Post-Acute Care Utilization Management Program

© 2018 eviCore healthcare. All Rights Reserved. This presentation contains CONFIDENTIAL and PROPRIETARY information.

Post-Acute Care Utilization Management Program for Blue Cross and Blue Shield of Minnesota

Facility Presentation

Provider Orientation

Agenda

eviCore healthcare Corporate Overview

Post-Acute Care Program Overview

Post-Acute Care Prior Authorization Requirements

Home Health Prior Authorization Process & Required

Information

Transitional Care Program Overview

Denial and Appeals Process

Prior Authorization Submission

eviCore healthcare Provider Resources

Q & A Session

Corporate Overview

© eviCore healthcare. All Rights Reserved.

This presentation contains CONFIDENTIAL and PROPRIETARY information.

Comprehensive

Solutions9The industry’s most

comprehensive clinical

evidence-based guidelines

4k+ employees including

1k clinicians

Engaging with 570k+ providers

Advanced, innovative, and

intelligent technology

100M Members

Managed

Nationwide

4

Headquartered in Bluffton, SC

Offices across the US including:

• Melbourne, FL

• Plainville, CT

• Sacramento, CA

• Lexington, MA

• Colorado Springs, CO

• Franklin, TN

• New York, NY

Post-Acute Care Program Overview

6

eviCore healthcare Prior Authorization for Blue Cross Members

Overview

eviCore healthcare (eviCore) will manage Prior Authorization requests for Post-Acute Care (PAC) and

Home Health Care (HHC) services on December 28, 2018 for dates of service beginning January 1,

2019 for Blue Cross and Blue Shield of Minnesota (Blue Cross) Medicare Advantage members. This

will include the following PAC Provider types:

Skilled Nursing Facilities (SNF)

Inpatient Rehabilitation Facilities (IRF)

Long Term Acute Care Facilities (LTAC)

Home Health Care Agencies (HHC)

Durable Medical Equipment (DME)

Effective January 1, 2019:

• Hospitals are responsible to submit the initial Post-Acute Care Prior Authorization requests directly to

eviCore for members being discharged to a SNF, IRF or LTAC.

• PAC Facilities (SNF, IRF and LTAC) will be responsible to submit concurrent Prior Authorization

requests to eviCore on all initial approved requests and for all existing PAC admissions.

• eviCore will accept initial Home Health Prior Authorization requests directly from either Home Health

Agencies, Hospitals or from Post-Acute Care facilities for members discharging from PAC facilities.

Providers should verify member eligibility and benefits on the secured provider

log in section at: www.availity.com

http://www.availity.com/

7

Review of Prior Authorization Requests Submission

Responsibilities

Prior Authorization

ResponsibilityComments

Hospitals

• Responsible for submitting the initial Post-Acute Care Prior Authorization

requests for PAC facility services to eviCore via the eviCore portal through

Availity, by Fax or by Phone

Post-Acute Care Facilities

• Responsible for submitting concurrent Prior Authorization requests for

PAC facility services via the eviCore portal through Availity, by Fax or by

Phone

• Responsible for submitting the initial Prior Authorization requests for

members admitting from the community via the eviCore portal through

Availity, by Fax or by Phone

• Responsible to verify SNF days used on CMS website for Medicare

Members

Home Health Care Agencies

• Responsible for submitting initial HHC Prior Authorization requests to

eviCore for members discharging directly from the hospital or for members

with a new community referral from a physician or treating practitioner via

the eviCore portal through Availity, by Fax or by Phone

• Responsible for submitting concurrent Prior Authorization requests for

HHC services via the eviCore portal through Availity, by Fax or by Phone

Hospitals, Post-Acute Care

Facilities or

Home Health Care Agencies

• The initial HHC Prior Authorization request for patients discharging from a

PAC facility may be submitted by either the admitting HHC Agency,

discharging Hospital or PAC facility via the eviCore portal through Availity,

by Fax or by Phone

Rationale for Hospital Submission PAC PA Requests

8

• Medicare PAC Guidance:

• Medicare’s position on PAC placement provides guidance for the least

intensive setting to adequately meet the patient’s need

• Appropriate Level of Care Determination:

• Hospitals present the most accurate clinical status for discharging patients

• Engagement with discharge planners to determine appropriate level based

on medical necessity

• Patient-Centered alternative PAC setting recommendations

• Coordinated Post Acute Care Placement:

• Proactively identify facility for optimal outcomes and patient experience

• Early initiation of plan of care with goals and risk assessment by eviCore

staff members

• Offer social work coordination to address discharge barriers

9

Initial Post-Acute Care Admission Requests

Prior- Authorization Process Overview

• Hospitals are responsible to submit the initial Post-Acute Care Prior Authorization requests

directly to eviCore for members being discharged to a SNF, IRF or LTAC, unless the Post-

Acute Care facility (i.e. IRF) has the same NPI or Tax ID number as the hospital.

• eviCore recommends that the hospital starts the process as soon as possible to facilitate a

timely Prior Authorization determination.

Discharge Planning

• Begins on day 1 of Hospital admission

Contact eviCore

• Provide Prior Authorization form and clinical information to support medical necessity

Utilization Management

• Four outcomes:

• Approved; expires after 7 days to allow patient transfer to PAC facility

• Request for additional clinical information

• Unable to approve

• Alternative recommendation

Determinations will be made within 1 business day, once clinical

information is received. An additional 2 business days is allowed if a

clinical consultation is requested. Urgent requests will have an

expedited review timeline and determinations will be based on

submitted medical information. eviCore will complete urgent reviews

within 72 hours.

Providers can obtain eviCore PAC forms through www.bluecrossmn.com from the provider tab to eviCore program

information. Post-Acute care Prior Authorization forms are also available on our implementation web site:

www.evicore.com/healthplan/bluecrossmn

http://www.bluecrossmn.com/

http://www.evicore.com/healthplan/bluecrossmn

10

Date Extension (PAC concurrent review) Requests

Post-Acute Facility (SNF/LTAC/IRF) Process Overview

The PAC facility is responsible to submit date extension (concurrent review) requests:

• eviCore requests that the date extension review request is submitted 72 hours prior to last

covered day to facilitate a timely “extension of Prior Authorization” determination

Plan of Care & Discharge

Planning

• Begins on day 1 of Post-Acute Care admission

Contact eviCore

• Provide Prior Authorization form and clinical information to support medical necessity


• Three outcomes:

• Approval


• Unable to extend authorization

Determinations will be made within 1 business day, once

clinical information is received. Add an additional 2

business days if a clinical consultation is requested,

however our typical response time is less.

Important: SNF Facilities should submit clinical for date extension (PAC concurrent review) Prior Authorization

requests 72 hours prior to the last covered day to allow time for Notice of Medicare Non-Coverage (NOMNC)

to be issued. eviCore will issue the NOMNC form to the provider. The provider is responsible to issue the

NOMNC to the member, have it signed and returned to eviCore

11

Post-Acute Care Facility (SNF/LTAC/IRF) Prior Authorization Overview

eviCore will provide Prior Authorizations by facility type in the following ways:

Prior Authorization Expiration

• The initial Prior Authorization is valid for 7 days to allow early initiation of hospital

discharge planning and reduce LOS

• If the patient is not discharged to a PAC facility within this time frame, a new Prior

Authorization is required

Once Determination is Complete:

• A notification will be communicated to the requesting facility

• Servicing facilities may obtain PAC Prior Authorizations details via

www.availity.com or by calling eviCore at 844-224-0494

Post-Acute Care Prior Authorization Criteria includes, but not limited to:

• McKesson InterQual® Criteria

• Medicare Benefit Policy Manuals and Clinical Findings

Prior Authorization Skilled Nursing Facility Inpatient Rehab Facility Long Term Acute Care

Initial 3 business days 5 calendar days 5 calendar days

Concurrent 7 calendar days 7 calendar days 7 calendar days

eviCore healthcare

Inpatient Post-Acute Care

Prior Authorization

Required Information

13

Required Information for Initial Post-Acute Care Prior Authorization

Submitted by Hospitals

Admission Details

• Facility type being requested

• Accepting Facility demographics

• Patient demographics

• Anticipated date of discharge

Clinical Information

• Hospital admitting diagnosis

• History & Physical

• Progress Notes, i.e. Attending physician, Consults & Surgical (if applicable)

• Medication list

• Wound or Incision/location and stage (if applicable)

Mobility and Functional status

• Prior and Current level of functioning

• Therapy evaluations PT/OT/ST

• Therapy progress notes including level of participation

Please note: eviCore Prior Authorization form and supporting

clinical documentation is required for all Post-Acute Care requests

14

Required Information for Date Extensions

(PAC concurrent review requests)

Prior Authorization

Details

• Facility type and demographics


• Number of days and dates requested


• Hospital admitting diagnosis and ICD10 code

• Clinical Progress Notes

• Medication list


Mobility and Functional

Status


• Focused therapy goals: PT/OT/ST


• Discharge plans (include discharge barriers, if applicable)

Please note: eviCore Prior Authorization form and supporting

clinical documentation is required for all Post-Acute Care requests

Home Health Prior Authorization

Process and Required Information

16

Home Health Initial Requests Overview

• The HHC agency is responsible to submit initial Prior Authorization requests for Home Health

Care services for patients discharging from the hospital or for members with a new

community referral.

• The initial HHC Prior Authorization request for patients discharging from a PAC facility may

be submitted by either the admitting HHC Agency or discharging PAC facility.

• Please clearly state on the Prior Authorization form if the patient is being admitted from a

Hospital, PAC facility or from a community referral to ensure members are transitioned to the

Transitional Care Program, when applicable.

Plan of Care & Discharge Planning

• eviCore will provide transitional care support for all Blue Cross members 90 days post hospitaldischarge

Contact eviCore

• Provide Home Health Prior Authorization form and clinical documentation to support medical necessity


• Three Outcomes:

• Approval


• Unable to authorize

Plan to receive a Prior Authorization notification for initial

and continued stay requests within one business day, once

clinical information is received

Important: Please ensure we receive an Ordering Physician for all initial requests with phone/fax numbers for

notification purposes. eviCore recommends that ALL home health disciplines be requested at the same time.

Individual requests for each discipline may cause a delay in authorization determinations.

17

Date extension (Home Health Concurrent review) Requests

Process Overview

• The Home Health Agency is responsible to submit date extension (concurrent review) requests.

• eviCore requests that the date extension review request is submitted 72 hours prior to last.

covered day to facilitate a timely “extension of Prior Authorization” determination

• eviCore recommends that ALL home health disciplines be requested at the same time.

Individual requests for each discipline may cause a delay in authorization determinations.

Plan of Care & Discharge Planning

• Begins on day 1 of Home Health Care admission

Contact eviCore

• Provide Home Health Prior Authorization form and clinical documentation to support medical necessity


• Three outcomes:

• Approval


• Unable to extend

Plan to receive a Prior Authorization notification for

continued stay requests within one business day, once

clinical information is received

Important: HHC agencies should submit clinical for date extension (HHA concurrent review) Prior

Authorization requests 72 hours prior to the last covered day to allow time for Notice of Medicare Non-

Coverage (NOMNC) to be issued. eviCore will issue the NOMNC form to the provider. The provider is

responsible to issue the NOMNC to the member, have it signed and returned to eviCore

18

Home Health Care Prior Authorization Overview

eviCore will provide Prior Authorizations by service type in the following ways:

Home Health Prior Authorization Expiration

• The initial Prior Authorization expires 7 days from the date of issue

• If the patient is not discharged within this time frame, a new Prior Authorization is required

Once Determination is Complete:

• A verbal and written notification will be provided to the requesting provider

• Servicing providers may obtain information on authorizations that have been approved

by calling eviCore at: 844-224-0494 (options 1, 8, 1, 1) for Home Health inquiries

Home Health Care Prior Authorization Criteria includes, but not limited to:

• McKesson InterQual® Criteria

• Medicare Benefit Policy Manual

• Other Evidence-Based Tools along with Clinical Findings

Prior Authorization Skilled Nursing, PT Home Health Aide Social Worker, OT, ST

InitialUp to 4 visits in 30

days

Up to 40 hours in 30

days

Approvals based on medical

necessity

Concurrent

(# of visits approved based on medical

necessity)

14 calendar daysUp to 40 hours in 14

calendar days14 calendar days

19

Required Information for Home Health Requests

Prior Authorization

Details

• Site of Care demographics


• Services requested (Skilled Nursing/OT/PT/Home Health Aide)

• Home Health ordering physician demographics

• Anticipated date of discharge


• PAC admitting diagnosis and ICD10 code

• Clinical Progress Notes

• Medication list


• Discharge summary (when available)

Mobility and Functional status


• Focused therapy goals: PT/OT


• Discharge plans (include discharge barriers, if applicable)

Once the patient is discharged from the HHC agency, the PCP will be notified by

eviCore. Patients utilizing HHC services following a hospitalization will be managed by

eviCore’s Transitional Care Program for 90 days post hospital discharge.

21

Transitional Care Program Offering


• eviCore’s Transitional Care Program follows the patient through the care continuum

to ensure timely interventions aimed at reducing readmissions. Upon discharge

from the hospital, eviCore will follow patients for a 90 day period via telephone

outreach. The frequency of patient contact will be based on nursing clinical

judgment and clinical disease state as captured through the risk assessment scale

of 0-100. Patients will have direct access to their transitional care nurse throughout

the 90 day period. Below is a description of the risk score intervention model that

eviCore utilizes in the transitional care program.

Key Program Objectives

• Patient centric care plans: transitional care nurses coach patients to create care

plans that meet their needs. The care plan follows the patient from the skilled

nursing facility to home.

• Readmission avoidance by engaging with patients via informative telephonic

sessions

• Connect Patients with Primary Care Physicians when necessary

• Provide short term targeted transitional coaching based on disease specific health

needs and eviCore risk assessment stratification

• Transitional Care nurse will discuss medication reconciliation with members

22

Transitional Care Program Offering

Patient Outreach Guidelines determined by eviCore Risk Scores

HIGH RISK CATEGORY

• High Acuity: First call conducted within 48 Hours of discharge to collect information

pertaining to patient status. Additional eviCore Nurse call within the following 24 hours.

Arrange Social Work support or local Primary Care Physician follow-up visits as

necessary.

• Nurse will schedule follow-up calls on a graduated rate from week 1 – 90 days

• Nurse will initiate at least three calls for the first month following discharge

MODERATE RISK CATEGORY

• Moderate Acuity: First call conducted within 48 Hours of discharge to

collect information, with follow-up call within the first seven days of

discharge.

• eviCore nurse will follow-up with patient on based on patient needs from

week 1 through the end of transitional care period with coordinated

support as necessary

LOW RISK CATEGORY

• Low Acuity: First call conducted within 48 Hours of discharge

• Nurse will follow-up with patient weekly for the first two weeks and

then develop a graduated approach for the remainder of the

program

eviCore healthcare Post-Acute Care


24

Unable to Provide Prior Authorization for Initial PAC Requests

Denial • Appeals Process

eviCore Process• Cases that do not meet Medical Necessity on Initial utilization management nurse review will be sent to

second level physician for review and determination.

• If potential adverse determination is made by an eviCore physician, outreach is made to the requesting

facility and a clinical consultation is offered to the requesting facility.

Initial Prior Authorization

Request

• Clinical consultations must be requested within1 business day, or additional clinical information

that supports medical necessity must be received within 1 business day, or the determination is

final and the case will be closed.

• Note: The clinical consultation must occur within 1 business day or a denial letter will be issued.

Request Denial• If the clinical consultations does not result in a reversal of the recommendation of denial,

eviCore will issue a denial letter. The physician reviewer may suggest an alternative level of

care and / or the appeals process.

Appeals Process

• Once a service has been denied, members and providers must file an appeal to have the

request re-reviewed. Requests for appeals may be submitted to eviCore using the process

outlined on the denial notification.

• 1st level appeal recommendations: eviCore will intake the appeal, acknowledge the appeal,

review the case and provide Blue Cross with our expert review. Blue Cross will make the final

determination and send out the appeal notification. Appeal requests may be submitted to

eviCore via phone at 844-224-0494 (Monday through Friday 7-5 CST) or fax to 866-699-8128.

The turnaround time after an Appeal has been requested by the member is up to 72 hours for an expedited appeal and

up to 30 days for a standard appeal. Medicare members have up to 60 calendar days to file an appeal.

25

Unable to Extend PAC Authorization • NOMNC • Appeals Process

eviCore Process• Cases that do not meet Medical Necessity on concurrent nurse review will be sent to 2nd level

physician for review and determination.

• If a potential adverse determination is made by physician, outreach is made to the PAC provider and a

clinical consultation may be requested by the provider.

Long Term Acute Care

(LTAC) & Inpatient

Rehabilitation Facility (IRF)

Date Extensions

• Clinical consultations must be requested within 1 business day, or additional clinical information that

supports medical necessity must be received within 1 business day, or the determination is final and

the case will be closed.

• Note: If the clinical consultation does not occur within 2 business days, or if the decision is upheld,

the third calendar day will not be covered unless the member appeals and the decision is

overturned.

SNF Date Extensions

(Concurrent review

requests)

• The Notice of Medicare Non-Coverage (NOMNC) will be issued no later than 2 calendar days prior

to the discontinuation of coverage. The third calendar day will not be covered unless the decision is

overturned or the NONMC is withdrawn

• A clinical consultation must be requested and occur within the 2 calendar day timeframe.

• If a clinical consultations does not occur, or if the decision is upheld, the member is responsible to

pay for the continued stay if they choose not to discharge on the 3rd calendar day.

Member Appeals Process

• Medicare Members requesting to appeal the decision to end skilled care in an IRF or LTAC facility

should contact eviCore via phone at 844-224-0494 (Monday through Friday 7-5 CST) or fax to 866-

699-8128.

• Medicare Members requesting to appeal the decision to end skilled care in a SNF facility should

follow the Quality Improvement Organization (QIO) process as outlined on the NOMNC.

eviCore healthcare Home Health Care


27

Unable to Provide Prior Authorization of HHC Requests

Denial • Appeals Process

• Initial Prior Authorization requests that do not meet Medical Necessity on Initial Nurse review will be sent to 2nd level

physician for review and determination. If potential adverse determination is made by the physician, outreach is made

to the requesting provider and a Clinical Consultation Review may be requested

• Date extensions requests that do not meet Medical Necessity on concurrent nurse review will be sent to 2nd level

physician for review and determination, if the provider or attending HHC Physician are in disagreement with the

decision to end skilled care. If a potential adverse determination is made by the physician, outreach is made to the

HHC provider and a Clinical Consultation review may be requested

Home Health Care

(Initial request)

• Clinical Consultation must be requested within 1 business day, or additional clinical information that

supports medical necessity must be received within 1 business day, or the determination is final

and the case will be closed

• Note: Clinical Consultation must occur within 1 business day or a denial letter will be issued.

Home Health Care

(NOMNC)

• The Notice of Medicare Non-Coverage (NOMNC) will be issued no later than 2 calendar days prior

to the discontinuation of coverage or the second to last day of service, if care is not being provided

daily. The following calendar day after services end will not be covered unless the decision is

overturned or the NOMNC is withdrawn.

Member Appeals Process

(Initial and Date

extensions)

• Members requesting to appeal a denial for Initial HHC services should follow the instructions

provided on the denial letter.

• 1st level Initial appeal recommendations: eviCore will intake the Appeal, Acknowledge the

Appeal, review the case and provide Blue Cross with our expert review. Blue Cross will make the

final determination and send out the appeal notification. Appeal requests may be submitted to

eviCore via phone at 844-224-0494 (Monday through Friday 7-5 CST) or fax to 866-699-8128.

• Date Extensions: Medicare Members requesting to appeal the decision to end skilled care by an

HHC agency should follow the Quality Improvement Organization (QIO) process as outlined on the

NOMNC.

eviCore healthcare

Prior Authorization Submission Methods

Authorization

Call Center

What we need

Prior Authorization Requests Methods

and Hours of OperationeviCore offers three methods to request Prior Authorizations:

1. eviCore Post-Acute Care Web Portal (preferred method):

www.availity.com

Single sign on process for Blue Cross Blue Shield of Minnesota

providers

2. Fax: Clinical documentation can be faxed to:

888-738-3916 (PAC)

866-506-3087 (HH)

Please send information for one patient per fax.

3. Telephone: Clinical information can be called to eviCore healthcare at

844-224-0494; options 1, 8, 1, 2 for PAC services; options 1, 8, 1, 1 for

Home Health - then follow appropriate prompts based on inquiry

Note: The Program will accept urgent requests by telephone and fax. Urgent requests

submitted via fax require the requestor to contact eviCore healthcare by telephone to ensure

the request can be placed in an urgent/expedited queue.

29

Hours of Operation Monday through Friday: 7am to 6pm CST

Saturday: 8am – 4pm CSTSundays and Holidays: 8am – 1pm CST

24 HOUR on-call coverage for urgent needs


eviCore healthcare

Provider Resources

Provider Resources

eviCore Provider Resources and Contact Information

31

Provider Services

Department:

eviCore Provider Customer Service Number: 844-224-0494

Choose the following prompts below to reach the appropriate area:

Post-Acute Care: Options 1, 8, 1, 2

Home Health Care: Options 1, 8, 1, 1

Program Inquires Prompt Menu:

• If you know your parties’ extension, option 1

• For status on an existing request, option 2

• If you are calling for a new Prior Authorization, option 3

• If you are calling for a concurrent review, option 4

• If you are calling for a clinical consultation, option 5

• To request an appeal, option 6

• For all other inquiries, option 7

• To repeat these options, option 9

eviCore Client Services, call (800) 575-4517 (Option #3) or email

[email protected] for general inquiries such as:

• Eligibility issues (member, rendering facility and or ordering physician)

• Issues during case creation

• Request for an authorization to be resent to health plan

mailto:[email protected]

Provider

Resources

eviCore healthcare Post-Acute Care

Provider Resources Implementation Site

32

Provider Services

Department

For more information regarding the eviCore utilization management

programs and reference documents, please visit our implementation

site:

www.evicore.com/healthplan/bluecrossmn

Below are provider resources being developed on our implementation

site via link listed above.

• Webinar training schedules with details on how to register

• Prior Authorization Forms

• Quick reference guide (QRG)

• Frequently asked questions (FAQ) document

• Training documents and program presentations

• Recorded demo of the orientation training sessions

Skilled Nursing Facility Clinical Capability Survey

http://survey.constantcontact.com/survey/a07efq32e9ajmj7hx2i/start

The implementation site includes a link to complete our SNF Clinical

Capability Survey. The Provider Survey is designed by eviCore to obtain

information about the clinical capabilities available at your facility.


http://survey.constantcontact.com/survey/a07efq32e9ajmj7hx2i/start

Web-Based

Services

Prior Authorization

Status

eviCore Post-Acute Care Provider Platform

33

Use the single sign on process through www.availity.com. This is available

24/7 and the quickest way to create Prior Authorizations and check existing

case status.

The eviCore PAC Platform allows providers to:

• Initiate a Prior Authorization request

• Submit clinical for concurrent stay Prior Authorization requests

• Access a User Specific Dashboard to:

• View and manage all pending and recently submitted cases on the same

page

• View and print real-time letter determinations for each case

• Export and print all authorization documents

• View multiple cases for providers registered with affiliated Tax ID numbers

Training Support can be obtained through www.bluecrossmn.com

Access the PAC implementation site:

www.evicore.com/healthplan/bluecrossmn for the following:

• Live Webinar Portal Training Schedule with details on how to register

• Recorded demo of the eviCore PAC platform education session

• PowerPoint presentation with step by step instructions on how to register and

navigate the platform


http://www.bluecrossmn.com/



34

• Provide user email to receive a

verification code

• Once user verification is

complete, enter the code and

provider demographics

• Code can be shared with all other

facility users

• Account registration is required for first time users. This may be completed by

logging into the eviCore healthcare platform through www.Availity.com



35

• Online access to:• Request an Authorization by providing all case

details:

• Member demographics

• Diagnosis

• Service Type

• Requesting provider

• Servicing provider

• Facility contact

• Attach clinical information

• Search Cases

• Search all cases for patients in the facility

• Access the dashboard with Prior Authorization

details

• Dashboard provides:

• Real time status

• Authorization details including authorization

number and dates for approved cases

• Notations if additional information is needed

• Access to all communication letters

eviCore Platform Services - Assistance

36

Cick online chatFor Portal Account Questions - Contact a

Web Support Specialist

Call: (800)646-0418 (Option 2)

Email: [email protected]

Web Portal Services-Available M-F 7am-6pm CST

Thank You

Post-Acute Care Utilization Management Program

Documents

Transcript of Post-Acute Care Utilization Management Program