ONLINE PRE-CERTIFCATION PORTAL ONLINE PRE-CERTIFCATION PORTAL

Transcription

1 ONLINE PRE-CERTIFCATION PORTAL 2016

2 Overview For troubleshooting, questions, or login issues, please call or The On-line Pre-Certification Portal, also referred to as Conifer or InforMed, is Quality Care Partners secured site that is used to submit prior authorization/certifications for medical review based on the employer s plan. All information that is accessed through the portal is confidential, please refer to the confidentiality and privacy statement that you signed to obtain a login. This document will provide users with the necessary elements for completing a prior authorization/certification. After reviewing this document, the user should be able to Search for a member Initiate a prior authorization/certification Search for a provider Submit supporting documentation/clinical Check the status of a prior authorization/certification Additional information can be found in the system by clicking on the field labels. These labels contain definitions of the values within the field. This document is also available by clicking on the Click here for help and troubleshooting link found on the Providers page of our website. PAGE 1

3 Table of Contents Glossary of Common Terms... 1 Session One... 3 Quality Care Partners Website... 3 Search for Providers... 3 Create a Printable Directory... 5 Accessing the On-Line Pre-Certification Portal... 5 Session Two... 7 Welcome to the On-Line Pre-Certification Portal... 7 Enrollment Verification... 8 Search for participant... 8 Session Three Enter Referral View Referral Provider Search Session Four Checking Status and Viewing Referrals Incoming Facility Referrals Outgoing Facility Referrals Session Five Submitting Medical Records/Clinical Information Session Six Downtime Procedure Notes: PAGE 2

4 Glossary of Common Terms It will be helpful for you to become for familiar with the On-Line Precertification Portal terms below, but never hesitate to ask a QCP staff member or nurse if you are unsure of what a word or phrase means. C Concurrent Non-Urgent: Admission or SNF that is not of an urgent nature that is under continued review through discharge. Concurrent Urgent: All ER/Urgent Admissions (example patient admitted yesterday or a baby delivery). Conifer: (InforMed) System vendor (CPT): 5 digit codes, procedure codes, medical code set for noninstitutional and non-dental professional transactions E Eligibility: population or census of all members that are loaded in the system from TPA or vendor. Employer: Group that holds the contract for Medical Management and network access through QCP Enrollment Verification: Application within Conifer (InforMed) that is used to search for members Episode: (EOS) a member s case I ID Number: Member s ID usually Social Security number or other unique assigned number WORD: definition WORD: definition J K Layman s Terms: style of communication that uses easy to understand, plain language with an emphasis on clarity, brevity, and avoidance of overly complex vocabulary Milliman: Criteria within the system used to make a determination L M MM Staff: Nurse responsible for reviewing and completing a referral in its entirety National Provider Identifier: (NPI) Unique ten-digit number used to N PAGE 1

5 identify a provider in a standard way throughout their industry. NPI Registry: ( Website used to search by provider demographics to find their NPI. O Ohio PPO Connect: (OPPOC) statewide network that QCP is partners of OON: Out of Network Place of Service: (POS) the location in which the service is rendered P Pre-Service Non-Urgent: Outpatient/Inpatient that is requested prior to the actual service date. Pre-Service Urgent: Outpatient/Inpatient that is an urgent request from a patient/provider. Post Service: Request after service date Tax Identification: (TIN, TaxID) identification number that is used to link the provider to a claim for billing Third Party Administrator: (TPA) organization that processes claims and performs other administrative service within accordance to the employer s benefits Urgent: An urgent request means any request for medical care or treatment with respect to the application of the time periods for making non-urgent care determinations: U A. Could seriously jeopardize the life or health of a member or the ability of the claimant to regain maximum function; B. In the opinion of a physician with knowledge of the claimant s medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request. T PAGE 2

6 Session One Visit our website Quality Care Partners Website The Quality Care Partners company website offers a vast amount of information about the services and products that QCP has to offer. Within the website you can view QCP s latest news and events, search for providers, and access our On-Line Pre- Certification Portal. Search for Providers The QCP website offers a provider search for each of the networks offered: QCP Plus QCP Partners QCP Home QCP Home Preferred Ohio PPO Connect Ohio Integrated Care Providers (OICP) Clinical Integration Ohio Integrated Care Providers (OICP) Medicare Shared Savings Program Paramount To access one of the network provider searches from the QCP website HOME page click on the Provider Search link at the top of the page. Verify the network that you are wanting to find a provider by checking the member s health plan card for one of the matching logos found on the website. Click on the corresponding logo displayed, to search for the provider. On the search screen, enter or select one of the following: Provider name (last name, first name) Organization name (practice name or facility) NPI Tax ID (The Tax ID number is kept confidential and will not be displayed) Provider s specialty Location (city, county, state, or zip code range) PAGE 3

7 After clicking submit, a list of providers matching your criteria are displayed showing provider s location(s) and phone number(s). Figure 1 - Provider Search Results Clicking on a provider name will display additional information about that provider. Figure 2 - Provider additional information sample PAGE 4

8 Create a Printable Directory Create a printable directory of the providers by clicking on the Create Directory button located below the search results. Clicking this button will display a PDF document of the providers found. Figure 3 - Create Directory Accessing the On-Line Pre-Certification Portal To access the portal, click on the Providers link on the blue menu bar on the HOME page of the QCP website. Next click on the Provider Login link, located below the blue menu bar. From this page you can access the portal by clicking the Provider Login. PAGE 5

9 Figure 4 - On-line Pre-Certification Portal login screen Enter your username and password provided to you at the training session. PAGE 6

10 Session Two You are responsible for any activity under your login. Please do not share usernames and passwords. Welcome to the On-Line Pre-Certification Portal Figure 5 - Portal Home Page with Message of the Day The portal s home page may contain a Message of the Day. The message of the day contains IMPORTANT information about the portal availability for enhancements or tips for functionality of the site. To access your applications within the portal, you can use the menu bar located above the Message of the Day or the picture menu located below the Message of the Day. PAGE 7

11 Enrollment Verification Enrollment Verification application is used to search for participants and start the pre-authorization/certification process. The application is located under the Population Health menu category Enrollment Verification. Figure 6 - Enrollment Verification Menu Bar Figure 7 - Enrollment Verification Picture Menu Search for participant Searching for a participant requires one of three demographics: PAGE 8

12 ID Number o Must be the complete ID o Typically, SSN Last Name, First Name o Separated by a coma o Can be partial name(s) Test,S T,Shrek Te,Sh,Shrek Date of Birth o ***Preferred way to search o Entered in format of mm/dd/yyyy 07/29/1980 After entering ONE of the above, click the submit button to show the search results. ID Name DOB Relation (is the participant the employee or card holder, spouse, or dependent) # Dependents (number of dependents covered under the participant) Address Employer Medical Plan TIP: If the participant is showing in red, we have received a termination date for the participant. If this appears to be incorrect, please verify eligibility with the TPA and contact our office at After verifying the participant s demographics in the results, click on the ID to open the participant s record. The participant s record will be displayed with all members under the plan. PAGE 9

13 Figure 8 - Participant's Eligibility Record Verify the participant s information and NOTICE the begin and end dates of the record(s) that you are choosing. This will notify you if the participant will be terminating soon. For example, if the participant has a procedure that is going to be scheduled for 08/15/2016 but the end date on the record is 7/31/2016 then the participant will not have coverage through the current plan for the procedure (according to the eligibility files that we received from the TPA). Benefits and Eligibility should always be verified with the participant s TPA After selecting the participant, on the record at the bottom is an Action dropdown select the appropriate option and click GO. PAGE 10

14 Session Three Enter Referral The Enter Referral function, opens the modifiable form to enter the preauthorization/certification. Participant Information Figure 9 - Participant Section This section contains participant s demographics such as: Full Name ID Gender Age Date of Birth Address Employer and Plan County Condition Code Contact numbers (home, office, cell) address Contact Guidelines (if you can contact them or not) Primary Doctor (PCP) name and contact number Last MM Activity: any episode or activity that the member has had in the past PAGE 11

15 When starting a referral, the participant s information should always be doublechecked for validity and to ensure you have the correct member. Provider Information This section is required by the system and the TPA all information for the provider must be complete in entirety. Figure 10 - Provider Information Section Providers can be selected from providers listed in the system or they can be manually loaded. If provider is loaded in the system, then this should be how the provider is entered to the referral Manual entry of provider should only be utilized when the provider is not listed within the referral entry system. Providers Loaded in the Portal When searching for providers loaded in the system, depending on the specific employer/plan, you may see results under different tiers: Tier 1, Tier 2, Tier 3 or Tier 4. Tier 1 Will always be in network providers. Pay attention to the directions listed in the tier heading, as some contracts have additional coverage criteria regarding in network providers. Tier 2, 3, 4 Depending on the specific employer, these tiers may be wrap networks or out of network providers. OON providers that are in the system are primarily for government contracts. o Some of the wrap networks are loaded (for example: OPPOC) For others the wrap networks are not loaded but there are links provided under the search results to the network s provider search website. PAGE 12

16 Entering a Provider that the Participant Has Been to Before You can select a provider by using a list of the providers that the member has been referred from or to. When you click on the pencil icon to search for a provider, use the View Providers from Past Referrals to see if the provider that the member is being referred from or to is in the list. If they are just click on the Select button to add the provider to the referral. Providers Requiring Manual Entry If the provider is not found in the system, click on the Non Par Provider button at the top of the Provider Screen to enter the provider as follows: PAGE 13

17 Enter NPI Enter Tax Identification Facility/Group Name Provider first Name Provider Last Name Provider Specialty Address Street # City State Zip Required for all groups. (The NPI number can be found by searching the NPI registry through the ICON on your desktop) Required for all groups. (To obtain the tax id, either ask the providers office that is calling in the referral, look at historical providers, or ask provider relations) This field will be used to send the Legacy ID to Paramount once the OON provider has been added. For all other groups this will be completed with the Facility or Group Name. Provider s First Name Provider s Last Name or The Organization Name (i.e. Hospitals) Required for all groups. Required for all groups. Required for all groups. Required for all groups. PAGE 14

18 Phone number Fax Number Required for all groups. Required for all groups. General Referral Information The General Referral Information is where the bulk of the information that is entered for the prior-authorization/certification. Required fields have been identified. Initiated By ***REQUIRED*** All providers/facilities entering prior authorization/certifications should ALWAYS select Provider. Receipt Method ***REQUIRED*** Providers/facilities entering Prior authorization/certifications should ALWAYS select Walk-In. Referral Service Type ***REQUIRED*** Pre-Service Non-Urgent Outpatient/Inpatient that is requested prior to the actual service date. Pre-Service Urgent Outpatient/Inpatient that is an urgent request from a patient/provider. Concurrent Non-Urgent Admission or SNF that is not of an urgent nature that is under continued review through discharge. Concurrent Urgent All ER/Urgent Admissions (example patient admitted yesterday or a baby delivery). Post Service Request after service date. New Born This is set to YES in the event that there is a new born and it is not in the system and the prior authorization/certification is entered under the guardian s record. Otherwise it should always be set to NO. PAGE 15

19 Pre-Auth Reason ***REQUIRED*** Pre-Authorization or Prior Authorization reason is a list of services that require review as stated in the plan document of the employer or client. Select the appropriate one from the list When to Use the Out of Network Provider pre-auth option Use OON Provider if the service does not require a pre-cert except when being performed by OON provider. If provider is OON and the service requires a prior authorization, utilize the pre-auth reason that reflects the requested service. Service Desired Services desired is used as a category for the type of service that is being requested for reporting purposes. Place of Service ***REQUIRED*** The place of service is based on where the service is rendered. The place of service locations are based off of the HCFA Place of Service Coding. Re-Admission ***REQUIRED*** This is used for tracking re-admissions for review. System default is No. Select yes if referral is for inpatient admission (not observation) and patient was previously inpatient within the past 30 days for any reason. Reason (Text Box) List details of the pre-auth reason, if needed. Procedure(s) (Text Box) ***REQUIRED*** This is a free text field for the layman s description of the procedure(s). No abbreviations are to be used in this field. This text is pulled to the letter templates as the procedure(s) that the participant is having performed. MRI of Brain 3 office visits PAGE 16

20 Is this a Work/Auto Related Injury Liability? Mark as appropriate for the services being reviewed. ICD Codes ***REQUIRED*** As of October 2015, ICD-10 codes were implemented. The system has been made to default to the ICD-10. However, if you only have the ICD-9 you can enter it in to get the conversion for ICD-10. Always make sure you click directly on the ICD-10 then click the green checkmark to save it to the list. Multiple ICD codes can be added to the pre-authorization/certification. Type the ICD number or partial name of the diagnosis to search. Example: To find the ICD codes for a Stress fracture of a shaft of femur, I can type in the search box, one of the three options: o Partial name: femur o ICD-10: M84.353A o ICD-9: PAGE 17

21 Click on the ICD that is needed to select. Next click the green check mark to save the ICD, it should appear in the box below. Repeat the same steps for additional ICD codes. CPT/NDC(s) ***REQUIRED*** Enter the appropriate CPT code (ie ) or text (ie. Office visit) to search for the code that referral is for. Click the green check mark to save the CPT code to the list. CPT codes are required for claims payment, when this is not properly completed it could lead to delay payment or denied claim. PAGE 18

22 Brief History (Text Box) Brief history is used to communication with the QCP Nurse working the referral. Use this box to enter additional information/clinical that may be needed when reviewing the prior authorization/certification. Only include pertinent information/clinical that directly relates to the reason for the review. (Please do not copy/paste the whole visit summary. If the whole visit summary is pertinent to the review, send via fax or Specifics (Text Box) Providers/Facilities please do not use this field for any reason. Explanation (Text Box) Providers/Facilities please do not use this field for any reason. Episode Information This section is used for QCP internal use to assign the episode and change the status of the prior authorization/certification. Days/Visits/Units Information PAGE 19

23 Most of the days/visits/units information is used for QCP internal use with the exception of the fields listed below. Confirmed Appt This field should be completed is the participant already has a scheduled day for the procedure(s). There is also a field to enter the time, if known. Requested (#Days/Visits/Units start & end dates) This is primarily for inpatient stays. Enter the admit date in the service start date field and then the day of expected discharge in the service end date. Based on the start and end dates entered the #Days/Visits/Units will be calculated automatically. Milliman Information This section is for QCP internal use. Turnaround Time (TAT) Information This section is for QCP internal use. Button Function At the bottom of the form are four (4) buttons. Cancel/Return: Cancels out what you have entered and takes you back a page. Submit: Saves what you entered and assigns a referral number. View Episodes: View other episodes for this patient that you have access to. View CCC: View Patient Clinical Claims Chart After clicking the submit button the screen will refresh and assign a referral number, this can be found by scrolling to the General Referral Information Section. View Referral View Referral is found in the Action dropdown box on the participant s enrollment screen. PAGE 20

24 View Referrals will display any referral that has been entered that has been referred by the provider or referred to the provider. Provider Search Provider Search is another option found in the Action dropdown box on the enrollment screen. See Provider Search instruction on page 4. PAGE 21

25 Session Four A referral that I entered is not showing, what do I do? Call QCP to have your login access reviewed Checking Status and Viewing Referrals At any given time, you can go in to review a submitted referral to check the status. To do this you can access Incoming Facility Referrals and Outgoing Facility Referrals under the Referral application menu. Both applications use the same filter or search to find the referrals. Typically, searching by the referral id by entering the id in the field on the filter screen and clicking submit is how this application is used. Another common way of searching for referrals is to use the Last Updated date span. Incoming Facility Referrals Incoming referrals are where the participant has been referred to your office/facility. Outgoing Facility Referrals Outgoing referrals are those in which you are referring the participant to another provider. PAGE 22

26 Session Five Tip Submitting Medical Records/Clinical Information Submitting the correct CPT code and ICD-10 not only will help with getting the prior authorization reviewed but it helps with claims payment. When submitting medical record, only submit the information that establishes reason for having the prior authorization done. o Submitting too much may cause delay in process the prior authorization. o Submitting too little may cause denial of the prior authorization. If there is a procedure that you submit for often, create a template of what medical records or clinical information that is needed to process the prior authorization quickly. PAGE 23

27 Session Six Downtime Procedure In the event of a system outage please review the following for steps to submit referrals. Prior Authorization Forms can be found on the QCP website ( by clicking on the Provider link then the Prior Authorization Forms menu. Each form is in PDF format. If you do not have Adobe Acrobat Reader available, please visit and download the latest version of Adobe Reader. Please complete the form in its entirety then send to QCP: qcpfax@qualitycarepartners.com Fax: PAGE 24

28 Notes: PAGE 25

29 August 16 PAGE 26