Provider DME Training SOUTH CAROLINA Q2 2022 DEPARTMENT OF HEALTH

Provider DME Training SOUTH CAROLINA Q2 2022 DEPARTMENT OF HEALTH & HUMAN SERVICES

PART ONE Introduction to Kepro

Kepro’s mission is to improve lives through healthcare quality and clinical expertise. Kepro’s Mission We work on behalf of government and private healthcare payers to maximize healthcare quality, improve accuracy and increase efficiency. As a result, we drive real change in the healthcare system that allow healthcare dollars to reach more people by ensuring the right care is delivered at the right time. Provider Education 2022 Page 3

Kepro at a Glance Currently servicing 250 state, federal and employer clients URAC accredited in UM, CM, DM, & IRO 14 offices and more than 1,000 employees Over 3,000 credentialed physicians and 500 clinicians on our Advisory and Review panel Currently holds both QIO and QIO-like designations Kepro provides Care Management, Quality Oversight, and Assessments, Eligibility & Enrollment services Provider Education 2022 Page 4

Kepro and SCDHHS Relationship Kepro has held a contract with SCDHHS for Utilization Management and quality of care services since 2012. Addition of New Programs / Service Lines in 2019 -2021 BRCA Fetal DNA Hospice therapies ASD Kepro has a high degree of expertise and knowledge in Utilization Management and Level of Care Screening in statewide programs. Provider Education 2022 Page 5

Durable Medical Equipment

Durable Medical Equipment All PA requests for DME codes must be submitted to Kepro. Providers for these services will continue to submit the Certificate of Medical Necessity (CMN), physician’s orders and all pertinent medical documentation. DME services and equipment requiring prior approval are identified in the “Covered Services and Definitions” section of the DME manual. Reference Durable Medical Equipment Services Provider Manual Section 4 Provider Education 2022 Page 7

Durable Medical Equipment Kepro reviews for a specific list of HCPCS codes, as listed in the Procedure Codes section of the DME Manual. Kepro does not provide authorization for recipients with the following coverage types: MCHM, HOAD, HOAP, MCSC For timely submission, providers must submit on or before requested start of care, or the request will be Administratively Denied. For DME requests, Kepro has 15 days to review requests for prior authorization Equipment may be approved that is currently covered under the SC State Plan. HCPCS codes may be approved that are included in the list of HCPCS codes that Kepro reviews. It must be medically necessary and appropriate for use in the beneficiary’s home. **Convenience and prevention items are not covered** Provider Education 2022 Page 8

Durable Medical Equipment Kepro shall perform HCPCS reviews on all DME requests submitted with Miscellaneous HCPCS codes (ex: E1399, A9999 or K0108). DME Providers are responsible for submitting and billing the correct HCPCS procedure code(s). PA requests for miscellaneous codes will be denied if the Kepro reviewer determines there are other more specific codes available. A provider must not use a miscellaneous code in place of the recognized HCPCS code for a DME item that is not covered. Reference Durable Medical Equipment Services Provider Manual Section 4 Provider Education 2022 Page 9

Durable Medical Equipment and EPSDT Kepro reviews for all codes under the age of 21 years old under the Early Periodic Screening, Diagnostic and Treatment (EPSDT) provision. Provider must specify that the request for authorization is to be reviewed as EPSDT. All coverable, medically necessary, services must be provided even if the service is not available under Healthy Connections Medicaid to beneficiaries through the month of their 21st birthday. Additional health care services are available under the federal Medicaid program if they are medically necessary to treat, correct or ameliorate illnesses and conditions discovered regardless of whether the service is covered by the State Plan. Provider Education 2022 Page 10

Durable Medical Equipment and EPSDT EPSDT Medical Necessity Does NOT include: Experimental or investigational treatments; Services or items not generally accepted as effective; and/or not within the normal course and duration of treatment; Services for caregiver or provider convenience. Services for which South Carolina Healthy Connections Medicaid has a waiver are also not considered to be State Plan benefits, and therefore are not a benefit under EPSDT. Items such as respite, behavioral interventions, in-home support services and home modifications are examples of waiver services. Reference https://msp.scdhhs.gov/epsdt/site-page/medical-necessity Provider Education 2022 Page 11

Durable Medical Equipment Submission of Medicaid Certificate of Medical Necessity (MCMN) is required. There are 6 versions: Equipment/Supplies (DME 001) Power/Manual wheelchair and/or Accessories (DME 003) Orthotics/prosthetics/diabetic shoes (DME 004) Enteral nutrition (DME 005) Parenteral nutrition (DME 006) Oxygen (DME 007) MCMN is valid for 12 months. Reference Durable Medical Equipment Services Provider Manual Section 4 Provider Education 2022 Page 12

Durable Medical Equipment Modifiers The following modifiers are acceptable for durable medical equipment and must be listed on the PA form: NU New Equipment LL Rental (equipment may be converted to purchase). Items cannot be initially purchased. Considered purchased when it has been rented for 10 months. RR Rental (equipment that will always remain on a rental basis) 00 Purchase (used for medical supplies) 52 Reduced Rate (Reduced rental payments are made every six months beginning on the sixteenth month of use regardless of the type or life span of the equipment) RT Right LT Left UE Used Equipment (Equipment that was issued on a rental basis and then returned to the provider by the beneficiary is considered used equipment. If the provider reissues this equipment, this modifier must be used on the MCMN and claim form) SC Medically necessary service or supply (This modifier is used only with certain home infusion codes when more than one home infusion therapy is being administered) Reference Durable Medical Equipment Services Provider Manual Section 6 Provider Education 2022 Page 13

Miscellaneous Tips Provider Education 2022 Page

Tips for Review Criteria InterQual When additional information is requested, please address the specific questions asked. When requesting inpatient surgical procedure, be concise as to what procedure is being performed and specify the date of service. Specify IVFs (i.e., volume expanders) administered and the rate as well as if continuous or titration frequency. Provide diet status (NPO, advancing, etc.) Note any failed outpatient treatment that has been attempted. Provide the route and frequency for all medications and treatments (i.e., PO meds, nebulizers, etc.) If nurse reviewer is unable to meet criteria with supplied clinical information (including additional clinical received after requested), case will be forwarded for physician review. Provider Education 2022 Page 15

Hereditary Breast Ovarian Cancer (HBOC) BRCA Genetic Testing A completed Hereditary Breast and Ovarian Cancer (HBOC) Genetic Testing Prior Authorization Request Form must be submitted to Kepro. The form must be completed in its entirety, signed and dated by the referring provider. The provider’s signature submitted on the HBOC is their attestation to the best of their knowledge, that the information provided in the document is true, accurate and complete. The physician must indicate one of the following on the HBOC form: The request is for initial BRCA1 and BRCA2 testing. The request is for repeat BRCA1 and BRCA2 comprehensive sequencing testing for the beneficiary because initial results are negative, or are not available, and large cell rearrangement testing is necessary Reference Physicians Services Provider Manual January 1, 2022, Section 4 Provider Education 2022 Page 16

Medical Necessity Denials Medical necessity denials are denials where clinical information that has been submitted has been reviewed by a Physician who has determined that the request is not medically necessary (based on the clinical submitted). If you disagree with denial decision, please follow instructions as outlined in your denial letter. Reconsideration request- Submit to Kepro within 60 days from receipt of denial letter. Appeals request- Submit to State within 30 days of receipt of denial letter. Appeals should be submitted after a reconsideration review has been completed. Provider Education 2022 Page 17

Administrative Denials Administrative denials are denials in which the request for services was submitted untimely or required SCDHHS forms were not submitted. Administrative denials are administered by the Clinical Nurse Reviewer. Administrative denials do not allow for reconsiderations, only appeals directly to SCDHHS. Appeals request- Submit to state within 30 days of receipt of denial letter. Provider Education 2022 Page 18

Turnaround Timeframes Response Time for Decisions from the QIO For all service types excluding DME and PRTF/Freestanding Psych, Kepro must render a decision within 5 business days. Kepro has 15 days to process DME requests. For beneficiaries under age twenty-one (21) receiving services in an Inpatient Psychiatric setting or Residential Treatment Facility, Kepro has 2 business days to process requests. If a review requires a physician consultation, Kepro will have one (1) additional business day to render the decision. NOTE: Requests for additional information by Kepro must be received within two (2) business days of the requested date from the provider. Reference Medicaid Bulletin MB# 14-008 dated March 27, 2014. Provider Education 2022 Page 19

Where to Access Training Materials and Forms Visit Kepro's website to access training material, training dates, direct access to Atrezzo Provider system, forms, and more! scdhhs.kepro.com Provider Education 2022 Page 20