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.