Service Authorization for Surgical Procedures (Service Type 0302)

Presented to Virginia Medicaid Providers

INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT

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Methods of Submission of Service Authorization (Srv Auth) Requests to KePRO

• KePRO accepts service authorization (Srv Auth) requests through direct data entry (DDE), fax and phone.

• Submitting through DDE puts the request in the worker queue immediately; faxes are entered by the administrative staff in the order received.

• For direct data entry requests, providers must use Atrezzo Connect Provider Portal.

• For DDE submissions, service authorization checklists may be accessed on KePRO’s website to assist the provider in assuring specific information is included with each request.

• To access Atrezzo Connect on KePRO’s website, go to http://dmas.kepro.com.

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• Provider registration is required to use Atrezzo Connect.

• The registration process for providers happens immediately on-line.

• From http://dmas.kepro.com, providers not already registered with Atrezzo Connect may click on “Register” to be prompted through the registration process. Newly registering providers will need their 10-digit National Provider Identification (NPI) number and their most recent remittance advice date for YTD 1099 amount.

• The Atrezzo Connect User Guide is available at http://dmas.kepro.com :  Click on the Training tab, then the General tab.

Methods of Submission of Srv Auth Requests to KePRO

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• Providers with questions about KePRO’s Atrezzo Connect Provider Portal may contact KePRO by email at atrezzoissues@kepro.com.

• For service authorization questions, providers may contact KePRO at providerissues@kepro.com.

• KePRO may also be reached by phone at 1-888-827-2884, or via fax at 1-877-OKBYFAX or 1-877-652-9329.

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Srv Auth Requests: Contact Information for KePRO/ DMAS Provider Information

• COPIES OF MANUALS• DMAS publishes electronic and printable copies of its Provider Manuals

and Medicaid Memoranda on the DMAS Web Portal at https://www.virginiamedicaid.dmas.virginia.gov/wps/portal.

• This link opens up a page that contains all of the various communications to providers, including Provider Manuals and Medicaid Memoranda.

• The Internet is the most efficient means to receive and review current provider information.

• If you do not have access to the Internet or would like a paper copy of a manual, you can order it by contacting:

Commonwealth-Martin at 1-804-780-0076. A fee will be charged for the printing and mailing of the manual updates that are requested.

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Provider Manual Copies Available

VIRGINIA MEDICAID WEB PORTAL

• DMAS offers a web-based Internet option to access information regarding Medicaid or FAMIS member eligibility, claims status, check status, service limits, service authorizations, and electronic copies of remittance advices. 

• Providers must register through the Virginia Medicaid Web Portal in order to access this information. The Virginia Medicaid Web Portal can be accessed by going to: www.virginiamedicaid.dmas.virginia.gov.  If you have any questions regarding the Virginia Medicaid Web Portal, please contact the Xerox State Healthcare Web Portal Support Helpdesk, toll free, at 1-866-352-0496 from 8:00 a.m. to 5:00 p.m. Monday through Friday, except holidays.

• The MediCall audio response system provides similar information and can be accessed by calling 1-800-884-9730 or 1-800-772-9996. Both options are available at no cost to the provider. Providers may also access service authorization information including status via KePRO’s Provider Portal at http://dmas.kepro.com.

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Srv Auth Information: Member Eligibility

• Decisions made by KePRO apply only to individuals enrolled in Medicaid fee-for-service on dates of service requested.

• KePRO’s decision does not guarantee Medicaid eligibility or fee-for-service enrollment.

• It is the provider's responsibility to verify member eligibility and to check for managed care organization (MCO) enrollment.

• For MCO enrolled members, the provider must follow the MCO's Srv Auth policy and billing guidelines.

• Because the individual may transition between fee-for-service and the Medicaid managed care programs, KePRO will honor the Medicaid MCO service authorization if the member has been disenrolled from the MCO.

 

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ELIGIBILITY VENDORS: How to check for Member Eligibility

• DMAS has contracts with the following eligibility verification vendors offering internet real-time, batch and/or integrated platforms. Eligibility details such as eligibility status, third party liability, and service limits for many service types and procedures are available. Contact information for each of the vendors is listed below:– Passport Health Communications, Inc.– www.passporthealth.com– sales@passporthealth.com– Telephone: 1 (888) 661-5657– SIEMENS Medical Solutions – Health Services– Foundation Enterprise Systems/HDX– www.hdx.com Telephone: 1 (610) 219-2322– Emdeon– www.emdeon.com Telephone 1 (877) 363-3666

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Surgical Procedures: Procedure/Service Codes that Require Srv Auth-How to Determine if Srv Auth is Needed.

• In order to determine if services need to be service authorized, providers should go to the DMAS website: http://dmasva.dmas.virginia.gov and look to the right of the page and click on the section that says Procedure Fee Files which will then bring you to this: http://www.dmas.virginia.gov/pr-fee_files.htm.

• You will now see a page entitled DMAS Procedure Fee Files. The information provided there will help to determine if a procedure code needs service authorization or if a procedure code is not covered by DMAS.

• To determine if a service needs Service Authorization determine whether you wish to use the CSV or the TXT format.

• Click on either the CSV or the TXT version of the file. Scroll until you find the code you are looking for.

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Surgical Procedures: Procedure/Service Codes that Require Srv Auth-How to Determine if Srv Auth is Needed (continued).

• The Procedure Fee File will tell you if a code needs to be prior authorized as it will contain a numeric value for the PA Type, such as one of the following:

00 – No PA is required

01 – Always need PA

02 – Only needs PA if service limits are exceeded

03 – Always need PA, with per frequency. • To determine whether a service is covered by DMAS you need to access

the Procedure Rate File Layouts page from the DMAS Procedure Fee Files.

• Flag codes are the section which provides you special coverage and/or payment information. A Procedure Flag of “999” indicates that a service is non-covered by DMAS.

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Srv Auth Information Specific to Surgical Procedures (0302)

• Service requests must be submitted by the provider prior to the service being performed, since this is a planned service ; per DMAS Memo dated 3/9/12 and Physician/Practitioner Manual Appendix D.)

• Inpatient hospitalization services must be authorized separately by KePRO should the procedure or service requires an inpatient hospital level of care. The provider is responsible for submitting this request.

• For those CPT/HCPCS codes that utilize SIMplus criteria, providers must submit a request within two (2) business days following the procedure to be considered timely

• Service authorization decisions are rendered for 1 unit and 90 days or as requested by provider but not to exceed a six month timeframe. 

• Administrative denials would occur if the provider did not respond to a pended request for initial clinical information or submitted a request after the request for service has been performed and the member is not retro-eligible

• Established timeframes listed above are also applicable to out of state providers.

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Srv Auth Information Specific to Surgical Procedures (0302)

• McKesson InterQual®, CMS or DMAS Specific Criteria is utilized to review Srv Auth request.

• If the Clinical or Nurse Reviewer is unable to approve the request based on established criteria the request is automatically referred for Physician Reconsideration Review.

• Application of EPSDT Criteria for members under the age of 21, are performed at a Physician Review level or as directed by the Contractor’s Medical Director. .

• KePRO will apply SIMplus® criteria to certain procedure codes (see Provider Memo dated 3/9/2012 and Physician Manual Ch IV and V.– These services will be reviewed retrospectively since SIMplus® is not designed for

prospective review of surgeries or for any type of prior authorization– Providers must submit their request timely, within 2 business days following the procedure. – If there is additional information required, the Contractor will pend the request for 20

business days. If the provider does not submit the additional information within the 20 business days specified, then the request will move forward in the review process and a final determination made with the information that has been submitted.

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Srv Auth Information Specific to Surgical Procedures (0302)

• For all Gastric Bypass/Bariatric surgical services, KePRO must verify that the treating facility is a CMS certified center of excellence. The link below has an updated site for all CMS certified facilities. If the treating facility is not CMS certified, the request can be administratively denied. This is supported by 12VAC30-50-580, facility selection standards for good surgery outcomes. 

• http://www.cms.gov/MedicareApprovedFacilitie/BSF/list.asp#TopOfPage• DMAS also requires KePRO to apply two levels of Physician Reviews for

all gastric bypass/bariatric procedure requests as noted under Physician Reconsideration Review section.

• For all Septoplasty surgeries, the DMAS Medical Director has modified McKesson InterQual® criteria to require a CT scan to confirm septal deviation. For requests that do not have a completed CT scan, the reviewer will reject the case until the provider obtains a CT scan, thus completing the required work up. The provider can then re-submit their request once a CT scan is obtained.

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Srv Auth Information Specific to Surgical Procedures (0302)

• Cosmetic surgery is not covered when provided solely for the purpose of improving appearance.

• The exclusion of cosmetic surgery does not apply to congenital deformities or to deformities due to recent injury. When surgery also restores or improves a physiological function, it is not considered cosmetic surgery. (Provider Manual and 14VAC5-140-60)

• Abnormal congenital malformations and deformities, in children under the age of 21 years, are not considered cosmetic.

• Medical necessity, for approval, in adults 21 years of age and older must be clearly documented.

• Treatment of trauma related deformity, especially in the acute stages, is not considered cosmetic. In chronic stages, medical necessity is required.

• Implantable devices for the sole purpose of Substance Abuse treatment is not covered for members 21 years of age and older (12VAC30-50-140). there needs to be documented evidence of an organic cause of pain in order to meet pain management services, including implantable drug infusion therapy. 14

Srv Auth Information Specific to Surgical Procedures (0302) Requests

• Should the date of service request change KePRO will update the service authorization while considering any untimely issues.

• Retrospective review will be performed when a provider is notified of a member’s retroactive eligibility for Virginia Medicaid coverage.

• Retrospective review will also apply when Medicaid dually eligible members exhaust their Medicare coverage.

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Faxing Requests to KePRO

• Providers must use the specific fax form listed below when requesting Surgical Procedures

• If the fax form is not accompanied by the request, KePRO will reject the request and the provider must resubmit the entire request with the correct fax form.

• The DMAS 351 (Procedures/Devices Service Authorization Request Form) is the appropriate form to use for Surgical Procedures)

• Forms are available on KePRO’s website at http://dmas.kepro.com. • Providers may click on the “Forms” tab to view a listing of all KePRO

fax forms, labeled by form number and service type. • Service authorization checklists may be accessed on KePRO’s website to

assist the provider in assuring specific information is included with each request for Surgical Procedures.

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Out of State Provider Requests

• Out of state providers must be enrolled with Virginia Medicaid in order to submit a request for out of state services to KePRO.

• If the provider is not enrolled as a participating provider with Virginia Medicaid, the provider is still encouraged to submit the request to the Contractor, as timeliness of the request will be considered in the review process.

• Out of state providers may enroll with Virginia Medicaid by going to: https://www.virginiamedicaid.dmas.virginia.gov/wps/myportal/ProviderEnrollment.

• (At the toolbar at the top of the page, click on Provider Services and then Provider Enrollment in the drop down box.  It may take up to 10 business days to become a Virginia participating provider.)

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Out of State Providers Not Enrolled in Virginia Medicaid

• KePRO will pend the request back to the provider for 12 business days to allow the provider to become successfully enrolled. 

 • If the provider responds with the necessary information within the 12

business days, the request will then continue through the review process and a final determination will be made on the service request.

 • If KePRO does not receive the information to complete the processing of

the request within the 12 business days, the request will be rejected, as the service authorization cannot be entered into MMIS without the providers National Provider Identification (NPI).

 • Once the provider is successfully enrolled, the provider must resubmit the

entire request.

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Review Process for Out of State Providers

• Procedures may be performed out of state only when the service cannot be performed in Virginia and/or meet any of the circumstances below.

• Services provided out of state for circumstances other than these specified reasons shall not be covered.

• For out-of–state facilities request, the Contractor will need to apply item number 3 and 4. – 1. The medical services must be needed because of a medical emergency; – 2. Medical services must be needed and the recipient's health would be endangered if he

were required to travel to his state of residence; – 3. The state determines, on the basis of medical advice, that the needed medical services,

or necessary supplementary resources, are more readily available in the other state; – 4. It is the general practice for recipients in a particular locality to use medical resources in

another state.

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• For out-of–state facilities request, the Contractor will need to apply item number 3 and 4 on the previous slide. If the provider is unable to establish item 3 and 4, the Contractor will:  – If surgery requested is Gastric Bypass/Bariatric Surgery then supply the provider with a list

of CMS Certified Hospitals in Virginia for Gastric Bypass/Bariatric Surgery– Pend the request for 20 days– Have the provider research and confirm items 3 or 4 and submit back to the Contractor

their findings

 • Should the provider not respond or not be able to establish items 3 or 4 the

request can be administratively denied. This decision is supported by 12VAC30-10-120 and 42 CFR 431.52.

 

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Review Process for Out of State Providers (continued)

DMAS Helpline Information

• The “HELPLINE” is available to answer questions Monday through Friday from 8:00 a.m. to 5:00 p.m., except on holidays. The “HELPLINE” numbers are:

•  • 1-804-786-6273 Richmond area and out-of-state long distance• 1-800-552-8627 All other areas (in-state, toll-free long distance)•  • Please remember that the “HELPLINE” is for provider use only. Please

have your Medicaid Provider Identification Number available when you call.

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Questions and Answers

Thank you for your Participation!

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