Wyoming Medicaid Behavioral HealthJuly 31, 2019

Qualis Health & HealthInsight have joined forces to do great things.

Together, we’re reimagining health care.

Who We Are: A national, nonprofit, health care consulting firm working collaboratively with patients, providers, payers and other stakeholders to reimagine, redesign and implement sustainable improvements in the health care system

Our Mission:Together, with our partners, we work to improve health and to create a better health care system so that people and communities will flourish.

About Us• Our services:

• Care Management• Systemwide Quality Improvement• Consulting and Research• Health IT and Analytics

• Providing care management to Medicaid and private contracts since 1984

• Office locations in Alabama, Alaska, California, District of Columbia, Idaho, Nevada, New Mexico, Oregon, Utah and Washington state

What We Do• Contract with Wyoming Medicaid to review for select

outpatient services: • Skilled Nursing (SN) reviews for waiver plans • Durable Medical Equipment (DME) • Home Health Services (HHS)• Physical Therapy (PT), Occupational Therapy (OT) and Speech

Therapy (ST)• Behavioral Health (BH) visits

• Utilize InterQual® (IQ), state guidelines and organizational policies to conduct reviews

• Offer web-based and telephonic provider education

What We Don’t Do

We do not receive financial incentives to deny or limit services

Objectives• Overview of the Comagine Health website• Provider portal registration process• How to submit a prior authorization (PA) request• Guidelines and criteria utilized • How to get your PA request processed timely• Reconsideration request submissions• How to use your provider portal dashboard

Comagine Health Website

Website Information

How to Register for the Portal

How to Start a Request

• Enter the patient’s Medicaid number, WY Medicaid for the client, and then Search

Working Steps to Set Up a Review

• Click on each tab in the left navigation panel to complete the steps

• Step 1 allows you to make edits • Complete all required steps (Steps 2,3,4

and 8)• You can preview the request prior

to submission• Click submit once your PA request is

completed

How to Get your Request Processed Quickly

• Submit all required information: Has the patient completed at least 20 visits this year Start and End Date for the requested PA request Number of visits/units being requested per code(s) Submit all PA requests for the patient (as outlined by

the treatment plan) at the same time Signed and dated treatment plan with frequency and

duration for each service/code requested clearly outlined

• Reviews will not be processed if past timely filing (Date of Service (DOS) greater than1 year)

How to Get your Request Processed Quickly cont.

• Required documentation: Initial Behavioral Health intake form Updated Behavioral Health intake form (required at

least annually as of 4/1/2018) The last 5 clinical notes for each service/code

requested & occurring prior to the authorization start date Signed and dated treatment plan with frequency and

duration for each service/code clearly outlined

UM Review Process• All documentation must be submitted to Comagine Health

for review of each client/patient In a case where the client is receiving case management,

individual therapy and group therapy, all information needs to be submitted through the Provider Portal for each service request per provider with required documentation for a comprehensive review

• Clinical reviewers use IQ criteria, state and organizational guidelines when conducting 1st level reviews

• Physician Reviewers will complete a 2nd level review when a 1st level determination cannot be made

• Only Physician Reviewers can make adverse determinations

Wyoming BH Guidelines• New as of 6/21/2018• Located at Comagine.org (link to visit

QualisHealth.org)

Reconsiderations

• Reconsiderations for adverse decisions can be requested within 30 days of the decision date

• Appeals are sent to Provider Services Program Manager

• Fair Hearings can be requested by the client or their legal representative

Dashboards and Alerts• Your dashboard will allow

you to view your client/patients

• To open a request, click on the ‘OP’ icon

• The episode number will give you an abstract view only

• You can monitor your alerts for updates to the PA request

Comagine Health Direct Contact Information

Teresa Kirn RN IQCIClinical Nurse Specialist, Clinical Care Management(208) 383-5960Tkirn@comagine.org

Lisa Layne Manager, Non-clinical Care(206) 288-2385LLayne@comagine.org

Yvette Stratton RN BSN CCMDirector, Care Management(206) 288-2443 YStratton@comagine.org

Deon Westmorland RN BSN CCMAssociate Vice President, Care Management(206) 288-2347DWestmorland@comagine.org

Utilization Review Contact Information

Utilization Review Toll-free Phone: (800) 783-8606 Toll-free Fax: (877) 810-9265

Utilization Review Hours 8:30am to 7:00pm MST Monday through Friday

Questions?