How to submit DME prior authorization request

Report
INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT
KePRO’s Service
Authorization
Process for Durable
Medical Equipment
WY DOH/KePRO Service Authorization Process
Durable Medical Equipment
• Overview of Service Authorization
Process
• Information needed for a Request
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Verifying Eligibility
• Eligibility verification avoids unnecessary
Service Authorization delays associated
with Service Authorization submission (due
to incorrect payer source). Eligibility should
be checked for each date of service.
• Providers must submit Service
Authorization requests for member eligible
dates under the Wyoming DOH Medicaid Fee
For Service Plan.
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Submitting Service Authorization
Requests
Requests may be submitted via:
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Atrezzo Provider Portal Connect
KePRO Fax: 855-294-1197
WY Call CenterTelephone: 855-294-1196
Mail: KePRO 2810 North Parham Rd., Suite
305, Henrico Va. 23294
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Information Needed for DME Request
From CMN/ DMAS 352 Certificate of Medical Necessity
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The CMN must be completed (signed & dated by the physician, nurse
practitioner, or physician assistant) PRIOR to the PA Request and
prior to the member receiving DME Medical Supplies and
equipment.
The only exception to this is a member who is Retroactive eligible or
who has had Medicare Part B denial or HCPCS Code is non covered
by Medicare Part B
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Information Needed for a Request (cont.)
Please include the following clinical information :
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Mobility Impairments
Endurance Impairments
Restricted Activity
Skin Breakdown if Applicable (Site, Size, Depth and
Drainage)
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Information Needed for a Request (cont.)
• Impaired Respiration if Applicable with Most
Recent PO2 Level.
• Does the member require Assistance with
ADL’s.
• Speech Impairments
• Required Nutritional Supplements
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Information Needed for a Request (cont.)
• Is the Item Suitable for Use In Home
• Does the Patient/Caregiver
demonstrate Willingness / Ability to
Use the Equipment
• Date Patient Last Examined By MD
• List ICD-9 Code, Diagnosis Description
and Date of Onset
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Information Needed for a PA Request (cont.)
For Each Item Requested:
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Begin Service Date
HCPCS Code
Item Description
Length of Time Needed
Quantity Ordered per Month
Quantity/Frequency of Use
Physician Signature and Date (References to “Physician” also
include Physician Assistant and/or Nurse Practitioner
Please note if equipment is a rental or purchase
CMN form, PA request form, and DME Fax request forms can be
accessed at http://wydoh.kepro.com
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Information Needed for a Request (cont.)
• Please also include a brief description of the patient
condition including:
–Current Symptoms
–Reason the Equipment is Needed
This information assists the reviewers in further
assessing the patient’s condition.
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Tips For Submitting Requests
• When requesting a wheelchair, please include the
wheelchair evaluation results and the correct
wheelchair code
• If member has Medicare Part B and benefits were
denied or exhausted please note that on the fax or in
your clinical notes if you use DDE
• If your member is retroactive eligible for medicaid
please note that on the fax or in your clinical notes if
you use DDE
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Reference Materials
• Criteria that is used for review consists of the McKesson
InterQual® Durable Medical Equipment, and for HCPCS Codes
not covered under McKesson InterQual® the Wyoming Medicaid
Rules, Chapter 11, Medical Supplies and Equipment are used.
• The Wyoming/KePRO website includes a list of HCPCS Codes
which require PA. This can be accessed by going to the
KePRO/Wyoming DOH website @: http://wydoh.kepro.com
.
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Retroactive Reviews
• Service Authorization requests for retroactively
eligible members or “retro-reviews” are only for
cases that the member has Medicaid retroactive
eligibility.
• Requested start of care date should be entered as
the first day hands-on service was provided to the
individual once Medicaid eligibility was effective.
• On the fax form –Please mark Retro Eligibility and
indicate if review is due to Medicare B denial
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WY DOH/KePRO DME Process
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The “ Wyoming Medicaid DME Medical Supplies and Equipment
requiring PA is based on the Health Care Financing Administration
Common Procedure Coding System (HCPCS) To access the HCPCS
codes requiring PA go to: http://wydoh.kepro.com and you will be able to
access this file.
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The Procedure Code file identifies and describes HCPCS Codes which
require Service Authorization. It also includes the age requirements,
maximum units of service, notates if Medicare Coverage for the item and
indicates if item is a rental. Please note that all rentals will require the rr
modifier when direct Portal access is used to submit your request.
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For Information on how to access the Wyoming DOH Fee File
Information for HCPCS Codes go to : http://wyequalitycare.acsinc.com/manuals/Manual_DME.pdf
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WY DOH/KePRO DME Process
• Service Authorization is requested by the enrolled
DME provider
• PA Approval letters are sent to the requesting
Provider
• Notice of Adverse Decision is sent to the Member
and to the requesting Provider
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Resources
Check the Wyoming DOH Medicaid Memos
and Manuals online at:
http://wyequalitycare.acsinc.com/manuals/Manual_DME.pdf
DME Medical Supplies & Equipment Manual
http://wydoh.kepro.com
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Resources (cont)
• KePRO Website http://wydoh.kepro.com
• For any questions regarding the submission
of Service Authorization Auth requests,
please contact KePRO at the WY Call Center
855-294-1196 OR 855-294-1197 – WY Fax
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WYDOH KePRO Service Authorization Process
Durable Medical Equipment
Thank you
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