Update October 2010 No. 2010-92 Department of Health Services Affected Programs: BadgerCare Plus, Medicaid To: Adult Mental Health Day Treatment Providers, Advanced Practice Nurse Prescribers, Ambulatory Surgery Centers, Anesthesiologist Assistants, Audiologists, Case Management Providers, Certified Registered Nurse Anesthetists, Chiropractors, Community Support Programs, Comprehensive Community Service Providers, Crisis Intervention Providers, Dentists, End-Stage Renal Disease Service Providers, Family Planning Clinics, Federally Qualified Health Centers, HealthCheck Providers, HealthCheck “Other Services” Providers, Home Health Agencies, Hospital Providers, Intensive In-Home Mental Health and Substance Abuse Treatment Services for Children Providers, Master’s Level Psychotherapists, Narcotic Treatment Services, Nurses in Independent Practice, Nurse Midwives, Nurse Practitioners, Nursing Homes, Occupational Therapists, Optometrists, Outpatient Mental Health Clinics, Outpatient Substance Abuse Clinics, Personal Care Agencies, Physical Therapists, Physician Assistants, Physician Clinics, Physicians, Podiatrists, Portable X-Ray Providers, Prenatal Care Coordination Providers, Psychologists, Rehabilitation Agencies, Rural Health Clinics, Speech and Hearing Clinics, Speech-Language Pathologists, Substance Abuse Counselors, Substance Abuse Day Treatment Providers, Therapy Groups, HMOs and Other Managed Care Programs New Prior Authorization Requirements for Advanced Imaging Services Effective for dates of service on and after December 6, 2010, ForwardHealth will require prior authorization (PA) for most advanced imaging services, including CT, MR, and PET imaging. MedSolutions, a private radiology benefits manager, will administer PA for these services on behalf of ForwardHealth. Providers may begin submitting PA requests to MedSolutions on November 29, 2010. This ForwardHealth Update introduces MedSolutions and provides information about the PA process and requirements. Overview of the New Prior Authorization Requirements In response to 2009-2011 biennial budget targets, the Department of Health Services (DHS), along with representative industry stakeholders, undertook the Medicaid and BadgerCare Plus Rate Reform Project. As a result of the Rate Reform Project, ForwardHealth will begin requiring prior authorization (PA) for most advanced imaging services in an effort to do the following: Reduce redundancy of tests and prevent administration of unnecessary tests. Ensure the medical necessity of tests. Minimize member exposure to radiation. Apply national clinical guidelines for imaging services. Effective for dates of service (DOS) on and after December 6, 2010, most advanced imaging services, including CT, MR, and PET imaging, will require PA when performed in either outpatient hospital settings or in non-hospital settings (e.g., radiology clinics). MedSolutions, a private radiology benefits manager, is authorized to administer PA for advanced imaging services on behalf of ForwardHealth. Providers will work directly with MedSolutions and should submit to MedSolutions all information necessary to make a PA determination. MedSolutions uses approved national clinical guidelines for imaging services when making PA determinations. The provider who orders the advanced imaging service (e.g., the member’s primary care physician, the member’s
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Update October 2010 No. 2010-92
Department of Health Services
Affected Programs: BadgerCare Plus, Medicaid To: Adult Mental Health Day Treatment Providers, Advanced Practice Nurse Prescribers, Ambulatory Surgery Centers, Anesthesiologist Assistants, Audiologists, Case Management Providers, Certified Registered Nurse Anesthetists, Chiropractors, Community Support Programs, Comprehensive Community Service Providers, Crisis Intervention Providers, Dentists, End-Stage Renal Disease Service Providers, Family Planning Clinics, Federally Qualified Health Centers, HealthCheck Providers, HealthCheck “Other Services” Providers, Home Health Agencies, Hospital Providers, Intensive In-Home Mental Health and Substance Abuse Treatment Services for Children Providers, Master’s Level Psychotherapists, Narcotic Treatment Services, Nurses in Independent Practice, Nurse Midwives, Nurse Practitioners, Nursing Homes, Occupational Therapists, Optometrists, Outpatient Mental Health Clinics, Outpatient Substance Abuse Clinics, Personal Care Agencies, Physical Therapists, Physician Assistants, Physician Clinics, Physicians, Podiatrists, Portable X-Ray Providers, Prenatal Care Coordination Providers, Psychologists, Rehabilitation Agencies, Rural Health Clinics, Speech and Hearing Clinics, Speech-Language Pathologists, Substance Abuse Counselors, Substance Abuse Day Treatment Providers, Therapy Groups, HMOs and Other Managed Care Programs
New Prior Authorization Requirements for Advanced Imaging Services Effective for dates of service on and after December 6, 2010, ForwardHealth will require prior authorization (PA) for most advanced imaging services, including CT, MR, and PET imaging. MedSolutions, a private radiology benefits manager, will administer PA for these services on behalf of ForwardHealth. Providers may begin submitting PA requests to MedSolutions on November 29, 2010. This ForwardHealth Update introduces MedSolutions and provides information about the PA process and requirements.
Overview of the New Prior Authorization Requirements
In response to 2009-2011 biennial budget targets, the
Department of Health Services (DHS), along with
representative industry stakeholders, undertook the Medicaid
and BadgerCare Plus Rate Reform Project. As a result of the
Rate Reform Project, ForwardHealth will begin requiring
prior authorization (PA) for most
advanced imaging services in an effort to do the following:
Reduce redundancy of tests and prevent administration
of unnecessary tests.
Ensure the medical necessity of tests.
Minimize member exposure to radiation.
Apply national clinical guidelines for imaging services.
Effective for dates of service (DOS) on and after December
6, 2010, most advanced imaging services, including CT, MR,
and PET imaging, will require PA when performed in either
outpatient hospital settings or in non-hospital settings (e.g.,
radiology clinics). MedSolutions, a private radiology benefits
manager, is authorized to administer PA for advanced
imaging services on behalf of ForwardHealth. Providers will
work directly with MedSolutions and should submit to
MedSolutions all information necessary to make a PA
determination. MedSolutions uses approved national clinical
guidelines for imaging services when making PA
determinations.
The provider who orders the advanced imaging service (e.g.,
the member’s primary care physician, the member’s
ForwardHealth Provider Information October 2010 No. 2010-92 2
specialist) is required to work with MedSolutions to complete
and submit the PA request for the service. Providers may
begin submitting PA requests to MedSolutions on
November 29, 2010, for DOS on and after December 6,
2010.
The provider or facility that renders the service should do the
following prior to rendering the service:
Verify the member’s enrollment.
Verify with MedSolutions (or with the ordering
provider) that a PA has been approved for the member.
Prior authorization requirements apply to advanced imaging
services for fee-for-service members enrolled in the
following ForwardHealth programs:
Medicaid.
BadgerCare Plus Standard Plan.
BadgerCare Plus Benchmark Plan.
BadgerCare Plus Core Plan.
BadgerCare Plus Basic Plan.
Express Enrollment for Children.
Express Enrollment for Pregnant Women.
Providers are not required to obtain PA separately for
different ForwardHealth programs. If a member’s
enrollment status changes, PA granted for advanced imaging
services under one plan will still be valid for the other plan.
Prior authorization is also required for members enrolled in
state-contracted managed care organizations (MCOs) who
receive physician and radiology services on a fee-for-service
basis (e.g., Children Come First).
Providers are encouraged to obtain PA for advanced imaging
services for members who are also enrolled in Medicare (dual
eligibles). Prior authorization is not required on Medicare
crossover claims, but if Medicare denies the claim or does
not cover the services and the provider submits the claim for
the services to ForwardHealth, all PA requirements apply.
Providers are encouraged to obtain PA for advanced imaging
services for members who have other primary commercial
health insurance. If commercial insurance denies or does not
fully reimburse the claim and the provider submits the claim
for the services to ForwardHealth, all PA requirements
apply.
Refer to Attachment 1 of this ForwardHealth Update for a
complete list of procedure codes that require PA. Services
that are ancillary to an advanced imaging service (e.g.,
contrast agents or sedation) are not subject to PA
requirements.
Providers are reminded that an approved PA does not
guarantee reimbursement for the service.
Wisconsin Medicaid may decline to reimburse a provider for
a service that has been prior authorized if one or more of the
following program requirements is not met:
The service authorized on the approved PA request is
the service provided.
The service is provided within the grant and expiration
dates on the approved PA request.
The member is eligible for the service on the date the
service is provided.
The provider is certified by Wisconsin Medicaid on the
date the service is provided.
The service is billed according to service-specific claim
instructions.
The provider meets other program requirements.
Situations When Prior Authorization Is Not Required
In the following situations, PA is not required for advanced
imaging services:
The service is provided during a member’s inpatient
hospital stay.
The service is provided when a member is in
observation status at a hospital.
The service is provided as part of an emergency room
visit.
The service is provided as an emergency service.
ForwardHealth Provider Information October 2010 No. 2010-92 3
Emergency services are defined in DHS 101.03(52), Wis.
Admin. Code, as "those services which are necessary to
prevent the death or serious impairment of the health of the
individual." Reimbursement is not guaranteed for services
that normally require PA that are provided in emergency
situations. As with all covered services, emergency services
must meet all program requirements, including medical
necessity, to be reimbursed by Wisconsin Medicaid. For
example, reimbursement is contingent on, but not limited to,
eligibility of the member, the circumstances of the
emergency, and the medical necessity of the services
provided.
If an integrated health plan or provider network implements
a decision support system or other tool to manage utilization
of advanced imaging services using comparable guidelines
and monitors the success of the tool, the health plan or
provider network may request to be exempted from
requesting PA from MedSolutions. A future Update will give
further details on the exemption request process.
MedSolutions Portal
Providers are encouraged to set up an account with
MedSolutions online via the MedSolutions Portal at
www.medsolutionsonline.com/. A MedSolutions Portal account
allows ordering providers and providers who render services
to perform the following business functions:
Submit PA requests.
Verify that an approved PA is on file for a member.
View MedSolutions guidelines for making PA
determinations.
Providers who have an existing account with MedSolutions
may use that account to submit PA requests for
ForwardHealth members beginning on November 29, 2010,
for DOS on and after December 6, 2010.
For technical assistance with the MedSolutions Portal,
providers may contact MedSolutions Portal Support at (800)
575-4594.
Requesting Prior Authorization for Advanced Imaging Services
The provider who orders the advanced imaging service
should obtain PA for the service from MedSolutions because
he or she likely has the most immediate access to the clinical
information necessary to complete the PA request.
ForwardHealth allows any provider who can order advanced
imaging services within their scope of practice to complete
and submit a PA request for advanced imaging services.
will e-mail a copy of the Microsoft® PowerPoint of the
training session in Portable Document Format (PDF).
Information Regarding Managed Care Organizations
This Update contains fee-for-service policy and applies to
advanced imaging services members receive on a fee-for-
service basis only. For policy regarding advanced imaging
services covered by an MCO, contact the appropriate MCO.
Managed care organizations are required to provide at least
the same benefits as those provided under fee-for-service
arrangements.
ForwardHealth Provider Information October 2010 No. 2010-92 13
The ForwardHealth Update is the first source of program policy and billing information for providers. Wisconsin Medicaid, BadgerCare Plus, SeniorCare, and Wisconsin Chronic Disease Program are administered by the Division of Health Care Access and Accountability, Wisconsin Department of Health Services (DHS). The Wisconsin Well Woman Program is administered by the Division of Public Health, Wisconsin DHS. For questions, call Provider Services at (800) 947-9627 or visit our Web site at www.forwardhealth.wi.gov/.
P-1250
ForwardHealth Provider Information October 2010 No. 2010-92 14
(A sample “Prior Authorization Confirmation Fax” is located on the following page.)
MedSolutions has been recognized for providing "An Outstanding Customer Service Experience" under the esteemed J.D. Power and Associates Certified Call Center Program. For J.D. Power and Associates Certified Call Center ProgramSM information, visit jdpower.com
Case ID : 7777777 Auth ID: A12121212 Status : Approved
Case Type : Phone Effective : Mon, Oct 05, 09 Expires : Thurs, Dec 03, 09
Patient Information Name : DOE, JOHN HP MemberID : 0000000001 Address : 123 ANY STREET ANYCITY, ST, 99999
DOB : Dec 20, 1900 HealthPlan :Sample Health Plan
Performing Provider Information Authorized Facility : ANYNAME RADIOLOGY Address : 456 ANY STREET, ANYCITY, ST 99999
HealthPlan Id : 00000000XXXX Phone : 800/555-1212 Fax :
Referring Physician Information Procedure Requested by: DOE, JANE Address : 1234 ANY STREET ANYCITY, ST 99999 Specialty : GENERAL SURGERY
HealthPlan Id : Phone : 800/555-1213 Fax :
Clinical Information ICD9 Procedure
784.0 Headache; Other symptoms involving the head or neck.
CPT Unit Status Procedure
70551 1 Approved MRI Brain or Head; without contrast material
MedSolutions is an independent company selected to manage high-tech radiology services. The authorization is for medical necessity and does not guarantee claims payment, which is based on member benefits.
If you have questions please contact Customer Service at 1-888-693-3211.
Confidentiality Notice: This information is intended for the use of the person or entity to which it is addressed and may contain information that is privileged and confidential, the disclosure of which is governed by applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this information is
STRICTLY PROHIBITED.
If you have received this message by error, please notify MedSolutions sender at the address shown immediately and delete the related message from your files.
Fax sent to 5555551212 on Mon, Oct 05, 09 2:33 PM
ForwardHealth Provider Information October 2010 No. 2010-92 24
ATTACHMENT 3 Sample Prior Authorization Decision Notice Letter
(A sample “Prior Authorization Decision Notice Letter” is located on the following page.)
MedSolutionsOnline.com
December 20, 2010 Dr. IMA DOCTOR PA Number: 9103540123 123 MAPLE STREET PA Status: DENIED ANYTOWN, WI 55555 IM A MEMBER Dear Dr. IMA DOCTOR: Your request for prior authorization (PA) has been finalized based on criteria established by the Department of Health Services and as stated in DHS 106.03 (4), Wis. Admin. Code. Refer to the adjudication detail on the enclosed attachment for the service specific authorization. An authorized PA does not guarantee payment. Reimbursement is contingent upon enrollment of the member and provider at the time the service is provided and the completeness of the claim information. Payment will not be made for services initiated prior to the approval or after the authorization expiration date. Reimbursement will be in accordance with ForwardHealth payment methodology and policy. If the member is enrolled in a BadgerCare Plus or Medicaid Managed Care Program at the time a prior authorized service is provided, ForwardHealth reimbursement will be allowed only if the service is not covered by the Managed Care Program. A “Notice of Appeal Rights” letter has been sent to the member. Only the member, or authorized person acting on behalf of the member, may file an appeal with the Division Hearings and Appeals. Providers are encouraged to remain in contact with the member during the appeal process. Providers may offer the member information necessary to file an appeal and help present his or her case during a fair hearing. If you have any questions regarding the decisions made on this PA, please contact MedSolutions at (888) 693-3211. Sincerely,
Gregg Allen, MD Chief Medical Officer MedSolutions, Inc.
MedSolutionsOnline.com
Member Name: IM A MEMBER Member Identification Number: 123456789
Provider Name: Dr. IMA DOCTOR Provider Address: 123 MAPLE STREET ANYTOWN, WI 55555| Provider Identification Number: 987654321 PA Number: 9103540123 PA Status: DENIED
78816 POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; WHOLE BODY 0178 - THE SERVICE REQUESTED IS NOT MEDICALLY NECESSARY.
ForwardHealth Provider Information October 2010 No. 2010-92 27