Health First Colorado Utilization Review

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Durable Medical Equipment

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

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

• Long Term Support Services

• PASRR

• Pediatric Long-Term Home Health

• Private Duty Nursing

• Out of State Non-emergency Inpatient

Stays

• Audiology

• Synagis®

• Vision

eQHealth Solutions Provides:

� 24-hour access for Utilization Review submissions

� Provider Communication and Support

� Provider Education and Outreach

� Comprehensive Utilization Management Program

� Prior Authorization Review (PAR)

� Retrospective Review

� PAR Reconsiderations & Peer-To-Peer Reviews

� PAR Revisions

� Real time access to provider reports

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Colorado Medicaid Rule 8.590.2.A(DME ONLY)

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Colorado Medicaid rule 10 CCR 2505-10, Section 8.590.2.A. under

states that, “DME, Supplies and Prosthetic or Orthotic Devices are a

benefit when Medically Necessary.”

•The item must be prescribed by a physician and, when

applicable; be recommended by an appropriately licensed

practitioner.

•The item must be reasonable, appropriate and effective method

for meeting the client’s medical need.

•Have an expected use that is in accordance with current medical

standards or practices.

Connectivity 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 Started

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Getting StartedRequest for eQSuite® Users Form

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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

New Users:

You will need to complete and submit an access form.

You can locate this form on our website

www.coloradopar.com

(Once received and entered you will receive an

email confirmation with your username and

password)

System Administrator:

� The person assigned will be responsible keeping all

user accounts updated. (Email address/phone

numbers etc.)

� You will have the ability to create additional User

Accounts.

� Keeping all users informed of any updates or

notifications sent from eQHealth.

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eQSuite® Access

Getting StartedObtaining an Authorization

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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.

The Utilization Review Website

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The Utilization Review Website

Forms and Instructions

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PAR Submission

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PAR request Receipt Dates:

� On business days:

• From 12:00 a.m. – 5:00 p.m.(MST) - it is considered received

that day.

� On holidays - it is considered received on the next business day.

� On days following state approved closures, i.e., natural disasters

- it is considered received on the next business day.

eQSuite® Login

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Login from the Utilization Review home page

eQSuite® LoginUsername and Password

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eQSuite® Menu Options

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Editing and Adding Users

eQSuite® User Administration

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New UserTrainer

eQSuite® Update my Profile

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NewUserTrainer

NewUser

Trainer

Creating a New Review

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Create New ReviewMenu Options

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Creating a New Review Provider Information & Recipient Information

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Test Provider

Test Provider

Creating a New ReviewPhysician Information

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Ordering Physician Information

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Type of Request: Urgent v. Non-Urgent

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Creating a New ReviewCheck Key

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Creating a New ReviewStart Tab

• Checking Errors

Creating a New ReviewDX and Procedure Codes

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Creating a New ReviewDX Codes

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Creating a New ReviewProcedure Codes- DME Example

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Miscellaneous Item Code

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After Submission

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Once you click submit for review

you will be assigned a Review ID.

You will then submit supporting

documentation by clicking Link

attachment.

Supporting Documentation

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Submitting Supporting Documentation

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It will be necessary to provide supporting documentation with authorization requests. We offer two methods of submitting the documentation:

You may:

• Upload and directly link the information to the eQSuite® review record.

• Or fax the documents using eQSuite®’s Principal Barcoded coversheet that is specific to that request and enables automatic linking to the correct record.

• Additional supporting documentation may be requested as needed to complete the review.

Do NOT copy or reuse fax cover sheets!

Supporting DocumentationExamples

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• Order / Prescription

• Physician visit notes

• Price Quote or Invoice (Details and Itemized)

• Other documentation including but not limited to: laboratory

tests, radiology studies, or any other pertinent medical

information to support the request

Supporting DocumentationLinking Attachments

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• Before proceeding, make sure that all requested documents are saved to your computer and available to upload in PDF, JPEG or TIF format.**

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Submitting Supporting DocumentationAttachments Tab

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eQSuite® “Attachments”

• The requestor will receive an email that the PAR is still Awaiting Required Attachments

• If the required attachment(s) is not received within 10 business days, you will receive a Lack of Information Denial, and either a new admission or a reconsideration request can be submitted.

• An algorithm driven review process to identify certain service requests that meet medical necessity criteria without further review.

• ALL applicable clinical questions must be answered.

• ALL documentation to support the review must STILL be uploaded even if an automatic approval occurs.

Benefits of the SMART review is that Providers may receive Immediate medical necessity approval!

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SMART Review Process

Submitting Supporting Documentation for the SMART Review Process

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Additional Documentation

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• Record status “Pended for Add’l Info” indicates that although you

have submitted a utilization review, either no documentation was

received at the time of submission or a nurse has reviewed the

request and needs additional documentation to make a medical

necessity determination.

• You will have 10 days (from the date the utilization review is set to

the status of “Pended for Add’l Info”) to upload the requested

documentation. If the requested documentation is not received

within the 10 business days, your request will receive a technical

denial and both you and the Member will receive a denial

notification.

Identifying What Additional Info is Needed

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You will receive email notification that your review has been

Pended For Add’l Info.

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 NeededViewing 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.

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

Clinical Review Determinations

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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.

Technical Denials for Lack of Information

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Prior Authorization Requests (PARs) submitted without requireddocumentation 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®

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If information is not received within 10 business days, the request will be denied due to lack of Information and the requestor must:

•Submit a new PAR request with the necessary information; OR

•Complete a reconsideration request and include the necessary information. This

request and the documentation must be submitted in eQSuite® or by fax within ten

(10) calendar days from the denial date.

• 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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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

from the date of the adverse determination.

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 for outpatient settings

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

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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. PAR Clinical documentation must be

attached/uploaded to this PAR to support medical necessity.

• 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.

eQSuite® Functions

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eQSuite® “Search”

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DMEtTrainer DMExxxxxx xxxxxxxx

eQSuite® Reports

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Checking the Status of a PAR

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eQSuite® “Letters Search”

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Client ID

Respond to Denial

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eQSuite® Online Helpline

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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 USCONTACT US

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Customer ServicePhone: 1-888-801-9355

(M-F, 8 a.m.-5 p.m., MST)

co.pr@eqhs.com

Or

Online Helpline via eQSuite®For more information please visit

www.coloradoPAR.com – Provider Resources

For HCPF Policy Questions

HCPF_UM@hcpf.state.co.us

Thank You!

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