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INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT

South Carolina KePRO QIO Request Submission Requirements

New 6/14/20121TopicsService Type(s)KePRO SCDHHS WebsiteService Type RequirementsContact Information

2Prior Authorization Service TypesTherapies (PT, OT, SP)

Home Health

Hospice

South Carolina Web Site

4Forms

Navigate to Form Tab to obtain Documents such as: Fax and Justification forms5Therapies PT, OT , and SP21 years and Older - OP HospitalUnder 21OP Hospital and Private setting Medicare Primary Medicare claim denied or benefits exhausted Then Medicaid PA could be obtainedMedicare Hospice- Therapy is not related to the illness.Provider Manual - Hospital Services provider manual, not the Private Rehab provider manualEvaluation = 1 Follow up session(s) - 1 unit = 15minutes See Hospital Provider Manual - Section 4-74 to 76 for Codes requiring PA and appropriate Unit designationTherapies-PT,OT,SPTherapy codes:92506 92507925089260792608926099261097001970029700397004970129701697018970229702497026970289703297033970349703597036

Therapy codes:97110971129711397116971249714097150975309753297533975359753797542975979759897605976069775097755977609776197762Home HealthHome Health covered services:

Nursing servicesHome health aide PT, OT, SPKePRO will review for the following procedure codes:T1030- Nursing care in home by Registered nurseT1031- Nursing care by a Licensed Practical nurseT1021- Home Health Aide VisitT1028- Assessment Visit DME EvaluationA9900- SuppliesS9127- Social Work visit, in the homeS9128- Speech TherapyS9129- Occupational TherapyS9131-Physical Therapy

Home HealthRecipients may receive up to 50 home health skilled nursing, PT, OT, SP visits per fiscal year without prior authorization.

Prior authorization is required for services beyond the first 50 visits

1 unit = 1 visit

Home HealthRequest for extended service beyond the initial authorization period must be submitted to KePRO prior to the last authorized day in the certification periodProvider has two business days to respond to additional information pend notices. If no response received to pend, the request will be forwarded for Higher level review or administratively deniedProviders have two business days to respond to Insufficient information request If no response received to pend, the request will be closed requiring re-submission for Prior authorizationHome HealthHospiceEffective October 1, 2012, all requests for Hospice Services for Medicaid-only Recipients will need to be submitted to KePRO for Prior Authorization

HospiceHospice Procedure codes

T1015- GIP General Inpatient Care

S9126- Routine home Care

S9123- Continuous home Care

S9125- Inpatient Respite Care

Hospice Required Documentation:KePRO Outpatient Fax FormDHHS 149 (Election Form)DHHS 151 (Physician Certification Form)Plan of Care (POC)DHHS 153 (Revocation Form)- If applicableDHHS 154 (Discharge Form)- If applicableDHHS 152 (Change Request Form)- If applicable

Clinical documentation to support request

HospiceKePRO Outpatient Fax FormPlease make sure that all necessary information has been filled out on the KePRO fax formInclude all 3 procedure codes (GIP should also be included if that is the status of the client upon submission)Requests for GIP should be submitted at the time of inpatient admission, and if approved, will be approved for a 30 day time spanHospiceDHHS 149 Form (Medicaid Hospice Election):To be eligible to elect Hospice under Medicaid:Person must be certified as being terminally ill.Person is considered terminally ill if he or she has a medical prognosis that his or her life expectancy is 6 months or less, if the disease runs its normal courseHospice coverage is available for an unspecified number of days.The days are subdivided into election periodsTwo 90-day periods eachAn unlimited number of subsequent periods of 60 days eachHospiceDHHS 149 Form (Medicaid Hospice Election):Designate an effective date for the election period to beginThe request must be submitted to KePRO within 15 business days of election of benefitsIf not received within 15 business days, the request will be approved effective the date the request was received by KePROHospice

DHHS 149 FormHospiceDHHS Form 151- Medicare Hospice Physician Certification and RecertificationHospice must ensure the following conditions are met:Written certification statements must be obtained within 2 calendar days after hospice care has been initiatedSigned by the Medical Director of the Hospice or the physician member of the Hospice interdisciplinary groupSigned by the persons attending physician (if the individual has an attending physician)HospiceDHHS Form 151- Medicare Hospice Physician Certification and RecertificationHospice must ensure the following conditions are met:If written certification if not obtained within 2 days after the initiation of Hospice care:A verbal certification may be obtained within these 2 daysA written certification must be obtained prior to submission of a request for prior authorizationHospiceDHHS Form 151- Medicare Hospice Physician Certification and RecertificationHospice must ensure the following conditions are met for recertification:The Hospice must obtain (no later than 2 calendar days after the beginning of that period):A written certification statement completed by the medical director of the hospice or the physician member of the Hospices interdisciplinary groupMust include the physicians signatureA statement that the individuals medical prognosis is of a life expectancy of 6 months or less, if the terminal illness runs its normal course

Hospice

DHHS Form 151- Medicare Hospice Physician Certification and RecertificationHospiceRevocationA beneficiary may revoke the election of Hospice care at any timeThe individual loses any remaining days in the Hospice benefit period and regular Medicaid benefits are reinstated effective the date of the revocationThe individual may at any time elect to receive Hospice coverage for any other Hospice election period for which he or she is eligible. HospiceDHHS Form 153- Medicaid Hospice RevocationTo revoke Hospice, the individual must:Complete DHHS form 153Designate an effective date to revoke HospiceSubmit Form 153 to KePRO within 5 business days of revocation of benefitsMail a copy of the form to the nursing facility or ICF/MRHospice

DHHS Form 153- Medicaid Hospice Revocation

HospiceDischarge: Discharge of an individual may occur for the following reasons:The individual expiresThe individual is noncompliantThe individual is determined to have a prognosis greater than 6 monthsThe individual moves out of the Hospices geographically defined service areaIf discharging for reasons other than death, the Hospice provider must send a copy of the Medicaid Hospice Discharge Statement to the beneficiary or responsible party upon discharge

HospiceDHHS Form 154- Medicaid Hospice Discharge:Form 154 must be completedDesignate an effective date to discontinue HospiceSubmit form to KePRO within 5 working days of the effective date of dischargeHospice

DHHS Form 154- Medicaid Hospice Discharge

HospiceDHHS Form 152- Medicaid Hospice Provider Change Request FormForm 152 is to be used when an individual chooses to change the designation of the particular Hospice from which he or she elects to receive Hospice Care in each election periodTo change the designation of Hospice providers, the individual must notify their current Hospice provider that they which to change HospicesHospiceDHHS Form 152- Medicaid Hospice Provider Change Request FormThe Hospice provider that is releasing the beneficiary must:Complete all appropriate portions of Form 152Submit a copy of Form 152 to KePRO within 5 business daysSend a copy to the receiving Hospice ProviderHospiceThe receiving Hospice Provider must:Receive a copy of Form 152 within 2 business days of the effective date of changeForward a completed copy to the SCDHHS Hospice Program Manager within 5 business days of the effective date of receiving Hospices first day of service to be included for billingMail a copy of the form to the nursing facility or ICF/MRFor Medicaid only beneficiaries, Form 152 can be faxed to KePROHospice

DHHS Form 152- Medicaid Hospice Provider Change Request Form

DMEEffective October 1,2012 the following two codes will require prior authorization request from KePRO:

S8189- Tracheostomy Supply, not otherwise classified

L0638- Lumbar-sacral orthotic (SLO)

Providers must attach pricing information on claims for procedure codes that are manually priced Outpatient Fax Form

KePRO Outpatient Fax Form cont.

KePRO Contacts

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37Thank You!