Advanced Diagnostic Imaging

(ADI)

July 2015

1

Introduction

2

• 2011 Contract award - The Agency for Health

Care Administration (AHCA) awarded

eQHealth Solutions the contract to provide

Comprehensive Medicaid Utilization

Management Services (CMUMP) for the state

of Florida

• Local office / operations in Tampa Bay area

5802 Benjamin Center Drive, Suite 105

Tampa, FL 33634

Partnership: Agency for Health Care

Administration and eQHealth

3

http://fl.eqhs.org

eQHealth Provider Manuals

eQSuite® User Guide

Links to AHCA Handbooks

Forms and Downloads

FAQs

Training Schedules & Registration

Training PowerPoints

Resources

4

Effective August 1, 2015, all Fee-For-Service

(FFS) outpatient advanced diagnostic imaging

(ADI) procedures, including magnetic resonance

imaging (MRI), computerized axial tomography

(CAT or CT), and positron emission tomography

(PET) scans, will require authorization through

eQHealth.

Advanced Diagnostic Imaging

5

AUGUST 1, 2015

MedSolutions will process ADI requests received prior to 8/1/15.

eQHealth begins accepting requests 8/1/15.

Start Date

6

Recipient Requirements

7

Recipients must be:

Enrolled in a Medicaid benefit program that covers the services:

Fee-for-Service;

Dually eligible recipients

Medicare/Medicaid

Commercial/Medicaid

Eligible at the time services are rendered*

*Medically Needy recipients must have active eligibility on the date of service. The date of service and the dates on the PA must be included in the eligibility span.

Requests Not Reviewed by eQHealth

8

Recipients who are:

Members of a Medicaid Managed Medical

Assistance (MMA)

Recipients enrolled in MMA must have

authorization from their managed care plan.

Not Medicaid eligible, but have other coverage for

radiology services through a third party liability

source such as:

Medicare

Commercial insurance

Services provided in the following locations require

authorization:

Outpatient Hospital Departments

Physician Offices

Ambulatory Surgery Centers

Independent Laboratories

Place of Service

9

ADI services do not require authorization if provided

during:

Hospital inpatient stays

23 hour observation

Emergency Department

Place of Service

10

Medical Necessity Criteria

11

Chapter 59G-1.010 (166), Florida Administrative Code:

“Medically necessary” or “medical necessity” means that the medical or allied care, goods, or services furnished or ordered must meet the following conditions:

1. Be necessary to protect life, to prevent significant illness or significant

disability, or to alleviate severe pain;

2. Be individualized, specific, and consistent with symptoms or confirmed

diagnosis of the illness or injury under treatment, and not in excess of

the patient’s needs;

3. Be consistent with generally accepted professional medical standards

as determined by the Medicaid program, and not experimental or

investigational;

4. Be reflective of the level of service that can be safely furnished, and

for which no equally effective and more conservative or less costly

treatment is available statewide; and

5. Be furnished in a manner not primarily intended for the convenience of

the recipient, the recipient's caretaker, or the provider.

Medical Necessity

12

Medicaid reimburses services that:

• Do not duplicate another provider’s service; and

• Are medically necessary for the treatment of a specific documented medical disorder, disease or impairment.

The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, goods or services medically necessary or a medical necessity or a covered service.

Medical Necessity

13

Codes Requiring Authorization

14

A full list of the ADI codes requiring authorization is posted

on:

http://fl.eqhs.org

Multi-Specialty tab

Forms and Downloads folder

Direct link: http://fl.eqhs.org/LinkClick.aspx?fileticket=lT0AtwYQh0g%3d&tabid=333&mid=942

Review Requests

15

Prior Authorization:

Ordering Provider

M.D./D.O

PA

ARNP

Dentist

Podiatrist

Chiropractor

Retrospective;

Rendering provider

Hospital

ASC

Physician Office

Independent Lab

Reading Radiologist

Review Request Submission

16

Requests may be submitted via fax, using the posted review request form until 10/1/15.

http://fl.eqhs.org, Multi-Specialty/ADI, Forms and Downloads.

Note: There are separate forms for Ultrasound/Bio-Physical Profile (BPP). It is important to use the correct form.

All requests submitted on or after 10/1/15 MUST be submitted via eQSuite®, the online utilization management system.

Exception: Ultrasound/BPP requests continue to be submitted via fax.

Review Requests

17

Initial Request Submission Review Completion Timeframes

Routine requests Prior authorization Timeframe begins upon receipt of all required

documentation

Approved at 1st level/nurse review - within 1

business day

Referral to second level review- within 3

business days

Retrospective Reviews Within one year of the

retroactive eligibility

determination

Within 20 business days

Reconsideration review Within 10 business days of

the denial notice

Within 3 business days of receipt of the request

for reconsideration.

Request Submission & Review

Completion Timeframes

18

Type Method Timeframe

Extension of

authorization time

frame

Providers can extend for an additional

30 days, using the eQSuite® utility.

Only one 30 day extension may be

submitted.

N/A

Change of facility Submit on-line helpline ticket

Call Customer Service

Within 2 business days

Upcoding/downcoding

Modifications to an Existing Review

19

When the prior authorized code

requires….

The following process is followed

Upcoding: e.g. the code for “no contrast” was

originally approved and contrast was used

A new review determination IS required.

The provider will:

o Contact eQHealth’s Customer Service

line or submit an online helpline request

to cancel the existing authorization.

o Enter a new review request with

documentation to substantiate the

medical necessity for the study that was

performed

Downcoding: e.g. the code for “with contrast” was

originally approved and contrast was not used

A new review determination is NOT required.

The provider will:

o Contact eQHealth’s Customer Service

line or submit an online helpline request

to change in the code.

Upcoding/Downcoding

20

Verification that there are no review exclusions:

• Recipient is not eligible for part of the

requested timeframe;

• Duplication of service;

• Requested service is not covered;

• Assessment of the submitted supporting

documentation to ensure it is complete,

legible and conforms to all AHCA policy

requirements.

First Level Review

Screening

21

The clinical reviewer performs the review by applying:

• Definition of medical necessity as stated in Chapter 59G-1.010

(166), Florida Administrative Code (F.A.C.)

• McKesson InterQual

• Agency-approved clinical criteria or guidelines

Resources:

• American College of Radiology: http://www.acr.org/

• ACR Appropriateness Criteria®

• American College of Radiology Practice Parameters

SmartReview algorithms will be loaded in eQSuite® on September 1, 2015

First Level Review

Clinical

22

First Level Reviewers may:

• Approve the services as requested;

• Pend the request for additional information from the provider;

• Refer the request to a physician peer reviewer for review and

determination; or

• Cancel or issue a technical denial of the request if appropriate,

e.g.:

• Duplicative service;

• Noncompliance with AHCA policy.

First Level Review Determinations

23

• Physician peer reviewers base their determination

on generally accepted professional standards of

care, on their clinical experience and judgment and

peer to peer consultation with the ordering

physician.

• Physician reviewers may render an approval or an

adverse determination.

• An adverse determination may be a full denial of

the requested services or a reduction in services.

Second Level Review

24

Determination notifications are issued within one business day of the determination.

• An electronic advisory message is immediately issued for the requesting provider.

• A written notification of the determination is posted on eQSuite®.

• Determination specifies the approved code(s) and the duration (from and through dates).

• Notifications may be downloaded and printed.

• The recipient or legal guardian receives written, mailed notification.

Review Determination Notification

25

Notifications include:

• Service(s) approved or denied;

• Dates of service(s) approved;

• Reason for an adverse decision;

• Rights to a reconsideration and how to request

one; and

• Recipient’s right to a fair hearing and how the

recipient may request one.

Review Determination Notification

26

Any party may request a reconsideration of an

adverse determination by:

• eQSuite® (electronic)

• Phone

• Mail

• Fax

Reconsiderations

27

A physician reviewer not involved in the original

adverse determination will render one of the following: • Uphold the original adverse determination;

• Modify the original determination, approving a portion

of the service requested; or

• Reverse the original determination, approving

services requested.

Reconsideration reviews are completed within three

business days of receipt of a complete and valid

request.

Please Note: When requesting a reconsideration, new and/or additional clinical information should be submitted.

Reconsiderations

28

Recipients, or their legal representatives, may appeal an

adverse decision by requesting a fair hearing.

The appeal must be submitted:

• By written statement to AHCA Medicaid Area Office;

and

• Within 90 calendar days of the date of the adverse

determination notification mailing.

Fair Hearings

29

Supporting documentation is determined by

AHCA policy and is required to substantiate the

necessity of services.

The ordering physician prescription is required

when the request is submitted by the facility or

the reading radiologist.

If additional supporting documentation is

required, the requesting provider will be notified

via an eQSuite® pend.

Required Supporting Documentation

30

Options for submitting documentation:

1. Upload and directly link the information to the

eQSuite® review record.

2. Download eQHealth bar coded fax covered

sheet(s) from http://fl.eqhs.org and submit the

information using our 24/7 toll free fax line

855-440-3747.

3. Attach documentation to the faxed request

form (for requests submitted prior to 10/1/15)

Submitting Supporting

Documentation

31

Each fax cover sheet includes a bar code that is specific to the particular recipient and the type of required information.

The review-specific fax cover sheets are available for downloading and printing as soon as the review request is completed and entered into eQSuite®.

You must use only the assigned fax cover sheet for the specific type of supporting documentation.

Do not copy or reuse fax cover sheets!

Submitting Supporting

Documentation

32

eQSuite®

33

Proprietary eQHealth web-based software:

• Secure HIPAA-compliant technology allows

providers to record and transmit information

necessary to obtain authorizations.

eQSuite®

34

Minimal Computer System Requirements:

• Intel Pentium 4 or higher CPU and monitor

• Windows XP SP2 or higher

• 1 GB free hard drive space

• 512 MB memory

• Internet Explorer 9 or higher, Mozilla Firefox

35 or higher, or Safari 6 or higher

• Broadband internet connection

eQSuite ®

35

• Create new reviews

• Respond to requests for additional information

• Submit documentation

• Respond to adverse determinations

• Search for authorization requests/reviews

• View and download reports and letters

• Online Helpline

• Control system access

• Update user profiles

eQSuite® Functions

36

Live Demonstration

eQSuite®

37

1. Complete the Provider Contact Form;

2. Assign logons to staff.

Getting Started

38

Provider Outreach, Education

and Technical Assistance

39

• Provider Outreach and Education

• Customer Service Representatives

1-855-444-3747

8 a.m. – 5 p.m. Eastern Time

Monday – Friday

(except recognized Florida state holidays)

Provider Education & Outreach Team

40

Dedicated Florida Provider Website

http://fl.eqhs.org

Blast email distribution list

Send request to pr@eqhs.org

Include email address and “ADI” in the

body of the email.

Provider Communications

41

Transition

42

MedSolutions is responsible for all Fair

Hearings for adverse determinations

made by MedSolutions.

eQHealth is responsible for all revisions,

corrections and modifications to

MedSolutions’ reviews.

For reconsideration of MedSolutions’

adverse determinations, submit a new

authorization request to eQHealth.

Questions and Answers

43