Anthem HealthKeepers Medicare-Medicaid Plan A Commonwealth Coordinated Care Plan
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Uniform Pre-Authorization/Authorization Process between MMPs and Nursing Facilities • • • •
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There will be a clear identification of Commonwealth Coordinated Care (CCC) beneficiaries on the insurance card Each plan will have a database available to the SNF/NF centers for on-line verification of benefits All MMPs will use the CMS criteria for the SNF admission as outlined in Chapter 8 of the CMS Benefits Policy Manual criteria Each MMP will provide a list of home health, DME companies that are participating with MMP. MMPs will keep this list current on their web portals. All MMPs agree to a 7 day authorization. The SNF/NF shall notify the appropriate MMP via fax or web submission on the day of admission. The MMP and the SNF/NF will begin to work collaboratively on the case during that 7 day period to determine ultimate disposition and plan for the beneficiary. 3
Referrals from Community/ED/Observation Stay/Inpatient Hospital Stay/Home Health •
Physician Order that beneficiary needs inpatient SNF stay
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The following is required when a member is referred from the Community/ ED/ Observation Stay:
Physician Order; History and Physical; MDS; Medication List; Prior Level of Function; and Projected discharge plan.
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Providers must submit via Fax or Online notification through the MMP web portal that patient met criteria and has been admitted
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PT,OT, ST-Evaluation must be completed at center within 48 hours of admission
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All MMPs agree to a 7 day authorization. The SNF/NF shall notify the appropriate MMP via fax or web submission on the day of admission. The MMP and the SNF/NF will begin to work collaboratively on the case during that 7 day period to determine ultimate disposition and plan for the beneficiary.
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The MMPs will make patient information available to the SNF/NF via the web portal. At this time, the MMPs cannot commit to implementing an electronic interface with EMR systems currently in use by various facilities. 4
Uniform update/review period • The MMPs agree that after the initial 7 day authorization period, future decisions will be made based on medical necessity. • The MMPs will notify the member beneficiary in the event of a non-coverage determination 48 hours prior to non-coverage... Facility is required to respond within 24 hours to requests for supporting documentation once an appeal has been initiated by the beneficiary. Coverage continues through denial or approval process. • MMP and SNF must be an agreement on the discharge destination prior to 48-hour notice (patient has met goals and is safe to transition to the next setting)
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Patients in the NF Receiving Long Stay Services That Require Skilled Care and Meet SNF Criteria • The NFs must have a physician order that indicates the patient needs skilled services. This must be faxed or submitted online to notify the MMP; this must be done within 24 hours of the change in status. • The MMPs agree to authorize all care at skilled rate until care is determined not to be medically necessary. • MMPs agree that all future authorizations will be done based on medical necessity.
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Referrals from Community/ED/Observation Stay to a NF for Long Stay Services •
The following is required when a member is referred from the Community/ED/Observation Stay to a NF for Long Stay Services:
Physician Order; History and Physical; MDS; Medication List; Prior Level of Function; and Projected discharge plan.
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Providers must submit via Fax or Online notification through the MMP web portal that patient met criteria and has been admitted
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PT,OT, ST-Evaluation must be completed at center within 48 hours of admission
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All MMPs agree to a 30 day authorization given at admission. The SNF/NF shall notify the appropriate MMP via fax or web submission on the day of admission.
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30-day authorization given at admission.
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Database available that would interface with NF electronic medical record that updates could be sent on line (different system may be developed for those NFs not utilizing EMRs)
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Recertification for NF services by the attending physician annually. 7
Patients no longer meeting Skilled Level of Care that are unable to be discharged safely into the community • Consistent with current DMAS practice the MMP agrees to work with the SNF/NF to develop a safe discharge for patients that no longer meet nursing facility level of care criteria. If there is no safe alternative the MMPs agree to pay the NF at the established rate until discharge. • Active discharge planning will be coordinated between the plan and SNF with weekly communication between the MMP and the NF to ensure that a safe discharge plan is following a reasonable timeline.
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Institutional Case Management Process
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Institutional Case Management Process
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Nursing Facility Level of Care The initial level of care (LOC) is determined by the state (custodial nursing home versus skilled nursing facility). HealthKeepers, Inc. is responsible for the coordination of annual redeterminations.
The LOC Department of Medical Assistance Services (DMAS) Form should be completed and submitted to the state.
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Nursing Facility Level of Care Criteria Custodial nursing facility (NF): • Functional and medical components. • Members must qualify on both functional and medical components. Functional (must meet one of the following): • Dependent in 2-4 activities of daily life (ADLs), plus one of the following: Semidependent or dependent in behavior pattern/orientation, Semidependent in joint motion Dependent in medication administration • Dependent in 5-7 ADLs, plus dependent in mobility • Semidependent in 2-7 ADLs, plus dependent in mobility and behavior pattern/orientation 12
NF Level of Care Criteria – Custodial NF Medical/nursing supervision (must meet one of the following): • Requires observation and assessments to prevent destabilization, and patient has demonstrated an inability to self-observe or evaluate the need to contact skilled medical professionals • Due to multiple, interrelated medical conditions, potential for medical instability is high or already exists • Needs at least one ongoing medical condition; potential for medical instability is high or already exists • Needs at least one ongoing medical/nursing service (e.g., applying aseptic dressings, routine catheter care, respiratory therapy, nutrition/hydration supervision, therapeutic exercise/conditioning, routine colostomy care, use of physical or chemical restraints, routine skin care to prevent pressure ulcers in immobile individuals, chemotherapy, radiation, suctioning, etc.) 13
NF Level of Care Criteria - Specialized Care In addition to the general/custodial NF LOC criteria, to meet specialized care LOC, the individual must at a minimum:
• Visit a physician at least once every 7 days (may alternate visits between a physician and a physician’s assistant/nurse practitioner) • Receive licensed nursing services 24/7 • Receive respiratory services provided by a licensed/certified respiratory therapist • Take part in a coordinated multidisciplinary team approach
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NF Level of Care Criteria - Specialized Care Additionally, to meet specialized care LOC, the individual must require at least one of the following: • Mechanical ventilation • Complex tracheostomy, meeting all of the following: • Have potential for weaning or past failed attempts at weaning • Require nebulizer treatments four times per day with or without chest physiotherapy • Require pulse oximetry monitoring at least every shift • Require respiratory assessment/documentation every shift by nurse of respiratory therapist • Have physician’s order for oxygen therapy with documented usage • Require tracheostomy care daily • Have physician’s order for suctioning, when necessary • Individual must be at risk to require subsequent mechanical ventilation
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Reservation of Days Therapeutic Leave: • A NF bed may be held for therapeutic leave when the member’s/resident’s Plan of Care (POC) provides for such leave and is noted in their chart. • Leave includes visits with relatives and friends, or admission to a rehabilitation center for up to seven days for an evaluation. • It does not include admission to an inpatient hospital. • Limited to 18 days in any 12-month period and HealthKeepers, Inc. should be notified. Bed Reservation (“Bed Hold”) - Hospitalized Residents: • Bed hold payments to NF are not applicable per DMAS. • All members/residents and their families should be informed that they have the right to be re-admitted at the time of the next available vacancy.
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Precertification and Notification Precertification is required for: • Precertification is required for all home health care services (skilled nursing visits, speech therapy, physical therapy, occupational therapy, social workers and home health aides). Home health aides must be under supervision of a registered nurse or physical therapist. • Precertification is required for all Private Duty Nursing services • Precertification is required for all Personal Care, Respite (LTSS services) Anthem HealthKeepers MMP providers can request precertification requests: • Online • By fax to: • •
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1-888-280-3725 for therapies, home health, durable medical equipment and discharge planning 1-888-280-3726 for concurrent review clinical documentation for inpatient
By calling Customer Service at 1-855-817-5788
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What can we do for you? Coordinate patient care • The Interdisciplinary Care Team (ICT) works with you and your patients to: Facilitate coordination between the health plan and all the providers for delivery of the member’s services and benefits
Schedule initial or annual meetings to review the person-centered care plan
Schedule periodic meetings to respond to significant changes in condition or needs, such as transition in care
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The ICT will notify all participants when an ICT meeting is scheduled concerning one of your patients; we welcome your attendance or attendance by your clinical designee 18
What can we do for you? Simplify administration • Coordinate access to patient information – all providers who are part of a patient’s care and service team can easily access the patient’s complete records and benefit information • Offer one stop for claims submission – quicker payments through streamlined electronic claims submission and payment processes • A self-service website and access to our web-based tool Patient 360 to save you time
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How can you work with us? As a member of the HealthKeepers, Inc. network, you have support from many different departments as you provide care for our members. Our Provider Relations team Our Medical Management program Specialized teams to help you with your claim questions
Our MMP Customer Service team offers assistance with claim issues, member enrollment, questions and general inquiries. MMP Customer Service team at 1-855-817-5788, Monday to Friday, 8 a.m.-8 p.m. Eastern time.
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Questions? For more information: • Call our MMP Customer Care team at 1-855-817-5788, Monday to Friday, 8 a.m.-8 p.m., Eastern time • Visit mediproviders.anthem.com/va to find resources and information or to download a copy of the Provider Manual Want to join our network? • Call 1-855-789-7989
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