Qualis Health Care Management Services for South Carolina ...

Qualis HealthCare Management Servicesfor South Carolina Medicaid

Barbara Excell, RN, MSHA, CPHQ, CPUR, PMC Director Medicaid Services Central/East

Goals and Objectives

• Provide a brief overview/background of Qualis Health including the mission, vision and values • New additions to the Prior Authorization list effective April 1, 2009• February 1, 2009 Prior Authorization changes and timeframe requirements for submission of retro charts• What these changes mean for providers• Prior authorization review form• Care Management Services and timeframes• Contact Information

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Qualis Health Background• Qualis Health, headquartered in Seattle, WA, is a

private, nonprofit health care quality improvement and care management organization (QIO).

• Qualis Health has offices in Cayce, SC; Anchorage, AK; Boise, ID; Tustin, CA and Lincoln, NE.

• Qualis Health has 30 years of experience providing health care utilization/case management and quality assessment/improvement services to public and private sector customers.

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Care Management Is Our Core Business

Vision: To be recognized for leadership, innovation and excellence in improving the health of individuals and populations

Mission: To generate, apply and disseminate knowledge to improve the quality of healthcare delivery and health outcomes

Values: Integrity, professionalism, collaboration and stewardship

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Qualis Health South Carolina Staff includes:

• Director Medicaid Services• Registered Nurses• RHIA• Professional Intake and Administrative Staff• Medical Director• Associate Medical Director• Physician Specialty Consultants

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Qualis Health SC Medicaid Services

• Care Management– Utilization Review and Quality of Care Reviews

• Retrospective reviews• DRG Analysis• Pre-authorization reviews• Support Documentation reviews • Sterilization reviews• Quality of care reviews utilizing CMS guidelines• HINN reviews• Therapeutic Foster Care onsite reviews• PRTF precert reviews• PRTF postcert reviews• PRTF annual reviews• ICF/MR reviews• IMD/RTF QOC reviews

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Qualis Health Supports the additional codes Qualis Health Supports the additional codes SC DHHS is implementing for Prior SC DHHS is implementing for Prior

Authorization Authorization Effective BeginningEffective Beginning

April 1, 2009April 1, 2009

The changes include additions to the Prior Authorization (PA) list. The changes include additions to the Prior Authorization (PA) list. These codes are in addition to all other codes requiring prior These codes are in addition to all other codes requiring prior authorization. authorization.

The following slides will assist providers in determining the best method The following slides will assist providers in determining the best method for updating daily operations/processes to comply with these new for updating daily operations/processes to comply with these new changes. Please refer to the SC DHHS provider manual to reference all changes. Please refer to the SC DHHS provider manual to reference all changes at: changes at:

http://www.dhhs.state.sc.us/dhhsnew/index.asphttp://www.dhhs.state.sc.us/dhhsnew/index.asp

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Effective April 1, 2009 Effective April 1, 2009 Additional ICD-9 Codes requiring Prior Authorization where Additional ICD-9 Codes requiring Prior Authorization where

the primary admission diagnosis is one of the following:the primary admission diagnosis is one of the following:

312.0 Undersocialized conduct disorder, aggressive type

312.1 Undersocialized conduct disorder

312.2 Socialized conduct disorder

312.3 Disorders of impulse control, not elsewhere classified

312.4 Mixed disturbance of conduct and emotions

312.8 Other specified disturbances of conduct, not elsewhere classified

312.9 Unspecified disturbance of conduct

313.81 Oppositional defiant disorder

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Qualis Health Supports the additional codes SC Qualis Health Supports the additional codes SC DHHS implemented for Prior Authorization on DHHS implemented for Prior Authorization on

February 1, 2009February 1, 2009

The changes included additions to the Prior Authorization (PA) list. These The changes included additions to the Prior Authorization (PA) list. These codes are in addition to all other codes requiring prior authorization. codes are in addition to all other codes requiring prior authorization.

The following slides will assist providers in determining the best method for The following slides will assist providers in determining the best method for updating daily operations/processes to comply with these new changes. updating daily operations/processes to comply with these new changes. Please refer to the SC DHHS provider manual to reference all changes at: Please refer to the SC DHHS provider manual to reference all changes at:

http://www.dhhs.state.sc.us/dhhsnew/index.asphttp://www.dhhs.state.sc.us/dhhsnew/index.asp

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These codes required Prior Authorization effective These codes required Prior Authorization effective February 1, 2009 February 1, 2009

19301 Partial Mastectomy 85.22

19302 P-Mastectomy W/LN Removal 85.22

19303 Mastectomy, Simple Complete 85.41

19304 Mastectomy, SQ 85.34

19305 Mastectomy, Radical 85.45

19306 Mastectomy, Radical, Urban Type 85.47

19307 Mastectomy, Modified Radical 85.43

19330 Removal of Implant Material 85.94

19370 Surgery of Breast Capsule 85

19371 Removal of Breast Capsule 85.21

19396 Design Custom Breast Implant 85.99

86.89 Skin Tissue Rearrangement

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Prior Authorization Update Prior Authorization Update Medicaid BulletinMedicaid Bulletin

The policy for Mastectomy and Reconstructive Breast The policy for Mastectomy and Reconstructive Breast Surgery did not change. Reimbursement is allowed for Surgery did not change. Reimbursement is allowed for reconstructive breast surgery following a mastectomy when reconstructive breast surgery following a mastectomy when performed for the removal of cancer or for prompt repair of an performed for the removal of cancer or for prompt repair of an accidental injury.accidental injury.

Breast reconstruction done for cosmetic reasons is non-Breast reconstruction done for cosmetic reasons is non-covered. Breast Augmentation is non-covered under all covered. Breast Augmentation is non-covered under all circumstances. Program information can be found in the circumstances. Program information can be found in the provider and hospital manuals located at provider and hospital manuals located at www.scdhhs.govwww.scdhhs.gov. .

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21899 Neck/Chest Surgery Procedure 78.41

22548 Neck Spine Fusion 81.01


22556 Thorax Spine Fusion 81.04

22558 Lumbar Spine Fusion 81.06

22585 Additional Spinal Fusion 81.62

22590 Spine & Skull Spinal Fusion 81.01

22595 Neck Spinal Fusion 81.01


22610 Thorax Spine Fusion 81.05


22614 Spine Fusion, Extra Segment 81.62


22632 Spine Fusion, Extra Segment 81.62

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22800 Fusion of Spine[arthrodesis, posterior] 81.05

22802 Fusion of Spine[7-12 vertebral segments] 81.05

22804 Fusion of Spine[13 or more vertebral segments] 81.05

22808 Fusion of Spine[arthrodesis, anterior] 81.04

22810 Fusion of Spine[4-7 vertebral segments] 81.04

22812 Fusion of Spine[8 or more vertebral segments] 81.04

22830 Exploration of Spinal Fusion 03.02

22840 Insert Spine Fixation Device[posterior non-segmental]

22841 Insert Spine Fixation Device[internal spinal fixation]

22842 Insert Spine Fixation Device[posterior segmental]

22843 Insert Spine Fixation Device[segments 7-12]

22844 Insert Spine Fixation Device[13 or more segments]

22845 Insert Spine Fixation Device[anterior with segments]

22846 Insert Spine Fixation Device[4-7 segments]

22847 Insert Spine Fixation Device[8 or more segments]

22848 Insert Pelvic Fixation Device

22849 Reinsert Spinal Fixation 81.30

22851 Apply Spine Prosth Device 84.51

22899 Spine Surgery Procedure 78.49

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63001 Removal of Spinal Lamina[laminectomy with exploration] 03.09

63003 Removal of Spinal Lamina[thoracic] 03.09

63005 Removal of Spinal Lamina[lumbar] 03.09

63011 Removal of Spinal Lamina[sacral] 03.09

63012 Removal of Spinal Lamina[laminectomy with removal of abnormal facets] 03.09

63015 Removal of Spinal Lamina[laminectomy with decompression and/or exploration] 03.09



63020 Neck Spine Disk Surgery[laminotomy] 80.51

63030 Low Back Disk Surgery[one interspace] 80.51

63035 Spinal Disk Surgery Add On[each additional interspace] 80.51

63040 Laminotomy, Single Cervical 03.02

63042 Laminotomy, Single Lumbar 03.02

63043 Laminotomy, Additional Cervical 03.02

63044 Laminotomy, Additional Lumbar 03.02

63045 Removal of Spinal Lamina[laminectomy, facetectomy and foraminotomy] 03.09



63048 Remove Spinal Lamina Add On[each additional segment] 03.09

63050 Cervical Laminoplasty 03.09

63051 C-Laminoplasty With Graft/Plate 78.49

63055 Decompress Spinal Cord 03.09

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63056 Decompress Spinal Cord[lumbar] 03.09

63057 Decompress Spinal Cord Add On[each additional segment] 03.09

63064 Decompress Spinal Cord[costovertrebral approach with decompression] 03.09

63066 Decompress Spinal Cord Add On[each additional segment] 03.09

63075 Neck Spine Disk Surgery[discectomy, anterior] 80.51

63076 Neck Spine Disk Surgery[cervical] 80.51

63077 Spine Disk Surgery, Thorax 80.51

63078 Spine Disk Surgery, Thorax 80.51

63081 Vertebral corpectomy 80.99

63082 Removal of Vertebral Body Add On[cervical] 80.99

63085 Removal of Vertebral Body[vertebral-partial] 80.99

63086 Removal of Vertebral Body Add On[thoracic] 80.99

63087 Removal of Vertebral Body[vertebral] 80.99

63088 Removal of Vertebral Body Add On[each additional segment] 80.99

63090 Removal of Vertebral Body[transperitoneal or retroperitoneal approach] 80.99

63091 Removal of Vertebral Body Add On[each additional segment] 80.99

63170 Incise Spinal Cord Tract(s) [laminectomy with myelotomy] 03.29

63172 Drainage of Spinal Cyst[laminectomy with drainage of intramedullary cyst to subarachnoid space] 03.09

63173 Drainage of Spinal Cyst[to peritoneal or pleural space] 03.09

63180Revise Spinal Cord Ligaments[laminectomy and section of dentate ligaments, w/wo graft segment]

80.49

63182 Revise Spinal Cord Ligaments[mre than 2 segments] 80.49

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63185 Incise Spinal Column/Nerves [laminectomy with rhizotomy, 1 or 2 segments] 03.1

63190 Incise Spinal Column/Nerves [more than 2 segments] 03.1

63191Incise Spinal Column/Nerves [laminectomy with section of spinal accessory nerve]

04.03

63194 Incise Spinal Column & Cord [laminectomy with cordotomy] 03.29

63195 Incise Spinal Column & Cord [thoracic] 03.29

63196Incise Spinal Column & Cord [laminectomy with cordotomy, both tracts one stage cervical]

03.29


63198Incise Spinal Column & Cord [laminectomy with cordotomy, both tracts two stages cervical]

03.29


63200Incise Spinal Column & Cord [laminectomy with release of tethered spinal cord, lumbar]

03.29

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Also Effective February 1, 2009Also Effective February 1, 2009Record receipt timeframe change per the SC DHHS bulletinRecord receipt timeframe change per the SC DHHS bulletin

South Carolina Department of Health and Human Services will no South Carolina Department of Health and Human Services will no longer grant the additional 60 days in which providers may submit longer grant the additional 60 days in which providers may submit medical records to Qualis Health for retrospective reviews. Once medical records to Qualis Health for retrospective reviews. Once Qualis Health has issued a technical denial for records that have not Qualis Health has issued a technical denial for records that have not been received within 30 days of the request, that decision stands as been received within 30 days of the request, that decision stands as final. To be sure that Qualis Health has the correct information, please final. To be sure that Qualis Health has the correct information, please contact us at (877) 717-8592 to confirm the correct mailing address contact us at (877) 717-8592 to confirm the correct mailing address and correct hospital contact in order to ensure notifications are and correct hospital contact in order to ensure notifications are received and records are submitted within the 30-day time period.received and records are submitted within the 30-day time period.Qualis Health encourages all providers to submit medical records on Qualis Health encourages all providers to submit medical records on CDs.CDs.

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Qualis Health SC Medicaid Services

Timeframes• Retrospective: Qualis Health’s goal is to provide a

decision to the provider within 30 days from receipt of all requested information. Effective February 1, 2009, providers now have 30 days to provide the retrospective records to Qualis Health.

• Pre-authorization: Qualis Health’s goal is to provide a decision to the provider within 15 days from receipt of all requested information.

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SC Medicaid PreauthorizationReview Process

Review Request ReceivedReview Request Received• FacsimileFacsimile• MailMail• TelephoneTelephone• iEXCHANGEiEXCHANGE®®

Review completed by qualified Review completed by qualified reviewersreviewers

Meets Criteria?Meets Criteria?

Notification to all Notification to all partiesparties

Approval # given to Approval # given to providers providers

telephonicallytelephonically

To physician reviewer To physician reviewer with option of peer-to-with option of peer-to-

peer discussion peer discussion offered when not offered when not

approvedapproved

Notification to facility, Notification to facility, provider and SC provider and SC

Medicaid via letter Medicaid via letter with reconsideration with reconsideration

rights includedrights included

YeYess

NoNo

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Qualis Health Supports the SC Medicaid Review Process

• Through formal training sessions

• Working consistently with SC DHHS

• During the utilization review process

• With outreach to local provider associations

• Through the local Qualis Health office. You may call us anytime at (877) 717-8592.

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As we continue to provide these QIO services, we’d like to hear from you

regarding:

• How the review process works for you• Any issues or concerns that may arise• Additional ways Qualis Health can assist you

with education on UM• Process improvement opportunities• Educational opportunities

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Contact Information

Address: Qualis Health440 Knox Abbott Drive, Suite 220Cayce, SC 29033

Phone: (803) 739-2755(877) 717-8592

Fax: (803) 739-2766(803) 739-2767(877) 717-8594

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Contact InformationBarbara Excell, RN, MHSA, CPHQ, CPUR, PMCBarbara Excell, RN, MHSA, CPHQ, CPUR, PMCDirector Medicaid Services Central/East, Director Medicaid Services Central/East, Qualis HealthQualis Health(803) 739-2758(803) [email protected]@qualishealth.org

SC DHHSSC DHHSHospital Services Hospital Services (803)-898-2665 (803)-898-2665 Physician ServicesPhysician Services (803)-898-2660 (803)-898-2660http://www.dhhs.state.sc.us/dhhsnew/index.asphttp://www.dhhs.state.sc.us/dhhsnew/index.asp

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