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Health First Colorado
Utilization Review
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Pediatric Long-Term Home Health
Agenda
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• Overview of PAR process
• HealthFirst Colorado Rules
• eQSuite® Training
• 1st level and 2nd level determinations
• PAR numbers, PAR letters
• eQSuite® Reports
• Reconsideration and Peer-to-Peer Process
• Review Types
• Retroactive PARs
• PAR Revisions
Introduction to eQHealth Solutions
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• A non-profit population health management and technology
solutions company.
• Selected by the Colorado Department of Health Care Policy
and Financing to prior authorize services for Colorado Medicaid
clients effective September 1, 2015.
Current Scope of Services
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• Diagnostic Imaging
• Durable Medical Equipment
• Physical & Occupational Therapy
• Medical
Transplants
Surgical Procedures: such as Bariatric surgery
• Molecular Testing – BRCA1 and BRCA2
• Inpatient
• Pediatric Behavioral Therapy
• Speech Therapy
• Pediatric Long-Term Home Health
• Private Duty Nursing
• Out of State Non-emergency Inpatient
Stays
• Audiology
• Synagis®
• Vision
Home Health Services include:
• Skilled Nursing (provided by a Registered Nurse or Licensed Practical Nurse)
• Certified Nurse Aide (CNA) services (may also be referred to as a Certified Nursing Assistant or Home Health Aide)
• Physical Therapy (PT)
• Occupational Therapy (OT)
• Speech/Language Pathology (SLP) services (or Speech Therapy)
Types of home health services:
Acute Home Health: Skilled Home Health services provided to clients who experience an acute health care need that necessitates
skilled Home Health care.
Long-Term Home Health: Skilled Home Health services provided to clients who require ongoing Home Health services beyond the
Acute Home Health period. Prior authorization is required for Long-Term Home Health Services.
Please view the Long-Term Home Health billing manual found here: https://www.colorado.gov/pacific/sites/default/files/UB-
04%20Home%20Health%20Billing%20Manual%20052019.pdf
Pediatric Long-Term Home HealthHome Health Benefit for Colorado Medicaid Clients
Medicaid Clients:
• Require Home Health Services for the treatment or amelioration of an illness, injury, or disability, which may include mental illness;
• Are unable to perform the health care tasks for him or herself, and he or she has no Family Member/Caregiver who is willing and
able to perform the skilled tasks
• Require services that cannot appropriately or effectively be received in an outpatient treatment office or clinic or for which the
client’s residence is the most effective setting to accomplish the care required by the client’s medical condition; and
• The services meet medical necessity criteria and are provided in a manner consistent with professional practice.
Please view the Long-Term Home Health billing manual found here: https://www.colorado.gov/pacific/sites/default/files/UB-
04%20Home%20Health%20Billing%20Manual%20052019.pdf
Pediatric Long-Term Home Health
Colorado Medicaid Rule
8.076.1.8 (All Services Except DME)
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Medical necessity means a Medical Assistance program good
or service that will, or is reasonably expected to prevent,
diagnose, cure, correct, reduce, or ameliorate the pain and
suffering, or the physical, mental, cognitive, or
developmental effects of an illness, injury, or disability. It
may also include a course of treatment that includes mere
observation or no treatment at all.
Getting Started in eQSuite
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Getting StartedConnectivity to eQSuite®
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Minimal Computer System Requirements
❖ Any one of the following browsers (please note it must be one of the two most recent
versions):
Internet Explorer
Google Chrome
Mozilla Firefox
Safari
❖ Broadband internet connection
❖ If you already have access to eQSuite® and experience connectivity issues, clear your cache –
Visit www.refreshyourcache.com
Select the browser you are using and follow the steps to clear your cache.
http://www.coloradopar.com/ProviderResources/ITRequirements.aspx
Getting StartedConnectivity to eQSuite®
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1.Complete the “Request for eQSuite® Users Form”. You can locate
this form by clicking on the link below or by visiting our website
➢ Assign a System Administrator
➢ Sign and date
➢ Scan or fax
2. System Administrator
➢ Assign logons to staff
➢ Assign roles to staff based on job responsibilities
Getting StartedWhy PAR?
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• Obtaining an authorization number is required when the item or service
code requires an authorization and to verify whether the service
requires prior authorization here before submitting a Utilization Review
via eQSuite®.
• VERIFY the Client’s eligibility for CO Medicaid (by contacting Colorado
Medicaid)
• Reminder: Authorization does not guarantee Medicaid payment for
services.
Getting StartedAccess Form
Must be an Active Biller and Provider Type in DXC
You can select multiple
services; however, access will
only be granted to
corresponding provider types
in DXC
Administrator for PARs
Most Direct Line
Getting Started eQSuite® Login
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Getting StartedEditing and Adding Users
Adding Additional Users
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Getting Started
LTHH Trainer
Adding Additional Users
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Getting Started
Last Day Of Service
LTHH Trainer
Getting StartedeQSuite® Update my Profile
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LTHH Trainer
LTHHTrain
Creating a New Review
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Creating a New ReviewHome Screen
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Creating a New ReviewStart Tab
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1
2
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Creating a New ReviewBeneficiary Information
Step 1
Step 2
LTHH Provider
LTHH Provider
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Creating a New ReviewStart Tab
Creating a New ReviewCase Supervisor
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Step 3
xxxxxxxxxx
Creating a New Review
Check Key
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1
2
Creating a New Review• Checking Errors
Creating a New ReviewDX and Item Codes
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Click to
Start
Xxxx
Creating a New ReviewDX and Procedure Codes
Creating a New ReviewDX Codes
Return to Review
Add Additional DX Codes
Creating a New Review
Verifying DX Codes
Creating a New ReviewProcedure Codes
Creating a New ReviewVerifying DX and Procedure Codes
Creating a New ReviewAssessment
xxxx
Creating a New ReviewReceiving Additional Services
Creating a New ReviewPAT
Creating a New ReviewPAT - Calculate
Creating a New ReviewProvider Location Specific Information
Creating a New ReviewDischarge Plan
Creating a New ReviewMedication
To input meds
click here
Medications will be listed here
Creating a New ReviewMedication
Creating a New ReviewSubmit for Review
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Enter any additional information that is relevant to
consideration that is NOT included in the previous
tabs, or with the documentation you will be
adding.
Submission
After Submission
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Supporting Documentation
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Creating a New ReviewSupporting Documentation
REFER TO THE HCPF’S PROVIDER MANUAL FOR ITEM SPECIFIC INFORMATION
Pediatric Long-Term Home Health Supporting Documentation:
• An HCFA-485 or other Plan of Care document identical in content. A Plan of Care must include, at a
minimum, the following:
• Member’s diagnoses that will be addressed by Home Health, using V-codes whenever appropriate;
• The specific frequency and expected duration of the visits for each discipline ordered; and
• The duties/treatments/tasks to be performed by each discipline during each visit.
• All other supporting documentation to support your request including physician’s orders, treatment plans,
nursing summaries, nurse aide assignment sheets, medications listing, etc.; and
• Any other documentation deemed necessary by the Department or its authorizing agency. The plan of care
must be created by a registered nurse employed with the Home Health Agency or when appropriate by a
physical, occupational or speech therapist. The plan of care must be signed by the member’s attending
physician prior to submitting the final claim for a certification period.
Creating a New ReviewSupporting Documentation
• A PT, OT, or ST therapy evaluation and assessment completed by the appropriate therapist
• Current treatment plan including short term goals, long term goals and interventions (this
may also be provided on a form designed specifically for PT, OT, or ST therapy plans of
care)
• Complete physician’s orders including frequency of requested PT, OT, or therapy services
clearly stated in the physician’s order section of the form
• All other written Plan of Care requirements listed in the Code of Colorado Regulations for
Home Health
For additional Information on Health First Colorado plan of care requirements refer to the
Home Health Services Benefit Coverage Standard referenced in 10 C.C.R 2505-10 § 8.522 –
Covered Services
Creating a New ReviewLinking Supporting Documentation
xxxxx
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• After you click Link Attachment, the following box will open:
Review Process Supporting Documentation
Fax Cover Sheet
Supporting Documentation
xxxx
Review Process Uploading Documents
• Before proceeding, make sure that all requested documents are saved to your
computer and available to upload in PDF, JPEG or TIF format.**
Review Process
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First Level Clinical Review Determinations
First Level Clinical (Nurse) Reviewers may:
Approve the service as requested based on Department approved criteria.
Pend for Additional Information- when a PAR is pended back to the requesting provider for additional or clarifying information, the requesting provider will receive an eQSuite® email.
Refer the request to a physician reviewer for further review and determination (2nd level Clinical Review).
Deny the request for non-compliance with HCPF policy for Technical reasons, they can NOT deny for medical necessity.
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Second Level Clinical Review
Second Level Clinical (Physician) Reviewers may:
Approve the service(s) as requested.
Pend: the review for additional information
Request for a peer-to-peer consultation with the ordering Provider.
Render an adverse determination. An adverse determination may be a full or partial denial of the requested services or a reduction in services.
Intermediate Statuses
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The request is currently being reviewed by a first level clinical nurse reviewer.At Nurse Review
The request is currently being reviewed by a physician. At PR Review
If your request receives Pended For Add’l Info Status again, please review the steps listed above.
Pended for Add’lInfo
Review ProcessResponding to Additional Information
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If a PAR request is pended back to the requesting provider for additional or clarifying
information and the requesting provider will be immediately notified by receiving an
eQSuite® email/notification
A follow-up phone call will be made to the requester prior to the request being denied
based on lack of information.
The additional information must be received within ten business days
If the information is not received, the request will be denied for a Lack of Information
(LOI) and a new request must be submitted.
Locating What Additional Info is Needed
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To locate the information that is being requested
• Click on the Respond to Add’l info tab
• Select Cases Needing Add’l Info
• Locate your review.
• Scroll to the far right of the page and click on View Letter.
Identifying What Additional Info is Needed
Viewing Letters
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• A copy of the memo from the nurse will open which will state the
documentation that is being requested for this review.
• The following box will pop up and you should select View.
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• Click on the Respond to Add’l info tab and select
Cases Needing Add’l Info.
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• Locate your review. Click on open.
Responding to the Request
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• You may type your response in the additional info box or upload
additional documents
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If you have all the needed documentation ready to
upload, you may click on Submit Info.
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The following box will pop up and you should click Link Attachment.
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• After you click Link Attachment, the following box will open.
Viewing Supporting Documents
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You can verify that you have successfully uploaded or faxed the documentation
because this review will no longer be listed under the Respond to Addl info tab and
you will see the record status of this review change to “At Nurse Review.” You can
view the status of your request by clicking on the Attachments tab.
Review ProcessTechnical Denials for Lack of Information
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Prior Authorization Requests (PARs) submitted without required
documentation may result in a Technical Denial.
This occurs when:
• PARs are missing appropriate attachments or documentation. The PAR will have record Status
of “Awaiting Required Attachments”
• PARs are pended because they require additional information to make a medical necessity
determination. The review will be located under the Respond to Add’l info Tab in eQSuite®
• Once the required documentation has been received, your PAR as well as the documentation submitted will be reviewed. On average, it will take up to four (4) business days from the time your documentation is received to receive a determination.
Final Determinations:
• Approved: If your request is approved, your authorization number will be generated. You may log into eQSuite® or into the Colorado Medical Assistance Program Web Portal to view your authorization number.
• Partial or Full Medical Denial: If the request receives a medical denial, the provider and the member will receive a denial letter. If you disagree with this decision, you may request a reconsideration or schedule a peer to peer consultation. Please see the reconsideration and peer-to-peer provider guides located under the provider resources tab on the Colorado PAR website
• Technical Denial: If your request is technically denied, the provider and the member will receive a denial letter. If you disagree with this decision, you may request a reconsideration via fax or submit a new PAR through eQSuite®.
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What to Expect Next
PAR NumbersPrior Authorization Requests
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PAR Numbers
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eQHealth makes PAR determination
eQHealth transmits PAR determinations into
Medicaid Management Information System
(MMIS)
If the transmission into InterChange (IC) is
successful, a PAR number is generated, will be visible in eQSuite and determination letters
will be generated
If the information is verified in InterChange (IC), a final PAR Number will be assigned and can be found:
eQSuite®
eQHealth Solutions Customer Service
Colorado Medical Web Assistance Portal
Finding a PAR Number
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Viewing a PAR Number in eQSuite®
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xxxxxx
xxxxxx
xxxxxx
xxxxxx
xxxxxx
xxxxxx
PAR Reconsiderations
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PAR Reconsiderations
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Both the ordering and treating provider may submit a request for a PAR
reconsideration of an adverse determination within 10 calendar days.
PAR reconsideration requests may be submitted electronically (eQSuite®)
or by fax.
• eQHealth Solutions’ response time for Reconsiderations:
• Expedited - two business days
• Standard – ten business days
Peer to Peer
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Peer to Peer Process
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The Peer-to-Peer (P2P) process offers the ordering or
treating physician an opportunity to discuss a medical
necessity denial with an eQHealth physician reviewer prior to
initiating a request for reconsideration.
▪The ordering/treating physician’s office may request a P2P
▪The request must be submitted within five (5) calendar days from
the date of the medical necessity denial
▪Submit the request via the online helpline, by calling customer
service, or by fax
Follow instructions in the Peer-to-Peer Guide at www.ColoradoPAR.com
Change of Provider
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Change of ProviderForm Location
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If a change of provider is required after a PAR is completed, please assist the client in completing
the “Change of Provider Form”. This form is located on the www.ColoradoPAR.com website, under
the provider resource tab, forms and instructions.
Review Types
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Definitions of Review Types
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1. Admission (Initial PAR request) – Select this review type for a new/initial PAR
request.
Please note: Admission is the terminology in eQSuite® for a new/initial PAR request
and does not indicate a hospital inpatient admission. The review type “admission”
should be used for most PARs submitted through eQSuite®.
2. Cont Stay – Select this review type to extend the date span for any previously
requested services. (applicable to PDN, LTHH and Therapy PARs)
3. Modify Authorization (PAR Revision) – Select this review type when there is a
clinical need to increase or decrease units in a currently approved PAR or to add a new
service code within the same “from” and “thru” dates to an existing eQHealth PAR.
PAR Revisions
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PAR RevisionsModifications
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If a client’s needs change after a PAR review has been completed, you would
submit a Modify Authorization Review Request. Examples:
• To add a new procedure code on an existing PAR within the same date span
o Only enter the date span needed. Enter the new code needed. Codes
already reviewed do NOT need to be entered.
• To add units to a procedure code(s) on an existing PAR within the same
date span o Only enter the date span needed. Enter the code and
additional units needed. Units already reviewed do NOT need to be
entered.
• To change or add modifiers for a procedure code on existing PAR Clinical
documentation must be attached/uploaded to this PAR to support medical
necessity.
PAR RevisionsModification Request
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To enter a Modification Request,
click Create a New Review and then
select the admission type Modify Authorization. You
will then enter the PAR# of the original review and hit
Retrieve Data. You will then finish out request as
previously instructed.
PAR RevisionsContinued Stay Requests
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Select this review type to extend the date span for any
previously requested services. (applicable to PDN,
LTHH and Therapy PARs).
To enter a Continued Stay Request,
click Create a New Review and then
select the admission type continued stay. You will then
enter the PAR# of the original review and hit Retrieve
Data. You will then finish out request as we previously
shown when entering an Admission. A Continued Stay
Review will generate a different Review ID than the
initial authorization.
Managing Your Reviews
Managing Your ReviewseQSuite® “Search”
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PLTHH PlTHHxxxxx
eQSuite® “Letters Search”
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Managing Your Reviews
Managing Your Reviews eQSuite® Online Helpline
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eQSuite® Reports
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Checking the Status of a PAR
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Helpful Resources
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Helpful ResourcesColorado Department of Healthcare Policy and Financing
Helpful ResourcesColorado PAR Website
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Questions?
Contact Us
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Customer Service
Phone: 1-888-801-9355 (M-F, 8 a.m.-5 p.m., MST)
Or
Online Helpline via eQSuite®
For more information please visit
www.coloradoPAR.com – Provider Resources
Thank You!
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