WELLCARE OF KENTUCKY MEDICAID QUICK REFERENCE GUIDE :
Transcription
WELLCARE OF KENTUCKY MEDICAID QUICK REFERENCE GUIDE :
WELLCARE OF KENTUCKY MEDICAID QUICK REFERENCE GUIDE November 2014 Web Address: http://kentucky.wellcare.com/provider/resources Important Telephone Numbers Provider Services Eligibility verification, Claims, Utilization Mgmt., Language Line and Provider Complaints TTY Care and Disease Management Referrals 1-877-389-9457 1-877-247-6272 1-866-635-7045 Nurse Advice Line Members may call this number to speak to a nurse 24 hours a day, 7 days a week. Risk Management WellCare Fraud, Waste and Abuse Hotline Kentucky Medicaid Division of Program Integrity 1-800-919-8807 1-866-678-8355 1-800-372-2970 Provider Resource Guide Claim Submissions Provider Services Questions related to claim submissions Claim Payment Appeals 1-877-389-9457 For inquiries related to your electronic submissions to WellCare, please contact our EDI team at [email protected]. Preferred EDI Partner RelayHealth (McKesson) EDI Payor ID 14163 Encounter Data Submissions The Claim Payment Appeals Process is designed to address claim denials for issues related to untimely filing, incidental procedures, unlisted procedure codes, noncovered codes, etc. Claim payment appeals must be submitted in writing to WellCare within 24 months of the date on the EOP. Mail or fax all claim payment appeals with supporting documentation to: WellCare of Kentucky Health Plans, Inc. Fax 1-877-277-1808 Attn: Claim Payment Appeals P.O. Box 31370 Tampa, FL 33631-3370 1-877-411-7271 59354 WellCare of Kentucky follows the Centers for Medicare and Medicaid Services’ (CMS) guidelines for paper claims submissions. Since October 28, 2010, WellCare accepts only the original “red claim” form for claim and encounter submissions. WellCare does not accept handwritten, faxed or replicated claim forms. Claims Payment Policy Appeals Claim forms and guidelines may be found on our website at: http://kentucky.wellcare.com/Provider/Claims_Updates The Claims Payment Policy Department has created a new mailbox for provider issues related strictly to payment policy issues. Appeals for payment policy related issues (Explanation of Payment Codes beginning with IHXXX, MKXXX or PDXXX) must be submitted to WellCare in writing within 24 months of the date of denial on the EOP. Mail paper claim submissions to: Mail all appeals related to payment policy issues to: WellCare of Kentucky Health Plans, Inc. Fax 1-877-277-1808 Payment Policy Appeals Department P.O. Box 31426 Tampa, FL 33631-3426 WellCare of Kentucky Health Plans, Inc. Claims Department P.O. Box 31372 Tampa, FL 33631-3372 Appeals (Medical) Providers may seek an appeal through the Appeals Department within thirty (30) calendar days of a claims denial for lack of prior authorization, services exceeding the authorization, insufficient documentation or late notification. Mail or fax medical appeals with supporting documentation to: WellCare of Kentucky Health Plans, Inc. Attn: Appeals Department P.O. Box 436000 Louisville, KY 40253 Fax 1-866-201-0657 Grievances Member grievances may be submitted in writing or by calling Customer Service within thirty (30) calendar days of the event causing dissatisfaction. Providers may also file a grievance on behalf of the member with the member’s written consent. Mail or fax member grievances to: WellCare of Kentucky Health Plans, Inc. Fax 1-866-388-1769 Attn: Grievance Department P.O. Box 436000 Louisville, KY 40253 For your convenience, items on this QRG in bold, underlined fonts are hyperlinks to supporting WellCare of Kentucky Provider job aids, resource guides and forms when the Quick Reference Guide is viewed in an electronic format. NOTE: This guide is not intended to be an all-inclusive list of covered services under WellCare of Kentucky Health Plans, Inc., but it substantially provides current referral and prior authorization instructions. Authorization does not guarantee claims payment. All services/procedures are subject to benefit coverage, limitations and exclusions as described in the applicable plan coverage guidelines. (Revised September 2014) Page 1 of 5 KY027754_PRO_GDE_ENG Internal Approved 10302014 © WellCare 2014 KY_10_14 62906 WELLCARE OF KENTUCKY MEDICAID QUICK REFERENCE GUIDE November 2014 Web Address: http://kentucky.wellcare.com/provider/resources Pharmacy Services Pharmacy Services Including after-hours and weekends (Catamaran®) Rx BIN 603286 Rx PCN 01410000 1-877-389-9457 Fax 1-855-620-1868 Submit a Coverage Determination Request Form for: Rx GRP 476257 Exactus Pharmacy Solutions (Specialty) [email protected] Coverage Determination Requests TTY Fax Medication Appeals 1-888-246-6953 1-855-516-5636 1-866-458-9245 1-888- 865-6531 Mail medication appeal forms with supporting documentation to: WellCare Health Plans, Inc. Attn: Pharmacy Appeals Department P.O. Box 31383 Tampa, FL 33631-3383 Drugs not listed on the Preferred Drug List (PDL) Drugs listed on the PDL with a prior authorization (PA) Duplication of therapy Prescriptions that exceed the FDA daily or monthly quantity limits (QL) Most self-injectable and infusion drugs (including chemotherapy) administered in a physician’s office Drugs that have a step edit (ST) and the first-line therapy is inappropriate Drugs that have an age limit (AL) Web-based information: Medication appeals may also be initiated by contacting Provider Services. Please note that all appeals filed orally also require a signed, written appeal. PDL Inclusions http://kentucky.wellcare.com/provider/pharmacy Pharmacy Services Overview Authorization Lookup Tool Participating Pharmacies Pharmacy Services Forms To request consideration for inclusion of a drug to WellCare’s PDL, providers may write WellCare explaining the medical justification. WellCare of Kentucky Health Plans, Clinical Pharmacy Department Director of Formulary Services Pharmacy and Therapeutics Committee P.O. Box 31577 Tampa, FL 33631-3577 Behavioral Health Urgent authorizations and Provider Services Crisis Hotline 1-855-620-1861 1-855-661-6973 Outpatient authorization request submissions Inpatient hospitalization clinical submissions Fax Fax 1-877-544-2007 1-877-338-3686 Emergency behavioral services do not require authorization. Inpatient admission notification is required on the next business day following admission. Care including inpatient, residential treatment, partial hospitalization, intensive outpatient, ECT, psychological testing and some outpatient services require contact with WellCare for authorization. Inpatient concurrent review will be done telephonically. All other levels of care requiring authorization can be submitted via fax. Please submit your request for more sessions at least two weeks prior to the completion of the current authorized session(s). CareCore National Programs Effective 12/1/14: Additional programs will be added to existing CareCore services: CareCore National is our in-network vendor for the following programs: advanced radiology, cardiology, lab management, pain management, physical and occupational therapy and sleep diagnostics. Contact CareCore for all authorization-related submissions for the services listed above rendered in outpatient places of service. Please click on the hyperlinks above for a listing of the specific services and related criteria included in the CareCore programs. Urgent authorizations and Provider Services 1-888-333-8641 Authorization request submissions Fax 1-866-896-2152 Web submissions may be submitted via the CareCore Provider Web Portal. A searchable Authorization Lookup and Eligibility Tool is also available online. Contracted Networks Dental – Avesis 1-855-469-3368 Optometry & Ophthalmology – Avesis 1-855-776-9466 Transportation Authorization requests for nonemergent air and land ambulance services (POS 41 & 42)* should be submitted to WellCare of Kentucky. All other nonemergency transportation (bus, cab, van, etc.) is covered by Kentucky fee-for-service Medicaid. For your convenience, items on this QRG in bold, underlined fonts are hyperlinks to supporting WellCare of Kentucky Provider job aids, resource guides and forms when the Quick Reference Guide is viewed in an electronic format. NOTE: This guide is not intended to be an all-inclusive list of covered services under WellCare of Kentucky Health Plans, Inc., but it substantially provides current referral and prior authorization instructions. Authorization does not guarantee claims payment. All services/procedures are subject to benefit coverage, limitations and exclusions as described in the applicable plan coverage guidelines. (Revised September 2014) Page 2 of 5 KY027754_PRO_GDE_ENG Internal Approved 10302014 © WellCare 2014 KY_10_14 62906 WELLCARE OF KENTUCKY MEDICAID QUICK REFERENCE GUIDE November 2014 Web Address: http://kentucky.wellcare.com/provider/resources Prior Authorization (PA) Requirements This WellCare of Kentucky prior authorization list supersedes any lists that have been distributed to our providers. Please ensure that older lists are replaced with this updated version. Authorization changes will be denoted with a symbol for easy identification. Requirements that have been edited for clarification only will be denoted with an symbol. There are authorization changes in this edition. All services rendered by nonparticipating providers and facilities require prior authorization. Primary care physicians (PCPs) must refer members to participating specialists. It is the responsibility of the provider rendering care to verify that the authorization request has been approved before services are rendered. WellCare of Kentucky supports the concept of the PCP as the “medical home” for its members. PCPs may refer members to network specialists when services will be rendered at an office, clinic or free-standing facility (11, 50, 71 & 72)*. PCPs may use a prescription or referral form of their own, or use the “Request a Referral” link on the WellCare provider Web portal to produce a document that can be given to the member and/or faxed to the specialist. The reason for the referral and the name of the specialist must be documented in the medical record. The specialist must document receipt of the request for a consultation and the reason for the referral in the medical record. No communication with the plan is necessary for participating providers. Prior authorization for Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Program diagnosis and treatment services and EPSDT special services: Except as otherwise noted by the health plan or in 907 KAR Chapter 1 or 3, an EPSDT diagnosis or treatment or an EPSDT special service which is not otherwise covered by the Kentucky Medicaid Program shall be covered subject to prior authorization if the requirements of subsections (1) and (2) of section 9 of 907 KAR 11:034 are met. Requests for services will be reviewed to determine medical necessity without regard to whether the screen was performed by a Kentucky Medicaid provider or a non-Medicaid provider. WELLCARE’S PRIOR AUTHORIZATION (PA) LIST: Urgent Authorization Requests and Admission Notifications – Call 1-800-351-8777 and follow the prompts. Notify the plan of unplanned inpatient hospital admissions within 24 hours of admission (except normal maternity delivery admissions). Telephone authorizations must be followed by a fax submission of clinical information – by the next business day. Outpatient authorizations may be requested by phone for urgent and time-sensitive services when warranted by the member’s condition. Please add CPT and ICD-9 codes with your authorization request. Standard authorization requests may be submitted online or via fax using the numbers listed below. Place of service codes (POS)* are specified for some services. *Place of Service Codes 11 – Office 12 – Home 20 – Urgent Care Facility 21 – Inpatient Hospital 22 – Outpatient Hospital 23 – Emergency Room 24 – Ambulatory Surgery Center 31 – Skilled Nursing Facility 41 – Ambulance – Land 42 – Ambulance – Air or Water 49 – Independent Clinic 50 – Federally Qualified Health Center 51 – Inpatient Psychiatric Facility 52 – Psychiatric Facility – Partial Hospitalization 53 – Community Mental Health Center 55 – Residential Substance Abuse Treatment Facility PROCEDURES and SERVICES = New or changed requirement = Clarification of current requirement Authorization Required 56 – Psychiatric Residential Treatment Center 57 – Nonresidential Substance Abuse Treatment Facility 61 – Comprehensive Inpatient Rehabilitation Facility 62 – Comprehensive Outpatient Rehabilitation Facility 65 – End Stage Renal Disease Treatment Facility 71 – Public Health Clinic 72 – Rural Health Clinic 81 – Independent Laboratory No Authorization Required Comments DME Services Fax: 1-877-338-3713 Durable Medical Equipment X Hearing Aids Orthotics and Prosthetics X X All DME rentals require authorization. DME purchase items reimbursed at OR below $250 per line item do NOT require authorization. Contact Provider Services regarding benefit limitations. Purchase items reimbursed at OR below $500 per line item do NOT require authorization. Home Health Services Fax: 1-855-620-1871 Home Health Care Services Private Duty Nursing X X Inpatient Services Fax: 1-877-338-2996 Acute Behavioral Health Alcohol and Substance Abuse Admissions Crisis Stabilization Services Elective Inpatient Hospital Procedures (21) Electroconvulsive Therapy (ECT) X X See Comments X X See Comments Please reference Prior Authorization Grid Clinical updates required for continued length of stay. For your convenience, items on this QRG in bold, underlined fonts are hyperlinks to supporting WellCare of Kentucky Provider job aids, resource guides and forms when the Quick Reference Guide is viewed in an electronic format. NOTE: This guide is not intended to be an all-inclusive list of covered services under WellCare of Kentucky Health Plans, Inc., but it substantially provides current referral and prior authorization instructions. Authorization does not guarantee claims payment. All services/procedures are subject to benefit coverage, limitations and exclusions as described in the applicable plan coverage guidelines. (Revised September 2014) Page 3 of 5 KY027754_PRO_GDE_ENG Internal Approved 10302014 © WellCare 2014 KY_10_14 62906 WELLCARE OF KENTUCKY MEDICAID QUICK REFERENCE GUIDE November 2014 Web Address: http://kentucky.wellcare.com/provider/resources PROCEDURES and SERVICES = New or changed requirement = Clarification of current requirement Authorization Required No Authorization Required Emergency Ambulance Services X Emergency Behavioral Health Services X Emergency Room Services (23)* X Inpatient Hospital Admissions (21)* X Long Term Acute Care Hospital (LTACH) Admissions X NICU/Sick Baby Admissions Clinical updates required for continued length of stay. Long Term Acute Care Hospital: Criteria for Admission X Observations (22) Comments X Notification is required within 24 hours following admission. Clinical updates required for continued length of stay. Observation services will not require authorization; however preplanned surgical procedures will be subject to outpatient authorization requirements. Clinical updates required for continued length of stay. Residential Treatment X Skilled Nursing Facility Admissions (31)* 1 X Substance Abuse Treatment X Outpatient Services Fax: 1-877-431-0950 Advanced Radiology Services: CT, CTA, MRA, MRI, Nuclear Cardiology, Nuclear Medicine, Obstetric Ultrasounds, PET & SPECT Scans Air & Land Ambulance Transportation Ambulatory Surgery Center Services (24)* X Contact CareCore National for authorization: CareCore Provider Web Portal Phone Number 1-888-333-8641 No authorization is required for the initial three OB ultrasounds. Advanced Radiology Program Criteria X Includes nonemergency and facility-to-facility transfers. Please reference Authorization Lookup Tool Authorization Lookup Tool Behavioral Health Services Cardiology Services: Cardiac Imaging, Cardiac Catheterization, Diagnostic Cardiac procedures and Echo Stress Tests Community Mental Health Services Cosmetic Procedures (ALL)* Cytogenetic, Reproductive and Molecular Diagnostic Laboratory Testing Note: Some tests are handled by CareCore. Please refer to Lab Management section below as well. Please reference Prior Authorization Grid X Contact CareCore National for authorization: CareCore Provider Web Portal Phone Number 1-888-333-8641 Cardiology Program Criteria Please reference Prior Authorization Grid Some behavioral health outpatient services require prior authorization. Please reference Prior Authorization Grid. X Please reference Authorization Look-up Tool Dialysis Electroconvulsive Therapy (ECT) Some behavioral health outpatient services require prior authorization. Please reference Prior Authorization Grid. Some services may require annual registration. Please refer to the BH Initial Service Request Form. Refer to Clinical Coverage Guidelines X X For your convenience, items on this QRG in bold, underlined fonts are hyperlinks to supporting WellCare of Kentucky Provider job aids, resource guides and forms when the Quick Reference Guide is viewed in an electronic format. NOTE: This guide is not intended to be an all-inclusive list of covered services under WellCare of Kentucky Health Plans, Inc., but it substantially provides current referral and prior authorization instructions. Authorization does not guarantee claims payment. All services/procedures are subject to benefit coverage, limitations and exclusions as described in the applicable plan coverage guidelines. (Revised September 2014) Page 4 of 5 KY027754_PRO_GDE_ENG Internal Approved 10302014 © WellCare 2014 KY_10_14 62906 WELLCARE OF KENTUCKY MEDICAID QUICK REFERENCE GUIDE November 2014 Web Address: http://kentucky.wellcare.com/provider/resources PROCEDURES and SERVICES = New or changed requirement = Clarification of current requirement Authorization Required Hospice Care Services X Investigational & Experimental Procedures and Treatment X Laboratory (Routine) Testing (11, 22 & 81)* Office Visits and Treatment (11)* Comments X Intensive Outpatient Program (IOP) Laboratory Management (Certain Molecular and Genetic Tests) No Authorization Required Refer to Clinical Coverage Guidelines X Testing must be consistent with CLIA guidelines. Effective until 11/30/14, services are handled by WellCare: Authorization Lookup Tool Please reference Authorization Lookup Tool Effective 12/1/14: Contact CareCore National for authorization: CareCore Provider Web Portal Phone Number 1-888-333-8641 Laboratory Management Program Criteria Authorization Lookup Tool Please reference Authorization Lookup Tool Authorization Lookup Tool Pain Management Treatment X Contact CareCore National for authorization: CareCore Provider Web Portal Phone Number 1-888-333-8641 Pain Management Program Criteria Partial Hospitalization Program (PHP) X Psychological Testing X Outpatient Hospital Procedures and Services (22)* Radiology Anesthesia X No authorization is required for CPT codes 01916–01933 Radiology (Routine) Services (11, 22 & 24)* X Includes Non-Obstetric ultrasounds and mammograms. Respiratory Care Services X Sleep Diagnostics Contact CareCore National for authorization: CareCore Provider Web Portal Phone Number 1-888-333-8641 Sleep Diagnostics Program Criteria X Sterilization Services X Consent Form Required Termination of Pregnancy X Certification Form for Induced Abortion Required Urgent Care Services (20)* X Substance Abuse Treatment X Prenatal Notifications Fax: 1-877-338-3659 Obstetric Global Care X Prenatal Notification Form Therapy Services Fax: 1-855-620-1871 Physical and Occupational Therapy Speech Therapy (11, 22 & 62)* Effective until 11/30/14, services are handled by WellCare: Please reference Authorization Lookup Tool Effective 12/1/14: Contact CareCore National for authorization: CareCore Provider Web Portal Phone Number 1-888-333-8641 Physical and Occupational Therapy Criteria X For your convenience, items on this QRG in bold, underlined fonts are hyperlinks to supporting WellCare of Kentucky Provider job aids, resource guides and forms when the Quick Reference Guide is viewed in an electronic format. NOTE: This guide is not intended to be an all-inclusive list of covered services under WellCare of Kentucky Health Plans, Inc., but it substantially provides current referral and prior authorization instructions. Authorization does not guarantee claims payment. All services/procedures are subject to benefit coverage, limitations and exclusions as described in the applicable plan coverage guidelines. (Revised September 2014) Page 5 of 5 KY027754_PRO_GDE_ENG Internal Approved 10302014 © WellCare 2014 KY_10_14 62906