Page 1 of 39 Provider Manual Section 5.0 Utilization Management Table of Contents 5.1 Utilization Management 5.2 Review Criteria/Standards for Review 5.3 Authorization Requirements 5.4 Online Authorization 5.5 Inpatient Admissions and Observation 5.6 Outpatient Services 5.7 High Cost Medication 5.8 Prior Authorization for Members with Original Medicare 5.9 Retrospective Authorization 5.10 Denials
39
Embed
Provider Manual Section 5.0 Utilization Managementpassporthealthplan.com/wp-content/uploads/2015/03/Section5... · 5.3 Authorization Requirements ... medical records. These should
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Page 1 of 39
Provider Manual
Section 5.0
Utilization Management
Table of Contents
5.1 Utilization Management 5.2 Review Criteria/Standards for Review
5.3 Authorization Requirements 5.4 Online Authorization 5.5 Inpatient Admissions and Observation 5.6 Outpatient Services 5.7 High Cost Medication
5.8 Prior Authorization for Members with Original Medicare 5.9 Retrospective Authorization 5.10 Denials
• Magnetic Resonance Imaging (MRI); Magnetic Resonance Angiogram (MRA)
• Positron Emissions Tomography (PET)
• Nuclear Cardiac Imaging (NCM)
Authorizations are performed at MSI using their own internal criteria and medical management system.
MSI performs initial review, retrospective review, denials and 1st level appeals. Authorization is
required for advanced diagnostic imaging services performed in any outpatient setting.
Authorization is NOT required if the imaging service is performed in:
• Emergency rooms
• Inpatient settings
• 23-hour observations – Service performed in observation do not require an authorization. There are three (3) ways to request an authorization:
1. Internet: www.medsolutionsonline.com - Available 24/7
2. Phone: (877) 791-4099 Available 8 a.m. - 9 p.m. EST, Monday through Friday Toll free
3. Fax: 1-888-693-3210 Forms available at www.medsolutionsonline.com or by calling MedSolutions Customer Service at (877) 791-4099 Only MedSolutions fax forms are accepted Available 24/7
See Appendix A for a list of codes that require an authorization.
5.6.3 Durable Medical Equipment
The Department for Medicaid Services (DMS) requires that an updated Certificate of Medical
Necessity (CMN) be signed by the provider for all supplies and equipment and kept on file by the
supplier for a period of five (5) years. The only exception is oxygen for which Passport Health Plan
follows Medicare guidelines.
DME PURCHASE
DME items with billable charges greater than $500 require an authorization. Requests for authorization
of purchase MUST be received PRIOR to the end of the rental period.
DME RENTAL
Authorization requirements of rentals are determined by the billable price of the item being rented.
Rental charges will be applied to purchase price.
If the billable price of the rental is $500 or less, no authorization is required. If the billable price of the
rental is greater than $500, authorization is required.
All items requiring customization or accessories require prior authorization.
does not apply to the pharmacy benefit. See Section 14 for prior authorizations related to pharmacy.
Authorizations for Synagis must be requested from Passport’s Pharmacy Benefits Manager. See section
14 for prior authorizations related to pharmacy.
For requests of high cost medications, providers may contact the UM Department at (800) 578-0636 or
fax the request to (502) 585-7989.
5.8 Prior Authorization for Members with Medicare
Prior authorization is not required for services listed on the prior authorization list when the member
has Medicare as the primary payer and benefits under Medicare have not been exhausted. This applies
to both inpatient and outpatient services. When benefits are exhausted, or if the service is not a benefit
covered under Medicare, and Passport Health Plan becomes the primary payer, prior authorization
requirements apply for both outpatient and inpatient services.
For those members who have exhausted their Medicare Part A inpatient lifetime reserve days, prior
authorization of inpatient services must be obtained. If a member’s lifetime reserve days are exhausted
during an inpatient hospitalization, notification to Passport Health Plan must be made within one
business day of the notification to the facility of the exhaustion of benefits by Medicare.
5.9 Retrospective Authorization
Retrospective review of inpatient services is performed when the patient was not a member of Passport
Health Plan prior to or at the time of the service. Outpatient services do not require retrospective
review by Utilization Management for members whose eligibility is determined retrospectively.
Providers have 60 days from the notification of eligibility on retrospectively enrolled members to submit
medical records for review and utilization management authorization request. If the practitioner does
not provide documentation, the card issue date, segment date, and claims history are used. A decision
and written notification is provided within ten (10) business days of receipt of the medical information
for the retrospective review request. An administrative denial is issued for retrospective requests when
the provider fails to request a utilization management review of the medical record within the timeframe
specified.
The provider is notified of all decisions regarding retrospective reviews. In cases of denial, a written
notification is provided.
Requests received beyond 60 days from the card issue date or from the provider’s documentation of the
date when they were aware of the member’s eligibility will be administratively denied.
Send requests for retrospective review to:
Utilization Management Retrospective Review
5100 Commerce Crossings Drive Louisville, KY 40229
Page 14 of 39
The phone number for retrospective review is: (502) 585-7972 or fax to: (502) 585-8207 (for large chart
review, please send records via mail).
5.10 Denials
An authorization request for a service may be denied for failure to meet guidelines, protocols, medical
policies, or failure to follow administrative procedures outlined in the Provider Contract or this Provider
Manual.
Members may not be billed by participating providers for deductibles, copays, and coinsurance except
those allowed by DMS. If pre-authorization criteria are not met resulting in a denied claim, members
must be held harmless for denied services.
To speak with the Medical Director or to the nurse reviewer regarding a denial, please contact
Utilization Management at (800) 578-0636.
5.10.1 Medical Necessity Denials
Utilization Management utilizes InterQual® Guidelines, medical policies and protocols to render
review decisions. Requests not meeting the guidelines, protocols, or policies are referred to a Medical
Director for clinical review.
A Passport Health Plan Medical Director renders all medical necessity denial decisions. Whenever a
denial is issued, Utilization Management provides the name, telephone number, title, and office hours
of the Medical Director who rendered the decision. The Passport Health Plan Medical Director is
available to discuss any decision rendered with the attending practitioner.
5.10.2 Administrative Denials
An administrative denial is issued for those services for which the provider has not followed the
requirements set forth in the Provider Contract or this Provider Manual. For example, an administrative
denial may be issued for failure to prior authorize an elective service, procedure, or admission. It may
also be issued for failure to notify Utilization Management within one business day of an emergency
service, procedure, or admission.
A provider may appeal an administrative denial by submitting the appeal request in writing to:
Clinical Appeals Department
5100 Commerce Crossings Drive
Louisville, KY 40229
Appendix A: Radiology Codes The codes on the list below require authorization through MedSolutions
CPT
® Category
CPT® Code
CPT® Description
MRI TMJ 70336 MRI Temporomandibular Joint (s)
CT 70450 CT Head without contrast
Page 15 of 39
CPT
® Category
CPT® Code
CPT® Description
CT 70460 CT Head with contrast
CT 70470 CT Head with & without contrast
CT 70480 CT Orbit, et al without contrast
CT 70481 CT Orbit, et al with contrast
CT 70482 CT Orbit, et al W & W/O
CT 70486 CT Maxillofacial area, (sinus) without contrast
CT 70487 CT Maxillofacial area, (sinus) with contrast
CT 70488 CT Maxillofacial area, (sinus) W & W/O
CT 70490 CT Soft-tissue Neck without contrast
CT 70491 CT Soft-tissue Neck with contrast
CT 70492 CT Soft-tissue Neck with & without contrast W & W/O
CT Angiography (CTA) 70496 CTA HEAD, with contrast, including noncontrast images, if performed, & image post-processing
CT Angiography (CTA) 70498 CTA NECK, with contrast, including noncontrast images, if performed, & image post-processing
MRI 70540 MRI Orbit, Face and/or Neck without contrast
MRI 70542 MRI Orbit, Face and/or Neck with contrast
MRI 70543 MRI Orbit, Face and/or Neck W & W/O
MRA 70544 MR Angiography (MRA) Head without contrast
MRA 70545 MR Angiography (MRA) Head with contrast
MRA 70546 MR Angiography (MRA) Head with and without contrast W & W/O
MRA 70547 MR Angiography (MRA) Neck without contrast
MRA 70548 MR Angiography (MRA) Neck with contrast
MRA 70549 MR Angiography (MRA) Neck with and without contrast W & W/O
MRI 70551 MRI Brain (Head) without contrast
MRI 70552 MRI Brain (Head) with contrast
MRI 70553 MRI Brain (Head) with and without contrast W & W/O
Functional MRI (fMRI) 70554 MRI Brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration
Functional MRI (fMRI) 70555 MRI, Brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing
CT 71250 CT Chest without contrast
CT 71260 CT Chest with contrast
CT 71270 CT Chest with and without contrast W & W/O
CT Angiography (CTA) 71275 CTA CHEST, (non-coronary), with contrast, including noncontrast images, if performed, & image post-processing
MRI 71550 MRI Chest without contrast
MRI 71551 MRI Chest with contrast
MRI 71552 MRI Chest with and without contrast W & W/O
MRA 71555 MR Angiography (MRA) Chest (excluding myocardium)- W or W/O
CT 72125 CT Cervical Spine without contrast
CT 72126 CT Cervical Spine with contrast
Page 16 of 39
CPT
® Category
CPT® Code
CPT® Description
CT 72127 CT Cervical Spine with and without contrast W & W/O
CT 72128 CT Thoracic Spine without contrast
CT 72129 CT Thoracic Spine with contrast
CT 72130 CT Thoracic Spine with and without contrast W & W/O
CT 72131 CT Lumbar Spine without contrast
CT 72132 CT Lumbar Spine with contrast
CT 72133 CT Lumbar Spine with and without out contrast W & W/O
MRI 72141 MRI Cervical Spine without contrast
MRI 72142 MRI Cervical Spine with contrast
MRI 72146 MRI Thoracic Spine without contrast
MRI 72147 MRI Thoracic Spine with contrast
MRI 72148 MRI Lumbar Spine without contrast
MRI 72149 MRI Lumbar Spine with contrast
MRI 72156 MRI Cervical Spine with and without contrast W & W/O
MRI 72157 MRI Thoracic Spine with and without contrast W & W/O
MRI 72158 MRI Lumbar Spine with and without contrast W & W/O
MRA 72159 MR Angiography (MRA) Spinal Canal and contents -with or w/o contrast
CT Angiography (CTA) 72191 CTA PELVIS, with contrast, including noncontrast images, if performed, & image post-processing
CT 72192 CT Pelvis without contrast
CT 72193 CT Pelvis with contrast
CT 72194 CT Pelvis with and without contrast W & W/O
MRI 72195 MRI Pelvis without contrast
MRI 72196 MRI Pelvis with contrast
MRI 72197 MRI Pelvis with and without contrast W & W/O
MRA 72198 MR Angiography (MRA) Pelvis -with or without contrast
CT 73200 CT Upper Extremity without contrast
CT 73201 CT Upper Extremity with contrast
CT 73202 CT Upper Extremity with and without contrast W & W/O
CT Angiography (CTA) 73206 CTA Upper Extremity, with contrast, including noncontrast images, if performed, & image postprocessing
MRI 73218 MRI Upper Extremity-other than joint-without contrast
MRI 73219 MRI Upper Extremity-other than joint-with contrast
MRI 73220 MRI Upper Extremity-other than joint-W & W/O
MRI 73221 MRI Any Joint of Upper Extremity--without contrast
MRI 73222 MRI Any Joint of Upper Extremity--with contrast
MRI 73223 MRI Any Joint of Upper Extremity—W & W/O
MRA 73225 MR Angiography (MRA) Upper Extremity -with or without contrast
CT 73700 CT Lower Extremity without contrast
CT 73701 CT Lower Extremity with contrast
CT 73702 CT Lower Extremity with and without contrast W & W/O
CT Angiography (CTA) 73706 CTA Lower Extremity, with contrast, including noncontrast images, if performed, & image postprocessing
MRI 73718 MRI Lower Extremity-other than joint-without contrast
MRI 73719 MRI Lower Extremity-other than joint-with contrast
Page 17 of 39
CPT
® Category
CPT® Code
CPT® Description
MRI 73720 MRI Lower Extremity-other than joint- W & W/O
MRI 73721 MRI Any Joint of Lower Extremity--without contrast
MRI 73722 MRI Any Joint of Lower Extremity--with contrast
MRI 73723 MRI Any Joint of Lower Extremity—W & W/O
MRA 73725 MR Angiography (MRA) Lower Extremity-with or without contrast
CT 74150 CT Abdomen without contrast
CT 74160 CT Abdomen with contrast
CT 74170 CT Abdomen with and without contrast W & W/O
CT Angiography (CTA) 74174 Computed tomographic angiography; abdomen and pelvis; with contrast material(s), including noncontrast images, if performed, and image postprocessing
CT Angiography (CTA) 74175 CTA ABDOMEN, with contrast, including noncontrast images, if performed, & image postprocessing
CT 74176 CT Abdomen & Pelvis, without contrast
CT 74177 CT Abdomen & Pelvis, with contrast
CT 74178 CT Abdomen & Pelvis, with and without contrast
MRI 74181 MRI Abdomen without contrast
MRI 74182 MRI Abdomen with contrast
MRI 74183 MRI Abdomen with and without contrast W & W/O
MRA 74185 MR Angiography (MRA) Abdomen-with or without contrast
Diagnostic CT Colonography (CTC)
74261 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material
Diagnostic CT Colonography (CTC)
74262 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non- contrast images, if performed
CT Colonography (CTC) for Screening
74263 Computed tomographic (CT) colonography, screening, including image postprocessing
Cardiac MRI 75557 Cardiac MRI for morphology and function without contrast
Cardiac MRI 75559 Cardiac MRI for morphology and function without contrast material; with stress imaging
Cardiac MRI 75561 Cardiac MRI for morphology and function without contrast, followed by contrast W & W/O
Cardiac MRI 75563 Cardiac MRI for morphology and function without contrast, followed by contrast; with stress imaging
Cardiac MRI 75565 Cardiac magnetic resonance imaging for velocity flow mapping
(List separately in addition to code for primary procedure)
Cardiac CT Calcium Scoring
75571 CT, heart, without contrast with quantitative
Cardiac CT 75572 CT, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image post processing, assessment of cardiac function, and evaluation of venous structures, if performed)
Page 18 of 39
CPT
® Category
CPT® Code
CPT® Description
Cardiac CT 75573 CT, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image post processing, assessment of cardiac LV function, RV structure and function and evaluation of venous structures, if performed)
CT Coronary Angiography (CTCA)
75574 CT, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image post processing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed)
CT Angiography (CTA) 75635 CTA ABDOMINAL AORTA and bilateral iliofemoral lower extremity runoff, with contrast, including noncontrast images, if performed, and image post-processing
3D Rendering 76376 3D Rendering with interpretation and reporting of CT,
3D Rendering 76377 3D Rendering with interpretation and reporting of CT,
CT guidance 77013 CT Guidance for, and monitoring of, parenchymal tissue
MR Guidance 77021 MR guidance for needle placement (eg, for biopsy,
MR Guidance 77022 MR guidance for, and monitoring of, parenchymal tissue
Breast MRI 77058 MRI BREAST, without and/or with contrast UNILATERAL
Breast MRI 77059 MRI BREAST, without and/or with contrast BILATERAL
CT Bone Density 77078 CT BONE MINERAL DENSITY study, 1 or more sites, axial
skeleton MRI Bone Marrow 77084 MRI Bone Marrow blood supply
Nuclear Cardiac Imaging 78451 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)
Nuclear Cardiac Imaging 78452 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection
Nuclear Cardiac Imaging 78453 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)
Page 19 of 39
CPT
® Category
CPT® Code
CPT® Description
Nuclear Cardiac Imaging 78454 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection
Cardiac PET 78459 PET Cardiac (myocardial imaging) – metabolic evaluation
Nuclear Cardiac Imaging 78472 Cardiac Blood Pool imaging, gated equilibrium; planar, single study at rest or stress
Nuclear Cardiac Imaging 78473 Cardiac Blood Pool imaging, gated equilibrium; multiple studies, wall motion plus ejection fraction, at rest and stress
Nuclear Cardiac Imaging 78481 Cardiac Blood Pool imaging, (planar), first pass technique; single study, at rest or with stress, wall motion study plus ejection fraction
Nuclear Cardiac Imaging 78483 Cardiac Blood Pool imaging, (planar), first pass technique; multiple studies at rest and with stress, wall motion study plus ejection fraction
Cardiac PET 78491 PET Cardiac (myocardial imaging), perfusion single study at rest or stress
Cardiac PET 78492 PET Cardiac (myocardial imaging), perfusion multiple studies rest/stress
Non-Cardiac PET 78608 PET Brain – metabolic evaluation
Non-Cardiac PET 78609 PET Brain – perfusion evaluation
Non-Cardiac PET 78811 PET imaging; limited area (eg, chest, head/neck)
Non-Cardiac PET 78812 PET imaging; skull base to mid-thigh
Non-Cardiac PET 78813 PET imaging; whole body
Non-Cardiac PET 78814 PET imaging with concurrently acquired CT for attenuation correction and anatomical localization; limited area (eg, chest, head/neck)
Non-Cardiac PET 78815 PET imaging with concurrently acquired CT for attenuation correction and anatomical localization; skull base to mid-thigh
Non-Cardiac PET 78816 PET imaging with concurrently acquired CT for attenuation correction and anatomical localization; whole body
Ceberal Perfusion 0042T Ceberal Perfusion Analysis using CT with contrast
Analysis
CAD for Breast MRI 0159T CAD, including computer algorithm analysis, BREAST
Magnetic Source Imaging
S8035 Magnetic Source Imaging
Page 20 of 39
CPT
® Category
CPT® Code
CPT® Description
MRCP S8037 MRCP (Magnetic ResonancE)
MRI Low field S8042 MRI Low field
Cardiac CT Calcium Scoring
S8092 CT ELECTRON BEAM (Ultrafast CT) for calcium scoring
L3214 Benesch boot pair junior L6694 Add. To upper ext. pros.,for use with locking mechanism
L3215 Orthopedic ftwear ladies oxf each L6695 Add. To upper ext. pros., not for use with locking mechanism, custom
L3216 Orthopedic ftwear ladies depth each L6696 Add. To upper ext. pros., congenital or atypical traumatic amputees, initial only
L3217 Ladies shoes hightop depth each L6697 Add. To upper ext. pros., other than congenital or traumatic amputees, initial only
L3219 Orthopedic mens shoes oxford each L6707 term dev hook, mech vol closing, any material, any size, lined or unlined
L3221 Orthopedic mens shoes dpth each L6708 term dev, hand, mech vol opening, any material, any size
L3222 Mens shoes hightop depth inl each L6709 term dev hand, mech vol. closing, any material, any size
L3224 Woman's shoe oxford brace each L6712 Terminal device, hook,mechanical vol. closing, any material, any size, lined or unlined, Pediatric, each
L3225 Man's shoe oxford brace each L6713 Terminal device, hand, mechanical, vol. opening, any material, any size,lined or unlined, Pediatric, each
L3230 Custom shoes depth inlay each L6714 Terminal device, mechanical, vol. closing, any material, any size, Pediatric, each
L3250 Custom mold shoe remov prost each L6721 terminal device, hook or hand, hvy, dty., mechanical, vol.opening, any material, any size, lined or unlined, each
L3251 Shoe molded to pt silicone s each L6722 Terminal device, hook or hand, heavy duty, mechanical, vol. closing, any material, any size, lined or unlined, each
L3252 Shoe molded plastazote cust each L6881 Automatic grasp, addt. To upper limb elect. Prosth. Terminal device
L3253 Shoe molded plastazote cust each L6882 Microprocessor control feature, addt. To upper limb prosth. Terminal device
L3254 Orth foot non-std size/w L6895 Custom glove
L3255 Orth foot non-std size/w L6900 Hand restorat thumb/1 finger
L3257 Orth foot add charge split L6905 Hand restoration multiple fi
L3330 Lift elevation, metal extension, (skate) each
L6910 Hand restoration no fingers
Page 26 of 39
L3649 orthopedic shoe modification NOS L6915 Hand restoration replacmnt g
L0468 TLSO sagittal-coronol control, rigid posterior frame - 1 per year *
L3929 Hand finger orthosis, incl. 1 or more nontorsion joints, turnbuckles, elastic bands/spring, straps, pre-fab, incl. fitting & adj., each
L0470 TLSO triplanar control - 1 per year * L3931 Wrist, hand, finger orthosis, incl. 1 or more nontorsion joints,turnbuckles, elastic bands/springs, straps, pre-fab, incl. fitting & adj., each
L0472 TLSO, triplanar control, hyperextension prefab - 1 per year *
L3970 Elevat proximal arm support
L0490 TLSO sagittal coronal control one piece prefab
L3972 Offset/lat rocker arm w/ ela
L0492 TLSO 3 rigid plastic shells, pre fab - 1 per year *
L3974 Mobile arm support supinator
L0621 Sacroiliac orthosis, flexible, pre fab L3980 Upp ext fx orthosis humeral
L0625 Lumbar orthosis, flexible, pre fab L3982 Upper ext fx orthosis rad/ul
L0626 Lumbar orthosis, sagittal control, pre fab
L3984 Upper ext fx orthosis wrist
L0627 Lumbar orthosis, sagittal control with rigid ant./post. Panels, pre fab
L3995 Add. To upper ext. sock, fracture, or equal, each
L0628 Lumbar-sacral orthosis, flexible, pre fab L4045 Replace non-molded thigh lac
L0630 Lumbar-sacral orthosis, sag. Control, pre fab
L4055 Replace non-molded calf lace
L0633 Lumbar-sacral orthosis, sag. Control, rigid post., pre fab
L4060 Replace high roll cuff
L0970 Tlso corset front L4070 Replace prox & dist upright
L0972 Lso corset front L4080 Repl met band kafo-afo prox
L0974 Tlso full corset L4090 Repl met band kafo-afo calf/