HP Provider Relations

February 2011

Prior Authorization

via Web interChange

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Agenda

– Objectives

– Valid provider types

– Demonstration

– Attachments

– Prior authorization (PA) inquiry

– PA status defined

– Helpful tools

– Questions

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Objectives

Following this session, providers will be able to:

– Determine which provider types can submit a PA request via Web interChange

– Complete the PA Submission screen in Web interChange

– Look up PA requests that were previously submitted

– Mail attachments related to a PA request

DescribeValid Provider Types

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Valid Provider Types405 IAC 5-3-10 identifies the provider types that may submit a PA request via hard copy or electronically:

–Doctor of medicine

–Doctor of osteopathy

–Dentist

–Optometrist

–Podiatrist

–Chiropractor

–Psychologist endorsed as a health service provider in psychology (HSPP)

–Home health agency (authorized)

–Hospital

–Transportation provider

–Any provider with prescriptive authority under Indiana law who prescribes drugs subject to PA

DemonstratePrior Authorization

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Certification TypeDemonstration

Listed below are definitions for the options available under "Certification Type":

– Appeal – Immediate• Informs the IHCP the request is for an administrative review

– Appeal – Standard• Informs the IHCP the request is for an administrative review

– Extension - Indicates the request is for an update to a previously approved PA

– Initial - Indicates a new request

– Renewal – Indicates an update to a previously approved PA

– Revised – Indicates a request for a change or update to a previously approved PA

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Type up to 264 characters

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Submitting the PADemonstration

– After submitting the PA, a pop-up window will display the member name and a Confirmation Number

– Web interChange will generate the PA number within 30 minutes after submitting the PA

– Until the PA number is generated, use the Confirmation Number to view the PA using the PA Inquiry function

ExplainAttachments

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Attachments

– Most PA requests require documentation to support medical necessity• Exception: Non-emergency transportation services

– To send required documentation for PA requests submitted via Web interChange, print the Prior Authorization System Update Request Form• The form is available under the Forms link at www.indianamedicaid.com

• Include the PA number – the PA number alerts CME staff that the documentation is related to a PA that has already been submitted and is in an Evaluation or Suspended status

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Attachments

CreateEnter PA #

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Attachments

– Fax the Prior Authorization System Update Request Form and supporting documentation to ADVANTAGE Health Solutions for

Traditional Medicaid Fee-for-Service and ADVANTAGE Care Select:

FAX: 800-689-2759

– Fax the Prior Authorization System Update Request Form and supporting documentation to MDwise Care Select:

FAX: 877-822-7186

DescribePrior Authorization Inquiry

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Prior Authorization Inquiry

DefinePA Status

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PA Status – Defined

Following are some of the statuses commonly assigned to PA requests:

–Approved – medical necessity guidelines are met

–Suspended – additional information requested from the member and/or the provider

–Modified – the request is approved; however, the approval is not in accordance to the requested dates, units, or dollar amount found on the original request

–Denied – the request is not approved

–Rejected – the request could not be processed

–Evaluation – request is awaiting a decision

–No PA required – procedure/revenue code does not require PA

Find HelpResources Available

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Helpful Tools

– IHCP Web site at www.indianamedicaid.com

– IHCP Provider Manual, Chapter 6

– ADVANTAGE Health Solutions – Care Select• Telephone: 1-800-784-3981

– MDwise – Care Select• Telephone: 1-866-440-2449

– ADVANTAGE Health Solutions – Fee For Service• Telephone: 1-800-269-5720

– Provider field consultant • http://provider.indianamedicaid.com/contact-us/provider-

relations-field-consultants.aspx

Q&A