molina/bms 2016 spring provider workshops
TRANSCRIPT
PowerPoint PresentationAPS HEALTHCARE-SUBSIDIARY OF
• Foster Care
• Waiver Members: I/DD Waiver; Aged & Disabled Waiver; TBI
• Other Populations Served:
• Bureau for Children and Families- Children & Families requiring Socially Necessary Services (non-Medicaid Services)
• Bureau for Behavioral Health & Health Facilities- Charity Care and Block Grant Services eligibility & prior authorization
APS SCOPE OF WORK
CONTRACT AWARD
• COMING SOON :
CHANGES IN THE UPCOMING CONTRACT
• NEW PROGRAMS/REVIEW AREAS WILL BE ADDED
• EXISTING PROGRAMS:
• STAFFING AND PROCESSES WILL REMAIN THE SAME
• TRAINING & TECHNICAL ASSISTANCE WILL CONTINUE TO BE PROVIDED
WEBSITES/DIRECT DATA ENTRY PORTALS
• IF YOU SUBMIT REQUESTS VIA DIRECT DATA ENTRY ON ONE OF APS’ WEB-PORTALS, THE WEB
ADDRESS AND SUBMISSION PROCESS HAS NOT CHANGED.
• MEDICAL REQUESTS: HTTPS://PROVIDERPORTAL.APSHEALTHCARE.COM
• HEALTH HOMES: HTTPS://PROVIDERPORTAL.APSHEALTHCARE.COM
• BEHAVIORAL HEALTH HTTPS://CARECONNECTIONWV.APSHEALTHCARE.COM
MEMBERS WITH CHRONIC CONDITIONS. HEALTH
HOME PROVIDERS COORDINATE ALL PRIMARY,
ACUTE, BEHAVIORAL HEALTH AND LONG-TERM
SERVICES AND SUPPORTS TO TREAT THE “WHOLE
PERSON” ACROSS A MEDICAID MEMBER’S LIFESPAN.
MEMBERS ARE FREE TO CHOOSE ANY PROVIDER
FOR TREATMENT SERVICES; THEREFORE, YOUR
CURRENT PATIENTS CAN REMAIN WITH YOU.
• CURRENT HEALTH HOME MEMBER ENROLLMENT =
APPROXIMATELY 700 MEMBERS.
WAYNE COUNTIES:
• PROCESS STRATEGIES
• SOUTHERN HIGHLANDS COMMUNITY HEALTH CENTER
HEALTH HOMES QUALITY MEASURES • DURING THE SFY 2015, A TOTAL OF 1,243 INDIVIDUALS RECEIVED HEALTH HOMES PROGRAM SERVICES; 82 WERE
NEW MEDICAID MEMBERS WHO HAD NOT RECEIVED ANY MEDICAID SERVICES IN SFY 2014.
• 118 HEALTH HOMES PROGRAM MEMBERS WERE REPORTED AS HEPATITIS POSITIVE; 161 WERE IDENTIFIED AT
HIGH RISK FOR HEPATITIS.
• 732 (59%) HEALTH HOMES PROGRAM MEMBERS SMOKE/AND/OR USE TOBACCO; 473 RECEIVED SMOKING AND
TOBACCO USE CESSATION.
• 100% OF THE ENROLLEES AGE 12 AND OLDER WERE SCREENED FOR DEPRESSION; 79% WERE CLINICALLY
DEPRESSED AT THE TIME OF THE SCREENING.
• SFY 2015 EMERGENCY DEPARTMENT COSTS WERE REDUCED BY $17,639 FOR HEALTH HOMES PROGRAM
MEMBERS.
• A 42% REDUCTION IN THE AVERAGE LENGTH OF STAY IN A HOSPITAL FOR ALL HEALTH HOMES PROGRAM
MEMBERS WHO HAD MEDICAID COVERAGE IN BOTH SFY 2014 AND SFY 2015. THOSE MEMBERS WHO WERE
ENROLLED IN A HEALTH HOMES FOR THE ENTIRE YEAR SAW A DECREASE OF 32% FROM SFY 2014. THE DECREASE
CAN BE ATTRIBUTED TO BETTER DISCHARGE PLANNING. ADDITIONAL HEALTH HOMES PROGRAM INFORMATION IS AVAILABLE ON THE WV BUREAU FOR MEDICAL SERVICES WEBSITE: WWW.DHHR.WV.GOV/BMS/ OR THE APS HEALTHCARE/KEPRO-WV WEBSITE; WWW.APSHEALTHCARE.COM/WV QUESTIONS/CONCERNS – CONTACT APS HEALTHCARE AT 304-343-9663 OR 1-800-461-0655
• NEW POLICY WENT INTO EFFECT 12/1/2015.
• STAFF MUST PASS A FITNESS DETERMINATION THROUGH THE WV CARES PROGRAM TO BE
ELIGIBLE FOR EMPLOYMENT.
• APPLICANTS FOR THE IDDW PROGRAM MUST MEET ALL OF THE PREVIOUS ELIGIBILITY CRITERIA
PLUS MUST:
• BE AT LEAST 3 YEARS OF AGE, AND
• VERIFY THEY ARE A PERMANENT RESIDENT OF WV
• OVERALL, SERVICE LIMITS BASED ON AGE AND LIVING ARRANGEMENT CHANGED FOR THOSE
IN A NATURAL FAMILY SETTINGS.
• IN ADDITIONAL TO PREVIOUSLY COVERED SERVICES, NEW SERVICES WERE ADDED:
PREVOCATIONAL TRAINING AND JOB DEVELOPMENT.
AGED AND DISABLED WAIVER UPDATES • NEW POLICY MANUAL WENT INTO EFFECT 12/1/2015.
• APPLICANTS MUST ESTABLISH FINANCIAL ELIGIBILITY BEFORE BEING ASSESSED FOR MEDICAL
ELIGIBILITY.
• STAFF MUST PASS A FITNESS DETERMINATION THROUGH THE WV CARES PROGRAM TO BE
ELIGIBLE FOR EMPLOYMENT.
• NO CHANGES WERE MADE TO THE ELIGIBILITY OR AVAILABLE SERVICES.
PERSONAL CARE UPDATES
• AVAILABLE TO ASSIST AN ELIGIBLE MEMBER TO PERFORM ACTIVITIES OF DAILY LIVING (ADLS)
AND INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADLS) IN THE MEMBER’S HOME, PLACE OF
EMPLOYMENT, OR COMMUNITY.
• TO BE MEDICALLY ELIGIBLE FOR PERSONAL CARE (PC) SERVICES, MEDICAID MEMBERS MUST
HAVE THREE (3) DEFICITS AS IDENTIFIED ON THE PRE-ADMISSION SCREENING AND REQUIRE
HANDS-ON ASSISTANCE/SUPERVISION/ CUEING IN ADLS/IADLS ORDERED BY A PHYSICIAN
AND BE PROVIDED BY A QUALIFIED PERSONAL CARE PROVIDER(S).
• NO MAJOR PROGRAM CHANGES; NEW POLICY WILL BE PUT OUT FOR PUBLIC COMMENT
SOON.
• NEW POLICY MANUAL WENT INTO EFFECT 10/1/2015.
• APPLICANTS MUST ESTABLISH FINANCIAL ELIGIBILITY BEFORE BEING ASSESSED FOR MEDICAL
ELIGIBILITY.
• STAFF MUST PASS A FITNESS DETERMINATION THROUGH THE WV CARES PROGRAM TO BE
ELIGIBLE FOR EMPLOYMENT.
• ELIGIBILITY CRITERIA WERE EXPANDED TO ALLOW CHILDREN AGE 3 AND OLDER TO APPLY
(PREVIOUSLY HAD TO BE AT LEAST 22 YEARS OLD).
• EXPANDED DEFINITION OF TBI TO INCLUDE ANOXIA DUE TO NEAR DROWNING.
BEHAVIORAL HEALTH UPDATES
• DURING FISCAL YEAR 2015, THE TOTAL REQUESTS REVIEWED FOR AUTHORIZATION WERE:
• HIGH INTENSITY SERVICE REQUESTS = 20,346
• (ACUTE PSYCHIATRIC INPATIENT, PRTF, PARTIAL HOSPITALIZATION, ETC.)
• OUTPATIENT SERVICE REQUESTS = 348,576
• PROVIDER TYPES REGISTERED WITH APS AS OF 4/8/16: (NOT INDENTED)
• 97 LICENSED BEHAVIORAL HEALTH CENTERS
• 161 PSYCHIATRIC PROVIDERS
• 217 PSYCHOLOGICAL PROVIDERS
• 8 LICENSED INDEPENDENT CLINICAL SOCIAL WORKERS
BEHAVIORAL HEALTH INFORMATION AND TIPS FOR SUBMISSIONS
• WHEN COMPLETING THE APS CARE CONNECTION, THE LEVEL OF FUNCTIONING AREAS
SHOULD BE RATED BASED UPON APPROPRIATE AGE AND DEVELOPMENTAL EXPECTATIONS
FOR CHILDREN.
• FOR CLINIC AND REHABILITATION PROVIDERS WITH INTENSIVE SERVICE (S) DESCRIPTIONS,
FUTURE MODIFICATIONS TO ANY IS DESCRIPTIONS WILL BE JOINTLY REVIEWED BY BMS AND
BBHHF.
• TRAINER CONSULTANTS ARE AVAILABLE TO PROVIDE ASSISTANCE RELATED TO THE PROPOSED
REVISIONS TO THE WV MEDICAID TARGETED CASE MANAGEMENT MANUAL OR ANY OTHER
BEHAVIORAL HEALTH SERVICE.
REMINDERS TO PROVIDERS SUBMITTING MEDICAL REQUESTS
• REMEMBER TO MAKE SURE THAT THE REFERRING/SERVICING PROVIDERS ARE ACTIVE IN MOLINA-
APS CANNOT EXPORT AUTHORIZATIONS TO MOLINA WHEN THE REFERRING OR SERVICING
PROVIDER IS TERMED.
• REMEMBER USER LOG-INS ARE ONLY TO BE USED BY THE PERSON THEY ARE ASSIGNED TO. EACH
REGISTERED PROVIDER HAS AN ORGANIZATION MANAGER WHO CAN ADD A USER. PASSWORD
RESETS COMPLETED BY APS STAFF CAN ONLY BE DONE FOR THE USER TO WHOM THE LOG-IN IS
ASSIGNED
• REMEMBER TO SEARCH BY CPT/HCPCS CODE WHEN SELECTING SERVICES-THIS WILL ENSURE THAT
WHEN SERVICES ARE GROUPED THE CORRECT GROUP IS SELECTED
• REMEMBER THAT FOR SERVICES THAT REQUIRE PRIOR AUTHORIZATION BEYOND SERVICE LIMITS
CONSULT THE APPROPRIATE BMS MANUAL CHAPTER FOR THE LIMIT AND BE SURE THE MEMBER HAS
EXCEEDED IT BEFORE SUBMITTING A PRIOR AUTHORIZATION REQUEST- LIMITS ON THE MASTER
CODE LIST RELATE TO REQUESTS BEYOND SERVICE LIMITS AND MAY NOT MATCH THE NUMBER OF
UNITS ALLOWED BEFORE PRIOR AUTHORIZATION-THIS STEP CAN SAVE YOU TIME AND WORK
REMINDERS TO PROVIDERS SUBMITTING MEDICAL REQUESTS
• REMEMBER TO ATTACH ALL CLINICAL INFORMATION REFERENCED OR REQUIRED IN THE
REQUEST IF YOU INDICATE ATTACHED (E.G. DIAGNOSTIC REPORTS, H&P, IMAGING FINDINGS,
LAB RESULTS, ETC.)
• PLEASE REMEMBER THAT A CASE MAY BE PENDED FOR ADDITIONAL INFORMATION. YOU MAY
WANT TO CHECK THE C3 SYSTEM TO BE SURE NO ADDITIONAL DOCUMENTATION HAS BEEN
REQUESTED. THIS WILL PREVENT CLOSURE OF THE REQUEST IN THE ABSENCE OF THE
NECESSARY CLINICAL DOCUMENTATION.
• A FACILITY’S IQ REVIEW DOES NOT REPLACE CLINICAL DOCUMENTATION. IT IS FINE TO
INCLUDE THIS WITH A REQUEST BUT WE MUST RECEIVE THE APPROPRIATE CLINICAL
INFORMATION TO CONDUCT A REVIEW.
MODIFICATION TO EXISTING AUTHORIZATIONS
• AUTHORIZATIONS MUST CONTAIN THE APPROPRIATE ICD-10/ICD-9 CODE FOR THE SERVICE
DATES-PLEASE CHECK TO BE SURE THE PROPER DIAGNOSTIC FORMAT IS USED WHEN COPYING
AN AUTHORIZATION REQUEST FOR NEW SUBMISSION, REQUESTING A MODIFICATION TO AN
EXISTING REQUEST OR REQUESTING A RETROSPECTIVE AUTHORIZATION.
• CHANGES IN MOLINA HEALTHPAS 5.0 HAVE RESULTED IN NEW PROCEDURES FOR
MODIFICATION OF EXISTING AUTHORIZATIONS. THERE ARE SOME MODIFICATIONS THAT
CANNOT BE PERFORMED IN THE SAME MANNER.
PEER-TO-PEER (LEVEL 1 RECONSIDERATION) & RECONSIDERATION (LEVEL 2)
• PEER-TO-PEER MAY BE REQUESTED FOLLOWING A SERVICE DENIAL BY SELECTING THE LEVEL 1
RECONSIDERATION ACTION AND SUBMITTING ANY ADDITIONAL INFORMATION
• PEER-TO-PEER REQUESTS ARE REVIEWED AND TRIAGED AND THE PROVIDER WILL BE
CONTACTED BY APS TO SCHEDULE A TIME FOR THE PEER-TO-PEER DISCUSSION IF THE REQUEST
CANNOT BE APPROVED BASED ON ANY ADDITIONAL DOCUMENTATION SUBMITTED.
• LEVEL 2 RECONSIDERATION MAY BE REQUESTED FOLLOWING A SERVICE DENIAL AND/OR
PEER-TO-PEER BY SELECTING THE LEVEL 2 RECONSIDERATION ACTION AND SUBMITTING ANY
ADDITIONAL INFORMATION.
• LEVEL 2 IS THE FINAL RECONSIDERATION ACTION AVAILABLE TO PROVIDERS.
FAXING REQUESTS OR ATTACHMENTS • IF YOU ARE FAXING REQUESTS OR ATTACHMENTS, PLEASE MAKE SURE YOU PROVIDE YOUR STAFF WITH THE
CURRENT LIST OF FAX NUMBERS. THE LIST OF FAX NUMBERS IS INCLUDED IN THIS PRESENTATION.
• IF FAXING ATTACHMENTS FOR A REQUEST THAT HAS BEEN SUBMITTED VIA DIRECT DATA ENTRY, PLEASE MAKE
SURE TO USE THE PROPER FAX COVER SHEET, AND MAKE SURE YOU PUT THE AUTHORIZATION REQUEST ID ON
THE FORM. WE CANNOT ATTACH INFORMATION WITHOUT THAT ID BECAUSE A PATIENT COULD HAVE MULTIPLE
REQUESTS AND WE WOULDN’T HAVE ANY WAY OF KNOWING WHICH ONE IT IS FOR.
• IF SUBMITTING AN AUTHORIZATION REQUEST VIA FAX, YOU MUST FILL OUT THE FORM IN ITS ENTIRETY. UM
SUPPORT STAFF WHO ENTER REQUESTS ARE NOT AUTHORIZED TO GUESS ON ANY INFORMATION THAT IS LEFT
BLANK.
• ANY ADDITIONAL DOCUMENTATION NEEDS TO BE SUBMITTED WITH THE FAXED REQUEST. FAILURE TO DO SO COULD
RESULT IN HAVING THE REQUEST FAXED BACK TO YOU OR THE REQUEST BEING CLOSED BECAUSE THE INFORMATION
WAS NOT REQUESTED IN A TIMELY MANNER.
• PROVIDERS WHO FAX REQUESTS ARE STILL REQUIRED TO CHECK THE C3WV SYSTEM TO DETERMINE
APPROVALS/DENIALS AND TO CHECK STATUS OF THE REQUEST.
ACUTE INPATIENT REQUESTS
• REMEMBER WHEN SUBMITTING CLINICAL INFORMATION TO INCLUDE SPECIFIC TREATMENTS
AND CLINICAL INFORMATION RELEVANT TO THE ADMITTING DIAGNOSIS (E.G. BASELINE O2
SATURATION AND ABG, IF APPLICABLE FOR RESPIRATORY ISSUES; IV RATES/HR, VITAL SIGNS;
NEURO CHECKS, ASSESSMENTS, ETC. AS THESE ARE OFTEN PART OF IQ CRITERIA AND CAN
SAVE THE NURSE HAVING TO CALL FOR THE INFORMATION AND DELAYING YOUR RESULT);
• PLEASE BE SURE TO INCLUDE A CLINICAL CONTACT IN CASE ADDITIONAL CLINICAL
INFORMATION IS NEEDED
OUTPATIENT SURGERY REQUESTS • INCLUDE ALL CPT CODES NEEDED ON THE REQUEST. THE PRIMARY PROCEDURE SHOULD BE ON
THE SERVICE REQUEST LINE-ADDITIONAL PROCEDURES MAY BE PLACED IN THE ANNOTATION
SECTION. WE DO NOT SELECT SERVICE CODES FOR YOU!
• ELECTIVE PROCEDURES REQUIRE THE CLINICAL DOCUMENTATION TO SUPPORT THE ELECTIVE
PROCEDURE: EXAM FINDINGS, LABS, IMAGING, PREVIOUS INTERVENTIONS ETC.
• THE REQUESTED SURGERY SHOULD CORRELATE TO THE PATIENT DIAGNOSIS AND CLINICAL
DOCUMENTATION. FOR EXAMPLE, A REQUEST FOR A HYSTERECTOMY FOR A DIAGNOSIS OF
EPILEPSY WHERE 100 PAGES OF DOCUMENTATION IS PROVIDED RELATED TO THE MEMBER’S
EPILEPTIC HISTORY AND VARIOUS HEALTH ISSUES DOES NOT CORRELATE. THE DOCUMENTATION
SUBMITTED SHOULD BE RELEVANT TO THE REQUEST AND SUPPORT THE MEDICAL NECESSITY OF
THE REQUEST.
DMEPOS (PROSTHETIC & ORTHOTIC) REQUESTS
• HOME EVALUATIONS ARE REQUIRED FOR ALL WHEELCHAIR REQUESTS, AND HOYER LIFTS. THIS IS PART
OF INTERQUAL CRITERIA FOR THESE REQUESTS. ALSO , THE DMEPOS MANUAL UPDATED JANUARY 1,
2016 REQUIRES: “A FACE-TO-FACE ENCOUNTER JUSTIFYING THE MEDICAL NECESSITY AND A WRITTEN ORDER BY THE
PRESCRIBING PRACTITIONER FOR THE DMEPOS SERVICES REQUESTED IS REQUIRED. DOCUMENTATION MUST BE MAINTAINED IN THE
MEMBER’S RECORD AND BE AVAILABLE TO BMS OR THEIR DESIGNEE UPON REQUEST “ WE DO REQUEST THIS FACE TO FACE
ENCOUNTER INFORMATION IF WE NEED MORE CLINICAL INFORMATION FOR REVIEW OF A REQUEST.
• WE ARE UNABLE TO ACCEPT CLINICAL INFORMATION OLDER THAN 6 MONTHS (EX: SLEEP STUDIES, OXYGEN
SATURATIONS, OFFICE NOTES, HOSPITAL RECORDS, ETC). TO SUPPORT A REQUEST FOR PRIOR
AUTHORIZATION.
• FOR DMEPOS EQUIPMENT AND SUPPLIES THAT REQUIRE PRIOR AUTHORIZATION BEYOND SERVICE LIMITS NO
REQUEST NEEDS TO BE SUBMITTED UNTIL THE INITIAL MEMBER BENEFIT SPECIFIED IN HAS BEEN USED. CODES
WITH PA REQUIRED AND REQUIRED BEYOND SERVICE LIMITS ARE INDICATED ON THE APS MASTER CODE LIST
(CODES REQUIRING PRIOR AUTHORIZATION).
DMEPOS (PROSTHETIC & ORTHOTIC) REQUESTS
• THE QUANTITIES FOR EACH ITEM MUST BE SUBMITTED (WHETHER IT IS DOCUMENTED IN C3
NOTES, OR, PREFERABLY LISTED ON THE CMN) BECAUSE C3 DEFAULTS THE QUANTITIES TO A
SPECIFIC AMOUNT WHICH MAY BE GREATER OR LESS THAN THE AMOUNT NEEDED.
• FOR CODES REQUIRING COST INVOICES- THE COST INVOICE MUST BE NON-ALTERED AND
SPECIFY THE INDIVIDUAL MEDICAID MEMBER. WE CANNOT ACCEPT QUOTES OR SCREEN-
SHOTS OF SHOPPING CARTS AS INVOICES.
• THE COST CALCULATION FORM SHOULD MATCH THE PRICING ON THE COST INVOICE.
• THE REQUESTED CODES SHOULD ALSO BE LISTED ON THE COST INVOICE.
DMEPOS (PROSTHETIC & ORTHOTIC) REQUESTS • VENT CODES UPDATED EFFECTIVE 1/1/16: E0465 FOR INVASIVE, E0466 FOR NON-INVASIVE.
• THE SERVICE LIMIT FOR TEST SOCKETS (L5620 – L5628) IS 2 PER YEAR. THIS WILL ACCOMMODATE 1
PER LOWER EXTREMITY. IF MORE THAN 2 ARE BEING REQUESTED, A JUSTIFICATION MUST BE
PROVIDED TO EXPLAIN THE NEED AND THERE MUST BE PROOF THAT THE ADDITIONAL SOCKET(S)
WILL BE PROVIDED TO THE PATIENT. THE “POTENTIAL NEED TO EXCEED SERVICE LIMITS” IS NOT
ADEQUATE JUSTIFICATION. IF IT IS DETERMINED THAT ADDITIONAL SOCKETS ARE NEEDED WHILE THE
PROSTHESIS IS BEING FABRICATED, AUTHORIZATION WILL NEED TO BE OBTAINED AT THAT TIME.
• E0260 SEMI-ELECTRIC HOSPITAL BED AND E0277 POWERED PRESSURE-REDUCING MATTRESS ARE
NON-REIMBURSABLE TOGETHER; AND REMAINS NON-REIMBURSABLE WHILE THE OTHER IS STILL
UNDER CAP RENTAL.
• SERVICE LIMITS FOR WHEELCHAIRS ARE ONE PER FIVE YEARS. JUST BECAUSE IT HAS BEEN 5 YEARS,
DOES NOT MEAN A NEW WHEELCHAIR IS NECESSARY- MEDICAL NECESSITY NEEDS TO BE JUSTIFIED.
HOME HEALTH REQUESTS • WE NEED ORDERS TO BE ATTACHED/ FAXED IN ADDITION TO OASIS/485 INFORMATION FOR
CASES THAT EXCEED 60 VISITS IN A CALENDAR YEAR . PER BMS HOME HEALTH MANUAL ---
“ALL HOME HEALTH SERVICES THAT EXCEED 60 VISITS IN A CALENDAR YEAR REQUIRE PRIOR AUTHORIZATION. PLEASE SEE
SECTION 508.10, PRIOR AUTHORIZATION FOR ADDITIONAL INFORMATION. IT IS THE RESPONSIBILITY OF THE PROVIDER
TO MAINTAIN THE PLAN OF CARE (POC) FORM, (CMS-485 & CMS-486) OR THE AGENCY’S POC FORM OF THEIR
CHOOSING, AND OASIS ASSESSMENTS ON FILE. HOME HEALTH AGENCIES MUST HAVE ALL REQUIRED POC DATA
ELEMENTS IN A READILY IDENTIFIABLE LOCATION WITHIN THE MEDICAL RECORD.”
HOSPICE REQUESTS • ALL REQUESTS MUST INCLUDE A SIGNED PHYSICIAN CERTIFICATION FORM AS WELL AS A
HOSPICE ELECTION FORM (HEF1).
• FOR ALL ELECTION PERIODS AFTER ELECTION 2 PLEASE BE SURE TO SUBMIT EVIDENCE OF
DECLINING STATUS INCLUDING DECREASED PPS SCORE OR ADDITION OF COMORBIDITIES.
• ALZHEIMER’S AS THE SOLE QUALIFYING CONDITION FOR HOSPICE IS NO LONGER PERMISSIBLE
BY MEDICARE & MEDICAID POLICY- PLEASE LIST ALL COMORBID CONDITIONS WHEN HOSPICE
IS REQUESTED FOR MEMBER’S WITH ALZHEIMER’S DIAGNOSES.
IMAGING REQUESTS • REMEMBER TO REPORT CONSERVATIVE TREATMENT HISTORY (E.G. PHYSICAL
THERAPY/DURATION; HOME EXERCISE/DURATION) AND NSAIDS HISTORY
(DURATION/DOSAGES)- THESE ARE THE TWO MOST COMMONLY OMITTED ITEMS THAT ARE
REQUIRED FOR REVIEW. IF THESE INTERVENTIONS ARE CONTRAINDICATED SPECIFY REASON IN
MEDICAL JUSTIFICATION.
• INCLUDE PREVIOUS IMAGING (MRI, CT, X-RAY) RESULTS AND DATE(S) OF PROCEDURES
PT/OT REQUESTS
• FOR PT/OT REQUESTS, PLEASE INCLUDE THE FOLLOWING WITH EACH REQUEST: A PHYSICIAN
ORDER THAT IS SIGNED AND DATED, THE INITIAL EVALUATION, RECENT PROGRESS NOTES
INDICATING PROGRESS TOWARD TREATMENT GOALS AND A TREATMENT PLAN INCLUDING
LONG AND SHORT TERM GOALS AND THE NUMBER OF VISITS ANTICIPATED TO MEET
ESTABLISHED GOALS.
• FOR SCHOOL-AGED CHILDREN, SUBMIT A SIGNED DOCUMENT FROM PARENT/GUARDIAN THAT
THEY HAVE NOTIFIED THE SCHOOL DISTRICT THAT THEY CANNOT SEEK MEDICAID
REIMBURSEMENT FOR THE SERVICE OR AN IEP OR NOTIFICATION FROM THE SCHOOL DISTRICT
THAT THE REQUIRED SERVICES ARE NOT AVAILABLE OR ARE INSUFFICIENT TO MEET THE
MEMBER’S NEEDS (THIS IS REQUIRED FOR SPEECH THERAPY SERVICES AS WELL).
• IF A MEMBER IS/HAS RECEIVED BOTH OT/PT IN THE CALENDAR YEAR, PLEASE NOTE THAT IN THE
DOCUMENTATION. REMEMBER BOTH OT/PT COMBINED COUNT FOR THE 20 INITIAL VISITS A
MEMBER MAY RECEIVE WITHOUT FULL CLINICAL REVIEW.
PT/OT REQUESTS
• DO NOT CHOOSE “INITIAL” AS THE STATUS FOR A REQUEST IF THE MEMBER HAS RECEIVED
ANY PHYSICAL OR OCCUPATIONAL THERAPY VISITS IN THE CURRENT CALENDAR YEAR. DO
NOT CHOSE “ESTABLISHED” IF THERE WAS NO PREVIOUS THERAPY IN THE CURRENT
CALENDAR YEAR, EVEN IF THE MEMBER HAS ALREADY STARTED THERAPY WHEN THE REQUEST
WAS SUBMITTED. EXAMPLE: MEMBER BEGAN THERAPY ON 03/26/2016, BUT REVIEW WAS
NOT SUBMITTED UNTIL 04/01/2016 WITH A START DATE OF 03/26/2016, WITH NO
PREVIOUS THERAPY IN 2016-THIS WOULD BE AN INITIAL REVIEW.
• UNSPECIFIED CODES, SUCH AS 97139 AND 97039, ARE UNLISTED CODES AND WILL NEED TO
SPECIFY TYPE OF THERAPY FOR 97139 AND TIME IF USING FOR CONSTANT ATTENDANCE
(97039).
• FOR CHIROPRACTIC REQUESTS, PLEASE INCLUDE THE FOLLOWING: RECENT X-RAY RESULTS
(NOT REQUIRED FOR A CHILD OR PREGNANCY), NUMBER OF VISITS ALREADY COMPLETED IN
THE CALENDAR YEAR PRIOR TO THE CURRENT REQUEST (IF ANY), PROGRESS NOTES,
TREATMENT PLAN/PROGNOSIS, AND MEMBER HISTORY.
APS HEALTHCARE, INC. CONTACT INFORMATION
BEHAVIORAL HEALTH
MEDICAL SERVICES EMAIL: [email protected]
ANGELA HOBBS UM NURSE SUPERVISOR [email protected] EXT. 4477
ALICIA PERRY OFFICE MANAGER [email protected] EXT. 4452
CINDY BUNCH ELIGIBILITY SPECIALIST [email protected] EXT. 4408
TONYA TACY ELIGIBILITY SPECIALIST [email protected] EXT. 4468
JASPER SMITH ELIGIBILITY SPECIALIST [email protected] EXT. 4490
GENERAL APS INFORMATION: WWW.APSHEALTHCARE.COM/WV
WEBSITE FOR SUBMITTING AUTHORIZATIONS: HTTPS://PROVIDERPORTAL.APSHEALTHCARE.COM
WEBSITE FOR ORG MANAGERS TO ADD/MODIFY USERS HTTPS://C3WV.APSHEALTHCARE.COM
REMEMBER: E-MAIL US AT WVMEDICALSERVICES2APSHEALTHCARE.COM TO BE ADDED TO OUR E-MAIL LIST. THIS WILL ENSURE YOU RECEIVE IMPORTANT INFORMATION AND ANNOUNCEMENTS DIRECTLY.
• Foster Care
• Waiver Members: I/DD Waiver; Aged & Disabled Waiver; TBI
• Other Populations Served:
• Bureau for Children and Families- Children & Families requiring Socially Necessary Services (non-Medicaid Services)
• Bureau for Behavioral Health & Health Facilities- Charity Care and Block Grant Services eligibility & prior authorization
APS SCOPE OF WORK
CONTRACT AWARD
• COMING SOON :
CHANGES IN THE UPCOMING CONTRACT
• NEW PROGRAMS/REVIEW AREAS WILL BE ADDED
• EXISTING PROGRAMS:
• STAFFING AND PROCESSES WILL REMAIN THE SAME
• TRAINING & TECHNICAL ASSISTANCE WILL CONTINUE TO BE PROVIDED
WEBSITES/DIRECT DATA ENTRY PORTALS
• IF YOU SUBMIT REQUESTS VIA DIRECT DATA ENTRY ON ONE OF APS’ WEB-PORTALS, THE WEB
ADDRESS AND SUBMISSION PROCESS HAS NOT CHANGED.
• MEDICAL REQUESTS: HTTPS://PROVIDERPORTAL.APSHEALTHCARE.COM
• HEALTH HOMES: HTTPS://PROVIDERPORTAL.APSHEALTHCARE.COM
• BEHAVIORAL HEALTH HTTPS://CARECONNECTIONWV.APSHEALTHCARE.COM
MEMBERS WITH CHRONIC CONDITIONS. HEALTH
HOME PROVIDERS COORDINATE ALL PRIMARY,
ACUTE, BEHAVIORAL HEALTH AND LONG-TERM
SERVICES AND SUPPORTS TO TREAT THE “WHOLE
PERSON” ACROSS A MEDICAID MEMBER’S LIFESPAN.
MEMBERS ARE FREE TO CHOOSE ANY PROVIDER
FOR TREATMENT SERVICES; THEREFORE, YOUR
CURRENT PATIENTS CAN REMAIN WITH YOU.
• CURRENT HEALTH HOME MEMBER ENROLLMENT =
APPROXIMATELY 700 MEMBERS.
WAYNE COUNTIES:
• PROCESS STRATEGIES
• SOUTHERN HIGHLANDS COMMUNITY HEALTH CENTER
HEALTH HOMES QUALITY MEASURES • DURING THE SFY 2015, A TOTAL OF 1,243 INDIVIDUALS RECEIVED HEALTH HOMES PROGRAM SERVICES; 82 WERE
NEW MEDICAID MEMBERS WHO HAD NOT RECEIVED ANY MEDICAID SERVICES IN SFY 2014.
• 118 HEALTH HOMES PROGRAM MEMBERS WERE REPORTED AS HEPATITIS POSITIVE; 161 WERE IDENTIFIED AT
HIGH RISK FOR HEPATITIS.
• 732 (59%) HEALTH HOMES PROGRAM MEMBERS SMOKE/AND/OR USE TOBACCO; 473 RECEIVED SMOKING AND
TOBACCO USE CESSATION.
• 100% OF THE ENROLLEES AGE 12 AND OLDER WERE SCREENED FOR DEPRESSION; 79% WERE CLINICALLY
DEPRESSED AT THE TIME OF THE SCREENING.
• SFY 2015 EMERGENCY DEPARTMENT COSTS WERE REDUCED BY $17,639 FOR HEALTH HOMES PROGRAM
MEMBERS.
• A 42% REDUCTION IN THE AVERAGE LENGTH OF STAY IN A HOSPITAL FOR ALL HEALTH HOMES PROGRAM
MEMBERS WHO HAD MEDICAID COVERAGE IN BOTH SFY 2014 AND SFY 2015. THOSE MEMBERS WHO WERE
ENROLLED IN A HEALTH HOMES FOR THE ENTIRE YEAR SAW A DECREASE OF 32% FROM SFY 2014. THE DECREASE
CAN BE ATTRIBUTED TO BETTER DISCHARGE PLANNING. ADDITIONAL HEALTH HOMES PROGRAM INFORMATION IS AVAILABLE ON THE WV BUREAU FOR MEDICAL SERVICES WEBSITE: WWW.DHHR.WV.GOV/BMS/ OR THE APS HEALTHCARE/KEPRO-WV WEBSITE; WWW.APSHEALTHCARE.COM/WV QUESTIONS/CONCERNS – CONTACT APS HEALTHCARE AT 304-343-9663 OR 1-800-461-0655
• NEW POLICY WENT INTO EFFECT 12/1/2015.
• STAFF MUST PASS A FITNESS DETERMINATION THROUGH THE WV CARES PROGRAM TO BE
ELIGIBLE FOR EMPLOYMENT.
• APPLICANTS FOR THE IDDW PROGRAM MUST MEET ALL OF THE PREVIOUS ELIGIBILITY CRITERIA
PLUS MUST:
• BE AT LEAST 3 YEARS OF AGE, AND
• VERIFY THEY ARE A PERMANENT RESIDENT OF WV
• OVERALL, SERVICE LIMITS BASED ON AGE AND LIVING ARRANGEMENT CHANGED FOR THOSE
IN A NATURAL FAMILY SETTINGS.
• IN ADDITIONAL TO PREVIOUSLY COVERED SERVICES, NEW SERVICES WERE ADDED:
PREVOCATIONAL TRAINING AND JOB DEVELOPMENT.
AGED AND DISABLED WAIVER UPDATES • NEW POLICY MANUAL WENT INTO EFFECT 12/1/2015.
• APPLICANTS MUST ESTABLISH FINANCIAL ELIGIBILITY BEFORE BEING ASSESSED FOR MEDICAL
ELIGIBILITY.
• STAFF MUST PASS A FITNESS DETERMINATION THROUGH THE WV CARES PROGRAM TO BE
ELIGIBLE FOR EMPLOYMENT.
• NO CHANGES WERE MADE TO THE ELIGIBILITY OR AVAILABLE SERVICES.
PERSONAL CARE UPDATES
• AVAILABLE TO ASSIST AN ELIGIBLE MEMBER TO PERFORM ACTIVITIES OF DAILY LIVING (ADLS)
AND INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADLS) IN THE MEMBER’S HOME, PLACE OF
EMPLOYMENT, OR COMMUNITY.
• TO BE MEDICALLY ELIGIBLE FOR PERSONAL CARE (PC) SERVICES, MEDICAID MEMBERS MUST
HAVE THREE (3) DEFICITS AS IDENTIFIED ON THE PRE-ADMISSION SCREENING AND REQUIRE
HANDS-ON ASSISTANCE/SUPERVISION/ CUEING IN ADLS/IADLS ORDERED BY A PHYSICIAN
AND BE PROVIDED BY A QUALIFIED PERSONAL CARE PROVIDER(S).
• NO MAJOR PROGRAM CHANGES; NEW POLICY WILL BE PUT OUT FOR PUBLIC COMMENT
SOON.
• NEW POLICY MANUAL WENT INTO EFFECT 10/1/2015.
• APPLICANTS MUST ESTABLISH FINANCIAL ELIGIBILITY BEFORE BEING ASSESSED FOR MEDICAL
ELIGIBILITY.
• STAFF MUST PASS A FITNESS DETERMINATION THROUGH THE WV CARES PROGRAM TO BE
ELIGIBLE FOR EMPLOYMENT.
• ELIGIBILITY CRITERIA WERE EXPANDED TO ALLOW CHILDREN AGE 3 AND OLDER TO APPLY
(PREVIOUSLY HAD TO BE AT LEAST 22 YEARS OLD).
• EXPANDED DEFINITION OF TBI TO INCLUDE ANOXIA DUE TO NEAR DROWNING.
BEHAVIORAL HEALTH UPDATES
• DURING FISCAL YEAR 2015, THE TOTAL REQUESTS REVIEWED FOR AUTHORIZATION WERE:
• HIGH INTENSITY SERVICE REQUESTS = 20,346
• (ACUTE PSYCHIATRIC INPATIENT, PRTF, PARTIAL HOSPITALIZATION, ETC.)
• OUTPATIENT SERVICE REQUESTS = 348,576
• PROVIDER TYPES REGISTERED WITH APS AS OF 4/8/16: (NOT INDENTED)
• 97 LICENSED BEHAVIORAL HEALTH CENTERS
• 161 PSYCHIATRIC PROVIDERS
• 217 PSYCHOLOGICAL PROVIDERS
• 8 LICENSED INDEPENDENT CLINICAL SOCIAL WORKERS
BEHAVIORAL HEALTH INFORMATION AND TIPS FOR SUBMISSIONS
• WHEN COMPLETING THE APS CARE CONNECTION, THE LEVEL OF FUNCTIONING AREAS
SHOULD BE RATED BASED UPON APPROPRIATE AGE AND DEVELOPMENTAL EXPECTATIONS
FOR CHILDREN.
• FOR CLINIC AND REHABILITATION PROVIDERS WITH INTENSIVE SERVICE (S) DESCRIPTIONS,
FUTURE MODIFICATIONS TO ANY IS DESCRIPTIONS WILL BE JOINTLY REVIEWED BY BMS AND
BBHHF.
• TRAINER CONSULTANTS ARE AVAILABLE TO PROVIDE ASSISTANCE RELATED TO THE PROPOSED
REVISIONS TO THE WV MEDICAID TARGETED CASE MANAGEMENT MANUAL OR ANY OTHER
BEHAVIORAL HEALTH SERVICE.
REMINDERS TO PROVIDERS SUBMITTING MEDICAL REQUESTS
• REMEMBER TO MAKE SURE THAT THE REFERRING/SERVICING PROVIDERS ARE ACTIVE IN MOLINA-
APS CANNOT EXPORT AUTHORIZATIONS TO MOLINA WHEN THE REFERRING OR SERVICING
PROVIDER IS TERMED.
• REMEMBER USER LOG-INS ARE ONLY TO BE USED BY THE PERSON THEY ARE ASSIGNED TO. EACH
REGISTERED PROVIDER HAS AN ORGANIZATION MANAGER WHO CAN ADD A USER. PASSWORD
RESETS COMPLETED BY APS STAFF CAN ONLY BE DONE FOR THE USER TO WHOM THE LOG-IN IS
ASSIGNED
• REMEMBER TO SEARCH BY CPT/HCPCS CODE WHEN SELECTING SERVICES-THIS WILL ENSURE THAT
WHEN SERVICES ARE GROUPED THE CORRECT GROUP IS SELECTED
• REMEMBER THAT FOR SERVICES THAT REQUIRE PRIOR AUTHORIZATION BEYOND SERVICE LIMITS
CONSULT THE APPROPRIATE BMS MANUAL CHAPTER FOR THE LIMIT AND BE SURE THE MEMBER HAS
EXCEEDED IT BEFORE SUBMITTING A PRIOR AUTHORIZATION REQUEST- LIMITS ON THE MASTER
CODE LIST RELATE TO REQUESTS BEYOND SERVICE LIMITS AND MAY NOT MATCH THE NUMBER OF
UNITS ALLOWED BEFORE PRIOR AUTHORIZATION-THIS STEP CAN SAVE YOU TIME AND WORK
REMINDERS TO PROVIDERS SUBMITTING MEDICAL REQUESTS
• REMEMBER TO ATTACH ALL CLINICAL INFORMATION REFERENCED OR REQUIRED IN THE
REQUEST IF YOU INDICATE ATTACHED (E.G. DIAGNOSTIC REPORTS, H&P, IMAGING FINDINGS,
LAB RESULTS, ETC.)
• PLEASE REMEMBER THAT A CASE MAY BE PENDED FOR ADDITIONAL INFORMATION. YOU MAY
WANT TO CHECK THE C3 SYSTEM TO BE SURE NO ADDITIONAL DOCUMENTATION HAS BEEN
REQUESTED. THIS WILL PREVENT CLOSURE OF THE REQUEST IN THE ABSENCE OF THE
NECESSARY CLINICAL DOCUMENTATION.
• A FACILITY’S IQ REVIEW DOES NOT REPLACE CLINICAL DOCUMENTATION. IT IS FINE TO
INCLUDE THIS WITH A REQUEST BUT WE MUST RECEIVE THE APPROPRIATE CLINICAL
INFORMATION TO CONDUCT A REVIEW.
MODIFICATION TO EXISTING AUTHORIZATIONS
• AUTHORIZATIONS MUST CONTAIN THE APPROPRIATE ICD-10/ICD-9 CODE FOR THE SERVICE
DATES-PLEASE CHECK TO BE SURE THE PROPER DIAGNOSTIC FORMAT IS USED WHEN COPYING
AN AUTHORIZATION REQUEST FOR NEW SUBMISSION, REQUESTING A MODIFICATION TO AN
EXISTING REQUEST OR REQUESTING A RETROSPECTIVE AUTHORIZATION.
• CHANGES IN MOLINA HEALTHPAS 5.0 HAVE RESULTED IN NEW PROCEDURES FOR
MODIFICATION OF EXISTING AUTHORIZATIONS. THERE ARE SOME MODIFICATIONS THAT
CANNOT BE PERFORMED IN THE SAME MANNER.
PEER-TO-PEER (LEVEL 1 RECONSIDERATION) & RECONSIDERATION (LEVEL 2)
• PEER-TO-PEER MAY BE REQUESTED FOLLOWING A SERVICE DENIAL BY SELECTING THE LEVEL 1
RECONSIDERATION ACTION AND SUBMITTING ANY ADDITIONAL INFORMATION
• PEER-TO-PEER REQUESTS ARE REVIEWED AND TRIAGED AND THE PROVIDER WILL BE
CONTACTED BY APS TO SCHEDULE A TIME FOR THE PEER-TO-PEER DISCUSSION IF THE REQUEST
CANNOT BE APPROVED BASED ON ANY ADDITIONAL DOCUMENTATION SUBMITTED.
• LEVEL 2 RECONSIDERATION MAY BE REQUESTED FOLLOWING A SERVICE DENIAL AND/OR
PEER-TO-PEER BY SELECTING THE LEVEL 2 RECONSIDERATION ACTION AND SUBMITTING ANY
ADDITIONAL INFORMATION.
• LEVEL 2 IS THE FINAL RECONSIDERATION ACTION AVAILABLE TO PROVIDERS.
FAXING REQUESTS OR ATTACHMENTS • IF YOU ARE FAXING REQUESTS OR ATTACHMENTS, PLEASE MAKE SURE YOU PROVIDE YOUR STAFF WITH THE
CURRENT LIST OF FAX NUMBERS. THE LIST OF FAX NUMBERS IS INCLUDED IN THIS PRESENTATION.
• IF FAXING ATTACHMENTS FOR A REQUEST THAT HAS BEEN SUBMITTED VIA DIRECT DATA ENTRY, PLEASE MAKE
SURE TO USE THE PROPER FAX COVER SHEET, AND MAKE SURE YOU PUT THE AUTHORIZATION REQUEST ID ON
THE FORM. WE CANNOT ATTACH INFORMATION WITHOUT THAT ID BECAUSE A PATIENT COULD HAVE MULTIPLE
REQUESTS AND WE WOULDN’T HAVE ANY WAY OF KNOWING WHICH ONE IT IS FOR.
• IF SUBMITTING AN AUTHORIZATION REQUEST VIA FAX, YOU MUST FILL OUT THE FORM IN ITS ENTIRETY. UM
SUPPORT STAFF WHO ENTER REQUESTS ARE NOT AUTHORIZED TO GUESS ON ANY INFORMATION THAT IS LEFT
BLANK.
• ANY ADDITIONAL DOCUMENTATION NEEDS TO BE SUBMITTED WITH THE FAXED REQUEST. FAILURE TO DO SO COULD
RESULT IN HAVING THE REQUEST FAXED BACK TO YOU OR THE REQUEST BEING CLOSED BECAUSE THE INFORMATION
WAS NOT REQUESTED IN A TIMELY MANNER.
• PROVIDERS WHO FAX REQUESTS ARE STILL REQUIRED TO CHECK THE C3WV SYSTEM TO DETERMINE
APPROVALS/DENIALS AND TO CHECK STATUS OF THE REQUEST.
ACUTE INPATIENT REQUESTS
• REMEMBER WHEN SUBMITTING CLINICAL INFORMATION TO INCLUDE SPECIFIC TREATMENTS
AND CLINICAL INFORMATION RELEVANT TO THE ADMITTING DIAGNOSIS (E.G. BASELINE O2
SATURATION AND ABG, IF APPLICABLE FOR RESPIRATORY ISSUES; IV RATES/HR, VITAL SIGNS;
NEURO CHECKS, ASSESSMENTS, ETC. AS THESE ARE OFTEN PART OF IQ CRITERIA AND CAN
SAVE THE NURSE HAVING TO CALL FOR THE INFORMATION AND DELAYING YOUR RESULT);
• PLEASE BE SURE TO INCLUDE A CLINICAL CONTACT IN CASE ADDITIONAL CLINICAL
INFORMATION IS NEEDED
OUTPATIENT SURGERY REQUESTS • INCLUDE ALL CPT CODES NEEDED ON THE REQUEST. THE PRIMARY PROCEDURE SHOULD BE ON
THE SERVICE REQUEST LINE-ADDITIONAL PROCEDURES MAY BE PLACED IN THE ANNOTATION
SECTION. WE DO NOT SELECT SERVICE CODES FOR YOU!
• ELECTIVE PROCEDURES REQUIRE THE CLINICAL DOCUMENTATION TO SUPPORT THE ELECTIVE
PROCEDURE: EXAM FINDINGS, LABS, IMAGING, PREVIOUS INTERVENTIONS ETC.
• THE REQUESTED SURGERY SHOULD CORRELATE TO THE PATIENT DIAGNOSIS AND CLINICAL
DOCUMENTATION. FOR EXAMPLE, A REQUEST FOR A HYSTERECTOMY FOR A DIAGNOSIS OF
EPILEPSY WHERE 100 PAGES OF DOCUMENTATION IS PROVIDED RELATED TO THE MEMBER’S
EPILEPTIC HISTORY AND VARIOUS HEALTH ISSUES DOES NOT CORRELATE. THE DOCUMENTATION
SUBMITTED SHOULD BE RELEVANT TO THE REQUEST AND SUPPORT THE MEDICAL NECESSITY OF
THE REQUEST.
DMEPOS (PROSTHETIC & ORTHOTIC) REQUESTS
• HOME EVALUATIONS ARE REQUIRED FOR ALL WHEELCHAIR REQUESTS, AND HOYER LIFTS. THIS IS PART
OF INTERQUAL CRITERIA FOR THESE REQUESTS. ALSO , THE DMEPOS MANUAL UPDATED JANUARY 1,
2016 REQUIRES: “A FACE-TO-FACE ENCOUNTER JUSTIFYING THE MEDICAL NECESSITY AND A WRITTEN ORDER BY THE
PRESCRIBING PRACTITIONER FOR THE DMEPOS SERVICES REQUESTED IS REQUIRED. DOCUMENTATION MUST BE MAINTAINED IN THE
MEMBER’S RECORD AND BE AVAILABLE TO BMS OR THEIR DESIGNEE UPON REQUEST “ WE DO REQUEST THIS FACE TO FACE
ENCOUNTER INFORMATION IF WE NEED MORE CLINICAL INFORMATION FOR REVIEW OF A REQUEST.
• WE ARE UNABLE TO ACCEPT CLINICAL INFORMATION OLDER THAN 6 MONTHS (EX: SLEEP STUDIES, OXYGEN
SATURATIONS, OFFICE NOTES, HOSPITAL RECORDS, ETC). TO SUPPORT A REQUEST FOR PRIOR
AUTHORIZATION.
• FOR DMEPOS EQUIPMENT AND SUPPLIES THAT REQUIRE PRIOR AUTHORIZATION BEYOND SERVICE LIMITS NO
REQUEST NEEDS TO BE SUBMITTED UNTIL THE INITIAL MEMBER BENEFIT SPECIFIED IN HAS BEEN USED. CODES
WITH PA REQUIRED AND REQUIRED BEYOND SERVICE LIMITS ARE INDICATED ON THE APS MASTER CODE LIST
(CODES REQUIRING PRIOR AUTHORIZATION).
DMEPOS (PROSTHETIC & ORTHOTIC) REQUESTS
• THE QUANTITIES FOR EACH ITEM MUST BE SUBMITTED (WHETHER IT IS DOCUMENTED IN C3
NOTES, OR, PREFERABLY LISTED ON THE CMN) BECAUSE C3 DEFAULTS THE QUANTITIES TO A
SPECIFIC AMOUNT WHICH MAY BE GREATER OR LESS THAN THE AMOUNT NEEDED.
• FOR CODES REQUIRING COST INVOICES- THE COST INVOICE MUST BE NON-ALTERED AND
SPECIFY THE INDIVIDUAL MEDICAID MEMBER. WE CANNOT ACCEPT QUOTES OR SCREEN-
SHOTS OF SHOPPING CARTS AS INVOICES.
• THE COST CALCULATION FORM SHOULD MATCH THE PRICING ON THE COST INVOICE.
• THE REQUESTED CODES SHOULD ALSO BE LISTED ON THE COST INVOICE.
DMEPOS (PROSTHETIC & ORTHOTIC) REQUESTS • VENT CODES UPDATED EFFECTIVE 1/1/16: E0465 FOR INVASIVE, E0466 FOR NON-INVASIVE.
• THE SERVICE LIMIT FOR TEST SOCKETS (L5620 – L5628) IS 2 PER YEAR. THIS WILL ACCOMMODATE 1
PER LOWER EXTREMITY. IF MORE THAN 2 ARE BEING REQUESTED, A JUSTIFICATION MUST BE
PROVIDED TO EXPLAIN THE NEED AND THERE MUST BE PROOF THAT THE ADDITIONAL SOCKET(S)
WILL BE PROVIDED TO THE PATIENT. THE “POTENTIAL NEED TO EXCEED SERVICE LIMITS” IS NOT
ADEQUATE JUSTIFICATION. IF IT IS DETERMINED THAT ADDITIONAL SOCKETS ARE NEEDED WHILE THE
PROSTHESIS IS BEING FABRICATED, AUTHORIZATION WILL NEED TO BE OBTAINED AT THAT TIME.
• E0260 SEMI-ELECTRIC HOSPITAL BED AND E0277 POWERED PRESSURE-REDUCING MATTRESS ARE
NON-REIMBURSABLE TOGETHER; AND REMAINS NON-REIMBURSABLE WHILE THE OTHER IS STILL
UNDER CAP RENTAL.
• SERVICE LIMITS FOR WHEELCHAIRS ARE ONE PER FIVE YEARS. JUST BECAUSE IT HAS BEEN 5 YEARS,
DOES NOT MEAN A NEW WHEELCHAIR IS NECESSARY- MEDICAL NECESSITY NEEDS TO BE JUSTIFIED.
HOME HEALTH REQUESTS • WE NEED ORDERS TO BE ATTACHED/ FAXED IN ADDITION TO OASIS/485 INFORMATION FOR
CASES THAT EXCEED 60 VISITS IN A CALENDAR YEAR . PER BMS HOME HEALTH MANUAL ---
“ALL HOME HEALTH SERVICES THAT EXCEED 60 VISITS IN A CALENDAR YEAR REQUIRE PRIOR AUTHORIZATION. PLEASE SEE
SECTION 508.10, PRIOR AUTHORIZATION FOR ADDITIONAL INFORMATION. IT IS THE RESPONSIBILITY OF THE PROVIDER
TO MAINTAIN THE PLAN OF CARE (POC) FORM, (CMS-485 & CMS-486) OR THE AGENCY’S POC FORM OF THEIR
CHOOSING, AND OASIS ASSESSMENTS ON FILE. HOME HEALTH AGENCIES MUST HAVE ALL REQUIRED POC DATA
ELEMENTS IN A READILY IDENTIFIABLE LOCATION WITHIN THE MEDICAL RECORD.”
HOSPICE REQUESTS • ALL REQUESTS MUST INCLUDE A SIGNED PHYSICIAN CERTIFICATION FORM AS WELL AS A
HOSPICE ELECTION FORM (HEF1).
• FOR ALL ELECTION PERIODS AFTER ELECTION 2 PLEASE BE SURE TO SUBMIT EVIDENCE OF
DECLINING STATUS INCLUDING DECREASED PPS SCORE OR ADDITION OF COMORBIDITIES.
• ALZHEIMER’S AS THE SOLE QUALIFYING CONDITION FOR HOSPICE IS NO LONGER PERMISSIBLE
BY MEDICARE & MEDICAID POLICY- PLEASE LIST ALL COMORBID CONDITIONS WHEN HOSPICE
IS REQUESTED FOR MEMBER’S WITH ALZHEIMER’S DIAGNOSES.
IMAGING REQUESTS • REMEMBER TO REPORT CONSERVATIVE TREATMENT HISTORY (E.G. PHYSICAL
THERAPY/DURATION; HOME EXERCISE/DURATION) AND NSAIDS HISTORY
(DURATION/DOSAGES)- THESE ARE THE TWO MOST COMMONLY OMITTED ITEMS THAT ARE
REQUIRED FOR REVIEW. IF THESE INTERVENTIONS ARE CONTRAINDICATED SPECIFY REASON IN
MEDICAL JUSTIFICATION.
• INCLUDE PREVIOUS IMAGING (MRI, CT, X-RAY) RESULTS AND DATE(S) OF PROCEDURES
PT/OT REQUESTS
• FOR PT/OT REQUESTS, PLEASE INCLUDE THE FOLLOWING WITH EACH REQUEST: A PHYSICIAN
ORDER THAT IS SIGNED AND DATED, THE INITIAL EVALUATION, RECENT PROGRESS NOTES
INDICATING PROGRESS TOWARD TREATMENT GOALS AND A TREATMENT PLAN INCLUDING
LONG AND SHORT TERM GOALS AND THE NUMBER OF VISITS ANTICIPATED TO MEET
ESTABLISHED GOALS.
• FOR SCHOOL-AGED CHILDREN, SUBMIT A SIGNED DOCUMENT FROM PARENT/GUARDIAN THAT
THEY HAVE NOTIFIED THE SCHOOL DISTRICT THAT THEY CANNOT SEEK MEDICAID
REIMBURSEMENT FOR THE SERVICE OR AN IEP OR NOTIFICATION FROM THE SCHOOL DISTRICT
THAT THE REQUIRED SERVICES ARE NOT AVAILABLE OR ARE INSUFFICIENT TO MEET THE
MEMBER’S NEEDS (THIS IS REQUIRED FOR SPEECH THERAPY SERVICES AS WELL).
• IF A MEMBER IS/HAS RECEIVED BOTH OT/PT IN THE CALENDAR YEAR, PLEASE NOTE THAT IN THE
DOCUMENTATION. REMEMBER BOTH OT/PT COMBINED COUNT FOR THE 20 INITIAL VISITS A
MEMBER MAY RECEIVE WITHOUT FULL CLINICAL REVIEW.
PT/OT REQUESTS
• DO NOT CHOOSE “INITIAL” AS THE STATUS FOR A REQUEST IF THE MEMBER HAS RECEIVED
ANY PHYSICAL OR OCCUPATIONAL THERAPY VISITS IN THE CURRENT CALENDAR YEAR. DO
NOT CHOSE “ESTABLISHED” IF THERE WAS NO PREVIOUS THERAPY IN THE CURRENT
CALENDAR YEAR, EVEN IF THE MEMBER HAS ALREADY STARTED THERAPY WHEN THE REQUEST
WAS SUBMITTED. EXAMPLE: MEMBER BEGAN THERAPY ON 03/26/2016, BUT REVIEW WAS
NOT SUBMITTED UNTIL 04/01/2016 WITH A START DATE OF 03/26/2016, WITH NO
PREVIOUS THERAPY IN 2016-THIS WOULD BE AN INITIAL REVIEW.
• UNSPECIFIED CODES, SUCH AS 97139 AND 97039, ARE UNLISTED CODES AND WILL NEED TO
SPECIFY TYPE OF THERAPY FOR 97139 AND TIME IF USING FOR CONSTANT ATTENDANCE
(97039).
• FOR CHIROPRACTIC REQUESTS, PLEASE INCLUDE THE FOLLOWING: RECENT X-RAY RESULTS
(NOT REQUIRED FOR A CHILD OR PREGNANCY), NUMBER OF VISITS ALREADY COMPLETED IN
THE CALENDAR YEAR PRIOR TO THE CURRENT REQUEST (IF ANY), PROGRESS NOTES,
TREATMENT PLAN/PROGNOSIS, AND MEMBER HISTORY.
APS HEALTHCARE, INC. CONTACT INFORMATION
BEHAVIORAL HEALTH
MEDICAL SERVICES EMAIL: [email protected]
ANGELA HOBBS UM NURSE SUPERVISOR [email protected] EXT. 4477
ALICIA PERRY OFFICE MANAGER [email protected] EXT. 4452
CINDY BUNCH ELIGIBILITY SPECIALIST [email protected] EXT. 4408
TONYA TACY ELIGIBILITY SPECIALIST [email protected] EXT. 4468
JASPER SMITH ELIGIBILITY SPECIALIST [email protected] EXT. 4490
GENERAL APS INFORMATION: WWW.APSHEALTHCARE.COM/WV
WEBSITE FOR SUBMITTING AUTHORIZATIONS: HTTPS://PROVIDERPORTAL.APSHEALTHCARE.COM
WEBSITE FOR ORG MANAGERS TO ADD/MODIFY USERS HTTPS://C3WV.APSHEALTHCARE.COM
REMEMBER: E-MAIL US AT WVMEDICALSERVICES2APSHEALTHCARE.COM TO BE ADDED TO OUR E-MAIL LIST. THIS WILL ENSURE YOU RECEIVE IMPORTANT INFORMATION AND ANNOUNCEMENTS DIRECTLY.