ColoradoPAR Program
Pediatric Long Term
Home Health Services
(LTHH)
August 2015
http://co.eqhs.org
Agenda
Introduction to eQHealth Solutions
Scope of Services
Overview of the PAR process
eQSuite ®
Contacts and resources at eQHealth
Solutions
• Key Dates for PAR’s during Transition
period
• Questions & Answers
• Training Evaluation and Feedback
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•
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http://co.eqhs.org
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Introduction to eQHealth
Solutions
• A non-profit population health management
and technology solutions company
• Selected by the Colorado Department of
Health Care Policy and Financing to prior
authorize services for Colorado Medicaid
clients
• Effective: September 1, 2015
http://co.eqhs.org
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APPROACH
Clinically Focused
Outcomes Oriented
Technology Driven
HIGH TECH
eQSuite ® - Proprietary cloud-based
technology platform
 Utilization Review/Prior
Authorization
 Clinical Integration
 Business intelligence
http://co.eqhs.org
HIGH TOUCH
 Denver based Project Director,
Medical Director, Clinical Nurse
Manager and Provider Education &
Outreach Specialist.
Colorado dedicated:
Customer Service staff
Provider website –
http://co.eqhs.org
(prior to 9/1/15)
 http://coloradoPAR.com
(after 9/1/15)
General and customized webinar
training
 Email communication specific to 4
service type
Scope of Services
Prospective PAR Determinations
•
•
•
Diagnostic Imaging
Durable Medical Equipment
Physical & Occupational Therapy
•
Medical
– Transplants
– Surgical Procedures: such as Bariatric surgery
– Molecular Testing – BRCA1 and BRCA2
Pediatric Long Term Home Health
Private Duty Nursing
Out of State Non-emergency Inpatient Stays
Audiology
Synagis®
Vision
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•
•
•
•
•
http://co.eqhs.org
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Scope of Services
• 24 hour access for PAR submissions
• Provider Communication and Support
• Provider Education and Outreach
• Comprehensive Utilization Management Program
– Prior Authorization Review (PAR)
– Retrospective Reviews
– Reconsiderations and Peer-To-Peer reviews
– PAR Revisions
– Real time access to provider reports
http://co.eqhs.org
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Scope of Services
Prior authorization through eQSuite ® is required when
the item or service code requires an authorization as
defined by the ColoradoPAR program.
Please be sure to VERIFY the Client’s eligibility for CO Medicaid
and determine whether the service requires prior authorization
before submitting a PAR request.
Reminder: Prior Authorization does not guarantee Medicaid
payment for services.
http://co.eqhs.org
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Long Term Home Health
The Home Health benefit provides services from a
licensed and certified Home Health Agency (HHA) for
clients who need Intermittent Home Health Services.
Home Health Services include:
– Skilled Nursing (RN/LPN)
– Certified Nurse Aide Services (CNA)
– Physical Therapy (PT)
– Occupational Therapy (OT)
– Speech/Language Pathology (SLP) services
http://co.eqhs.org
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Medical Necessity
To meet the criteria for Medically Necessity the
services shall:
• Be reasonably expected to prevent, diagnose,
cure, correct, reduce or ameliorate the pain
and suffering, or the physical, mental,
cognitive, or developmental effects of an
illness, injury or disability. It may include a
course of treatment that includes mere
observation or no treatment at all;
• Be provided in accordance with generally
accepted standards of medical practice in the
United States;
http://co.eqhs.org
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Medical Necessity
Continued
• Be clinically appropriate in terms of type,
frequency, extent, site, and duration;
• Not be primarily for the economic benefit of the
provider or for the convenience of the client,
caretaker, or provider; and
• Be performed in a cost effective and most
appropriate setting required by the client’s
condition.
http://co.eqhs.org
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PAR Required
Acute Home Health: 60 days or less– No PAR
required
Long Term Home Health Services – PAR required
– Pediatric recipients under the age of 21
– Services to be authorized: Skilled Nursing, Certified
Nursing Assistant, Physical Therapy, Occupational
Therapy, Speech Therapy
– Long Term home based therapy services are only
available to recipients 20 years of age or younger.
• Recipients ages 21 and older who continue to require therapy
after the initial Acute Home Health period may obtain Long Term Therapy Services in an outpatient setting
http://co.eqhs.org
http://co.eqhs.or
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Early and Periodic Screening,
Diagnosis and Treatment
•
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
is a federal Medicaid regulation that requires the state Medicaid
agency to cover services, products, or procedures for Medicaid
clients ages 20 and younger if the service is medically necessary
to correct or ameliorate the physical, mental cognitive or
developmental effects of an illness, injury or disability.
•
EPSDT covers most of the medical or remedial care a child
needs to improve or maintain his/her health in the best
condition possible, compensate for a health problem, prevent it
from worsening, or prevent the development of additional
health problems.
•
Under EPSDT, children ages 20 and younger are eligible for
Home Health care with less restrictive limitations than adults
over age 21.
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LTHH Visit Types
Discipline
Type of Visit
RN/LPN
• Standard Nursing Visit • First nursing visit of
the day
•
Brief Nursing Visit
Comments
• Multiple visits in one
day for uncomplicated
skilled tasks that can be
completed in a shorter
or brief visit
PT/OT/SLP
Visit up to 2.5 hours
For clients ages 20 and
younger.
CNA
• Initial Visit
• One Hour
• Extended Visit
•
For visits lasting
more than one hour,
extended units of 1530 minutes
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LTHH PAR Submission Requirements
All LTHH PAR submissions must include:
• The complete and current plan of care using the CMS-485 or
other document that is identical in content which must include
a clear listing of:
• Client’s diagnoses that will be addressed by Home Health, using
V-codes whenever appropriate,
• The specific frequency and expected duration of the visits for
each discipline ordered,
• The duties/treatments/tasks to be performed by each discipline
during each visit,
• All other supporting documentation to support your request
including physician’s orders, treatment plans, nursing
summaries, nurse aide assignment sheets, medications listing,
etc,
• Any other documentation deemed necessary by the Department
or its authorizing agency.
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Pediatric Assessment Tool (PAT)
• Providers are required to submit the PAT Tool with
PAR requests. Initially this will be done as a paper
attachment.
• The score on the PAT tool is used as a piece of the
necessary information by eQhealth reviewers to
determine the medical necessity of requested
Home Health services.
• When requesting additional services outside of
those identified in PAT, provide additional clinical
information demonstrating medical necessity.
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PAR Required
A full list of codes requiring prior authorization can be found in the:
COLORADO MEDICAL ASSISTANCE PROGRAM
Home Health
Billing Manual
https://www.colorado.gov/pacific/hcpf/billing-manuals
http://co.eqhs.org
http://co.eqhs.or
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Prior Authorization
Requests
All prior authorization requests (PARs)
must be submitted via eQSuite ® ,
eQHealth’s proprietary, web-based
utilization management system.
http://co.eqhs.org
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First Level Screening
Verification:
• The client is eligible for services on the
date of service requested.
• The request is for a benefit reviewed under
the ColoradoPAR Program.
• The request is not a duplication.
• The required supporting documentation is
complete, legible and conforms to all
Colorado Medicaid’s policy requirements.
http://co.eqhs.org
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First Level Clinical
Review
After submission through eQSuite ® , the review goes
to a 1st level clinical reviewer who performs the
review by applying Colorado Medicaid approved
criteria.
Our 1st level reviewers are licensed registered nurses
who have at least 3 years of clinical experience who
are trained in Medicaid state specific regulations.
http://co.eqhs.org
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First Level Clinical Review
Determinations
First Level Clinical Reviewers may:
• Approve the service as requested based on
Department approved criteria.
• Pend if additional or clarifying information is
needed.
The requesting provider will be immediately notified by:
Receiving an eQSuite ® email/notification
• Refer the request to a physician reviewer for review
and determination.
• Deny the request for non-compliance with HCPF
policy (technical denial).
http://co.eqhs.org
First level clinical
reviewers do not make medical necessity adverse determinations.
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Second Level Clinical
Review
Our 2nd level physician reviewers are licensed
physicians of Medicine or Osteopathy in active practice
and board certified in the specialty for the service they
are asked to review.
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
http://co.eqhs.org
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Second Level Clinical
Review
Physician reviewers may:
•
Approve the service(s) as requested
•
Pend the review for additional information, including a request
for a peer to peer consultation. If the request for additional
information is not received and/or the peer to peer consultation
is not completed within 4 business days, the physician reviewer
will render a determination based on the information available.
•
Render an adverse determination. An adverse determination
may be a full or partial denial of the requested services or a
reduction in services
Note: A peer to peer consultation will be attempted prior to
an adverse determination
http://co.eqhs.org
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PAR Determinations
PAR Determinations are completed within 4 business
days of receipt of all the required information.
Up to an additional 4 business days may be granted,
prior to an adverse determination, to complete a
peer to peer consultation.
 Determination notification letters are mailed to the
provider and the client by the Department’s fiscal
agent.
http://co.eqhs.org
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PAR Reconsiderations
• Both the ordering and treating provider may request a PAR
reconsideration of an adverse determination.
• PAR reconsiderations must be submitted within 10
calendar days of the adverse determination.
• PAR reconsideration requests may be submitted:
• Electronically (eQSuite ® )
• Fax
• Mail
• Phone
• eQHealth Solutions’ response time for Reconsiderations:
• Expedited - two business days
• Standard – four business days
http://co.eqhs.org
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Timelines
Submission
Prior to delivery of
services
eQHealth Response
Expedited – 2 business
days
PAR Duration
May be up to 364 days
(From and Through
dates)
Standard – 4 business
days*
Retrospective – client
was not eligible at the
time services were
provided and services
have ended.
4 business days
* An additional 4 days may be allowed for completion in order to complete a
peer-to peer review.
http://co.eqhs.org
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PAR Submission
When eQHealth is provided with the
complete PAR request:
– On business days:
• From 12:00 a.m. – 5:00 p.m.(MST) - it is considered
received that day
• After 5:00 p.m. thru 11:59 p.m. (MST) - it is
considered received on the next business day
– On holidays - it is considered received on the
next business day.
– On days following state approved closures,
e.g., natural disasters - it is considered
received on the next business day.
http://co.eqhs.org
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Expedited Review
A PAR review that is required to be done on an
expedited basis because a delay could:
a) Seriously jeopardize the life or health of the client
or the ability of the Client to regain maximum
function, or
b) In the opinion of a physician with knowledge of the
Client’s medical condition, would subject the Client
to severe pain; and cannot be adequately managed
without the care or treatment that is the subject of
the claim.
http://co.eqhs.org
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Lack of Information
If a PAR request is pended back to the requesting provider for additional or
clarifying information:
The requesting provider will be immediately notified by:
•
Receiving an eQSuite ® email/notification.
A follow-up phone call will be made to the requester prior to the request
being denied based on lack of information.
The additional information must be received within four business days
If the information is not received, the request will be denied for a
Lack of Information (LOI) and a new request must be submitted.
http://co.eqhs.org
http://co.eqhs.org
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Examples of Supporting
Documentation
REFER TO THE HCPF’S PROVIDER MANUAL FOR ITEM
SPECIFIC INFORMATION:
https://www.colorado.gov/pacific/hcpf/provider-forms
– PDN Acuity Tool
– Plan of Care (CMS-485) or other document with
nursing assessment, hospital discharge summary,
physician’s plan of treatment and orders and
other documents to support the medical
necessity and frequency of requested services.
http://co.eqhs.org
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Change of Provider
If a change of provider is required after a PAR is
completed, assist the client in completing the
“Change of Provider Form” located on
(ColoradoPAR.com, Provider Resources, Forms and
Instructions)
– Faxed submissions – include the form with the Prior
Authorization Form.
– eQSuite ® submissions:
• Fax the “Change of Provider Form” prior to
entering the review request in eQSuite ®
• Include the form with the supporting
documentation.
http://co.eqhs.org
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PAR Revisions
If a client’s needs change after a PAR review has been completed:
eQSuite ® submitters can:
• Respond “yes” to the question “Is the request to modify a
previously approved Treatment Authorization Number
(TAN)?
• Enter the previous PAR number
• Proceed with the review request
Paper submitters:
• Submit a new Prior Authorization Request form
• Clearly document “revision” on the top of the form
All revision requests require clinical review.
http://co.eqhs.org
Turn-around time for PAR Revisions is 4 Business Days
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eQSuite ®
eQSuite ® is eQHealth Solutions proprietary
web-based HIPAA compliant software system
that offers providers 24/7 accessibility to
the information and functions needed to
obtain prior authorizations.
http://co.eqhs.org
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eQSuite ®
eQSuite ® features include:
Create and submit electronic review requests
Respond to requests for additional information
Submit documentation
Respond to adverse determination
Search for previously submitted requests
Real-time access to view and download reports
Online helpline module for submission of inquiries
and issues
• Update user profiles
•
•
•
•
•
•
•
http://co.eqhs.org
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eQSuite ®
Minimal Computer System Requirements
 Any of the two most recent versions of:
Internet Explorer
Google Chrome
Mozilla Firefox
Safari
 Broadband internet connection
http://co.eqhs.org
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eQSuite ® Login
Login from coloradoPAR.com home page
http://co.eqhs.org
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eQSuite ® Login
http://co.eqhs.org
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eQSuite ® Functions
http://co.eqhs.org
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eQSuite ® Home Page – To
create a New Review
http://co.eqhs.org
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eQSuite ® Home Page – To
create a New Review
http://co.eqhs.org
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To create a New Review
http://co.eqhs.org
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eQSuite ® PAR Request
http://co.eqhs.org
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eQSuite ® PAR Request
Diagnosis
http://co.eqhs.org
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eQSuite ® PAR Request
Item
s
http://co.eqhs.org
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eQSuite ® PAR Request
Dates Tab
http://co.eqhs.org
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eQSuite ® PAR Request
All Tabs for PDN review
http://co.eqhs.org
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eQSuite ® PAR Request
http://co.eqhs.org
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Uploading Supporting
Documentation
http://co.eqhs.org
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Uploading Supporting
Documentation
http://co.eqhs.org
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Submitting Supporting
Documentation
Please submit all supporting documentation electronically.
If unable to submit electronically, please submit by fax.
The review- specific fax cover sheets are available for download and print as
soon as the review request is completed and entered into eQSuite ®.
Each fax cover sheet includes a bar code that is specific to the particular
recipient and the type of information required.
You must use only the assigned fax cover sheet for the specific type of
supporting documentation.
Do NOT copy or reuse fax cover sheets!
http://co.eqhs.org
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eQSuite ® Attachments
http://co.eqhs.org
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eQSuite ® “Search”
http://co.eqhs.org
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eQSuite ® Reports
http://co.eqhs.org
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Respond to Denial
http://co.eqhs.org
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eQSuite ® Online Helpline
http://co.eqhs.org
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Getting Started
1. Complete the “Request for eQSuite ® Users Form”. You can locate this
form by clicking on the link below or by visiting our website
http://co.eqhs.org
http://co.eqhs.org/Portals/2/Request%20for%20eQSuite%20Access.pdf
 Assign an eQHealth Liaison
 Assign a System Administrator
 Sign and date
 Scan or fax
2. System Administrator
Assign logons to staff
Assign roles to staff based on job responsibilities
http://co.eqhs.org
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eQSuite ® User Administration
http://co.eqhs.org
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eQSuite ® Update my Profile
http://co.eqhs.org
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ALL PARs must be submitted
via eQSuite ®
Exceptions to this requirement are only if:
– The provider is visually impaired, or
– The provider is out-of-state, or the request is
for an out-of area service, or
– The provider submits, on average, five or
fewer PARs per month and would prefer to
submit a PAR by telephone or facsimile.
The eQSuite ® Exception Request Form can be downloaded from
our website, Provider Resources, Forms and Instructions.
http://co.eqhs.org
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Transition
Providers should continue to submit online PARs using the
current provider portal, CareWebQI, until the following
dates:
 Last day to submit a new non-urgent PAR is
Tuesday, August 25th.
If a provider does not submit the new PAR by August 25th, the
provider must wait until September 1st to submit the PAR via the
eQSuite ® PAR portal. The PAR may be backdated to August 26 th .
 Last day to submit an expedited PAR is Friday, August
28 th .
http://co.eqhs.org
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Contact Us
Customer Service –toll free
Phone: 1-888-801-9355 (M-F, 8 a.m.-5 p.m., MST)
Fax: 1-866-940-4288
Jennifer Wick – Sr. Provider Relations Specialist 720.573.7935
[email protected]
Michael Modiz – Colorado Program Director
[email protected]
Website effective now
http://co.eqhs.org
Website effective September 1 st
http://coloradoPAR.com
http://co.eqhs.org
eQHealth Solutions Colorado
303 East 17th Avenue, Suite 220, Denver, CO 80203
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