WY Medicaid Behavioral Health Provider Outreach Teresa Kirn, RN IQCI Manager, Care Management Department July 23, 26, and 27, 2018 Advancing Healthcare Improving Health
One of the nation’s leading healthcare consulting organizations, partnering with our clients across the country to improve care for millions of Americans every day www.qualishealth.org Advancing Healthcare Improving Health
Qualis Health • A private nonprofit organization established in 1974 • Corporate Office located in Seattle, Washington with regional offices in Alabama, Alaska, California, District of Columbia, Idaho, Kansas, and New Mexico • Providing care management to Medicaid and Private contracts since 1984 3
What We Do • Contract with Wyoming Medicaid to review for select outpatient services: – Durable Medical Equipment (DME), – Home Health Services (HHS), Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) and Behavioral Health visits. • We use InterQual and organizational policies to conduct our review • Offer telephonic provider consultation • Provider review support resource accessibility on our webpage 4
What We Don’t Do We do not receive financial incentives to deny or limit services 5
Objectives • Details of the behavioral health review guidelines • How Qualis Health uses the guidelines • Everything you need to submit with your review request • How to get your reviews approved • What you can do if you disagree with Qualis Health’s decision 6
New WY BH guidelines • New as of 6/21/2018 • Located at Qualishealth.org • How we apply these guidelines 7
Getting Started • Submit all required documentation Initial Behavioral Health intake form Updated Behavioral Health intake form (required at least annually as of 4/1/2018) The last 5 clinical notes for each service/code requested & occurring just prior to the authorization start date Signed and dated treatment plan with frequency and duration for each service/code requested clearly outlined 8
Getting Started, cont. • Date of the 20 th visit • Start and end date for the requested authorization • Number of visits/units being requested per code(s) • Submit all requests for a patient (as outlined by the treatment plan) at the same time 9
Comprehensive Qualis Health Reviews • All documentation must be submitted to Qualis Health for review of each client. For example, the client receiving case management, individual therapy and group therapy: all information will need to be submitted through the Qualis Health Provider Portal for each service request per provider with required documentation for a comprehensive review. • No reviews will be completed if past timely filing (DOS over 1 year old). 10
UM Review Process • Cases reviewed for required documents and services • Clinical reviewers use the WY BH guidelines and InterQual criteria Clinical Reviewers will approve per the guidelines and IQ criteria Clinical Reviewer will forwarded to a physician when 1 st level determination cannot be made • Physician Reviewer will make all denial determinations 11
UM Review Process, cont. • Request a reconsideration for decisions that you disagree with within 30 days of the decision • All appeals are sent to Provider Services Program Manager • Fair Hearing requests can be made by the client or their legal representative 12
Community of Care Document - CCD Viewer • CCD viewer allows authorized users to search & retrieve Patient Summary CCD for current Medicaid recipients. • This will show how many visits/services have been billed to Medicaid and if patients are being seen by other therapy providers . 13
CCD Access • Please send an email containing: − Provider Names – Clinic Name − Provider email Addresses – Address − Primary Contact – Phone number • Send to Andrea Bailey at andrea.bailey@wyo.gov • For more information visit: http://wyomingthr.wyo.gov/ccd-viewer 14
Training WebEx Schedule Date Time (MST) Training Topic 07/23/2018 10am -12pm WY Behavioral Health Provider outreach 07/26/2018 11am – 1pm WY Behavioral Health Provider outreach 07/27/2018 1 – 3PM WY Behavioral Health Provider outreach 15
Qualis Health Contact Information Phone: (800) 783-8606 Fax: (877) 810-9255 Teresa Kirn RN IQCI Manager, Clinical Care Management (208) 383-5960 teresak@qualishealth.org Lisa Layne Manager, Non clinical Care (206) 288-2385 lisal@qualishealth.org Deon Westmorland RN BSN CCM Associate Vice President, Care Management (206) 288-2347 deonw@qualishealth.org 16
Utilization Review Contact Information Utilization Review Toll-free Phone: (800) 783-8606 Toll-free Fax: (877) 810-9265 Utilization Review Hours 8:30am to 7:00pm MST Monday through Friday 17
Questions? 18
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