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Texas MCO PriorAuthorizationsWhat Texas providers need to knowSept. 1, 2015KELLY ROBERTS-TRETAJASON JONESVP, Reimbursement & Ancillary ServicesChief Technology OfficerCreative Solutions in HealthcareSimpleLTC
What we’ll cover today1. Review the new Standard Prior Auth Form2. Review MMP Prior Auth process3. Using the MCO Prior Auth Crosswalk tostreamline information4. Review the MMP Service Plan codes onMESAV5. Creating Prior Auth forms in SimpleCFS 2
PRIOR AUTH PROCESSES
Texas Standard Prior Authorization Form Beginning Sept. 1, 2015, health benefit plan issuersmust accept the Texas Standard Prior AuthorizationRequest Form for Health Care Services if the planrequires prior authorization of a health careservice Created by Texas Department of Insurance (TDI) tostandardize prior auth requests across multipleMCOs
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MMP Prior Authorization process Review skilled nursing facility MMP quick referencedocument (page 4) Review prior authorization request form Review prior authorization criteria for Part A/SNFadmissions
SNF MMPquickreferencedocument(pg. 4)7
MCO Prior Auth Crosswalk We’ll review the items on the Prior Auth form andcompare to the crosswalk for easy reference Items required:––––––DX codeTreatment CPT codeFrequencyDuration# of visits requestedStart and end dates
MCO Prior Auth CrosswalkSimpleLTC will provide a downloadable version of thiscrosswalk at simpleltc.com/prior-auth9
MMP Service Plan codes on MESAVEach MCO hasa differentplan code4FAmerigroup Texas, Inc.Bexar3GAmerigroup Texas, Inc.El Paso7ZAmerigroup Texas, Inc.Harris6FAmerigroup Texas, Inc.Tarrant4GMolina Healthcare of TexasBexar9JMolina Healthcare of TexasDallas3HMolina Healthcare of TexasEl Paso7VMolina Healthcare of TexasHarrisH9Molina Healthcare of TexasHidalgo4HSuperior Health PlanBexar9KSuperior Health PlanDallasHASuperior Health PlanHidalgo7QUnited Healthcare ant
MCOinformationon MESAV
SIMPLECFS PRODUCT DEMO12
First, a few quick poll questions Help us understand – How do you currently submit Prior Authorizationrequests?– What’s your anticipated average daily volume of PriorAuths after Sept. 1 (per facility)?– How many pages of supporting documentation (onaverage) do you include with a Prior Auth request?13
Demo: Prior Auth forms in SimpleCFS Creating a new form in a resident profile Attaching files Form options– Saving a draft– Printing a form– Finalizing a form Locating completed/archived forms14
Additional capabilities we’re testing Submitting forms to MCOs via fax Verifying MCO approval To be determined:– Can we do it cost-effectively?– Can we do it electronically via data interchange?– Will we be able to get data back from MCOs?15
QUESTIONS & ANSWERS16
Thank you for attending!Slides and a recording of this webinar will be available shortly at:simpleltc.com/prior-authFor further help:support@simpleltc.com469.916.2803
MMP Service Plan codes on MESAV 4F Amerigroup Texas, Inc. Bexar 3G Amerigroup Texas, Inc. El Paso 7Z Amerigroup Texas, Inc. Harris 6F Amerigroup Texas, Inc. Tarrant 4G Molina Healthcare of Texas Bexar 9J Molina Healthcare of Texas Dallas 3H Molina Healthcare of Texas El Paso 7V Molina Healthcare of Texas Harris H9
