correspond to the treatment plan dates)• Signature of Requesting Provider

– Authorized provider must sign and date the form (signature stamps acceptable)

Note: Authorized provider can mean providers or authorized designees

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How to Complete the IPRAR Form

How to access the form•Go to www.indianamedicaid.com•Select Forms from the right side of the web page•Scroll down to Prior Authorization •Select either the Word version or Adobe Acrobat version of the Dental Prior Review and Authorization Form

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How to Complete the IPRADR Form

Note: Information found in the IHCP Provider Manual Ch 6, Section 2, p. 6-22

Dental PA Form Field:• Requesting provider NPI

– Enter requesting or rendering provider’s National Provider Identifier (NPI)

• Phone – Enter the phone number of the requesting or rendering provider’s NPI

• Mail to Provider– Enter the address of the requesting or rendering provider

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How to Complete the IPRADR Form

• Mailing provider ID and Service Location – Note: If this field is completed and the address is valid, the mailing

provider ID and service location address receives the PA Decision Letter• Managed Care Organization (MCO)/590/Fee-for-Service

(FFS)/Care Select (CS) – Enter the program the member is eligible for on the date of service

• RID No/Date of Birth/Name, Address, City, State, and Zip – Enter the information requested for the member to receive the service

• Date of Service (Start) – Enter the requested start date for the service (Note: continued service

requests require a start date AFTER the previous PA’s end date)

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How to Complete the IPRADR Form

• Date of Service (Stop) – Enter the service stop date

• Service Code – – Enter the requested service code(s)

• Requested Service – – Enter a short description of the service

• Place of Service – Enter the location where the service will occur

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How to Complete the IPRADR Form

• Units – Enter the number of desired units

• Dollars– Enter the estimated or known IHCP cost of the service (optional)

• Caseworker– Enter the member’s caseworker and phone number

• MCO/590/FFS/CS/MS – Check member program

• Is the member employed?

– Check either YES or NO

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How to Complete the IPRADR Form

• Circumstances (Place/Type) – Enter employment information, if applicable

• Is member in Job Training? – Check either Yes or No

• Type of Job Training – – Type training information, if applicable

Dental Treatment Plan• Does the member have missing teeth?

– Check either Yes or No. If yes, indicate missing teeth with “X” on diagram • Endodontics –

– Enter which tooth or teeth to be treated– Root canal therapy (1-32)

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How to Complete the IPRADR Form

Periodontics – Briefly summarize the member’s periodontal condition

Partial Dentures • Date or dates of extractions of missing teeth, • tooth or teeth to be extracted (tooth #),• Tooth or teeth to be replaced (tooth #)• Description of materials and design of partial• Is member wearing partials now • age of current partial

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How to Complete the IPRADR Form

• Describe treatment if different from above – – Enter description of any treatment not previously listed on this form

• Is the member on any parenteral or enteral nutritional supplements?

– Check Yes or No– If yes, include treatment plan to wean member from nutritional

supplements• Brief dental/medical history – Enter relevant information

about member’s medical and dental history

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How to Complete the IPRADR Form

• Signature of Requesting Dentist – – The authorized provider must sign and date the form (Note: Signature

stamps are allowed)• Date of Submission –

– Enter the date of actual submission to the member’s health plan

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Prior Authorization

– ADVANTAGE Health Solutions, Inc.sm

• www.advantageplan.com/advcareselect• 1-800-784-3981 – Care Select PA• 1-800-269-5720 – Traditional PA

– ADVANTAGE was selected to function as the Traditional Medicaid fee – for–service and MRO Transformation PA administrator.

– MDwise, Inc.• www.mdwise.org• 1-800-356-1204 – Care Select PA

– Note: All PA for prescription drugs are processed and adjudicated by ACS and not the CMOs

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Web interChangePresented by HP

The following provider types can submit PA requests via Web interChange:• Chiropractor• Dentist• Doctor of Medicine• Doctor of Osteopathy• Home Health Agency (authorized agent)• Hospice• Hospitals• Optometrist• Podiatrist• Psychologist endorsed as a Health Service Practitioner in Psychology

(HSPP)• Transportation providers

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Q&A

Thank you for attending!