Provider Notice 12-23

 

Dear provider,

 

Effective for dates of service on and after April 1, 2012, the Medicaid Program of the Health Care Authority (the Agency) will:

 

·                     Update the Outpatient Hospital and Outpatient Prospective Payment System (OPPS) Fee Schedule with added codes and coverage changes;

·                     Update changes in prior authorization requirements for certain Current Procedural Terminology (CPT®) Codes; and

·                     Implement a utilization review program to determine the medical necessity of emergency room (ER) use for conditions that could be treated in a primary care office or urgent care clinic.

 

 

Effective for dates of service on and after April 15, 2012, the Medicaid Program of the Health Care Authority (the Agency) will require prior authorization for a select group of surgical procedure codes.  Qualis Health or the Agency will be conducting the medical necessity review as indicated on the fee schedule.  Submitting requests for medically necessary reviews will begin April 1, 2012.

 

 

Overview

 

All policies previously published remain the same unless specifically identified as changed in this provider notice.

 

Fee Schedule Changes

 

Added/Changed Procedure Codes

 

The Agency will update the Outpatient Hospital and Outpatient Prospective Payment System (OPPS) Fee Schedule for procedures performed in an outpatient hospital setting. 

Updates to the Outpatient Prospective Payment System (OPPS) and Outpatient Hospital Fee Schedule will be available online at: http://hrsa.dshs.wa.gov/RBRVS

 

Effective for dates of service on and after April 1, 2012, the Agency will add the following CPT and Healthcare Common Procedure Coding System (HCPCS) procedure codes.  Procedures with a value in the alternate payment method column may be paid using the method listed.

 

 

 

Retroactive to dates of service on and after January 1, 2012, the Agency changed the following procedure codes from noncovered to covered.  Procedures with a value in the alternate payment method column may be paid using the payment method listed. The Agency will adjust claims for these services.

 

 

 

Effective for dates of service on and after April 1, 2012, the Agency will change the following CPT® codes from noncovered to covered.  Procedures with a value in the alternate payment method column may be paid using that method.

 

 

 

Effective for dates of service on and after April 1, 2012, the Agency will change the following CPT® codes from covered to noncovered in an outpatient setting:

 

 

Authorization Requirement Changes

 

Effective for dates of service on and after April 15, 2012, the following CPT codes require providers to submit PA requests via Qualis Health rather than directly to the Agency:

 

 

 

Effective for dates of service on and after April 15, 2012, the Agency will require PA for the following CPT® codes:

 

 

 

Utilization Review to Determine Medical Necessity of Emergency Room Use

 

Effective for dates of service on and after April 1, 2012, the Agency will implement a utilization review program to determine the medical necessity of emergency room (ER) use for conditions that can be treated in a primary care office or urgent care clinic.  Claims submitted for these conditions will be denied.  The Agency has worked with ER physicians and other providers to develop expedited prior authorization (EPA) criteria that will allow the emergency room physician to certify the use of the emergency room setting as medically necessary to treat one of these conditions due to extenuating clinical circumstances.  Efforts are being made to establish processes for primary care and urgent care referrals.  The Agency will continue to pay for visits to the emergency department when it determines the ER setting was the medically necessary place of service for the care.  The Agency will make available an updated list of Frequently Asked Questions, the Expedited Prior Authorization Criteria and other tools at: http://hrsa.dshs.wa.gov/authorization/

 

Authorization Requirements for Surgical Procedures

 

Changes in Authorization Requirements for Certain Surgical Procedures

 

Effective for dates of service on and after April 15, 2012, the Agency is expanding its prior authorization requirements to include selected surgical procedures.  The medical necessity review for these procedures will be conducted by the Agency or Qualis Health.

 

For more information about submitting medical necessity request reviews, go online at: Surgical Reviews.  These reviews can be submitted starting April 1, 2012.

 

The Agency and Qualis Health have contracted to provide web-based access for utilization review and prior authorization (PA) for surgeries in the following categories:

 

·                     Spinal,

·                     Major joints,

·                     Upper and lower extremities,

·                     Carpal tunnel release, and

·                     Thoracic outlet release

 

Qualis Health conducts the review of the request to establish medical necessity for surgeries, but does not issue authorizations. Qualis Health forwards its recommendations to the Agency for final authorization determination

 

Surgical services require Agency authorization regardless of place of service or when performed as:

 

·                     Urgent;

·                     An emergency; or

·                     A scheduled surgery.

 

 

The Agency will require prior authorization on some procedures that will not be reviewed by Qualis Health.  These reviews will continue to be conducted by the Agency.  Please check the OPPS fee schedule online at: Outpatient Fee Schedule, go to “O” for outpatient.  The specific review requirements will be available online April 1, 2012.

 

BC/AD

Provider Publications Team

The Medicaid Program of the Health Care Authority

 

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