Inpatient Certification Transition

Will HCE be completing Retrospective reviews?

Starting December 28th, HCE will focus on retrospective reviews based on Interqual criteria.

What telephone and fax number will I use to contact ACS? And what address will I use to send Retrospective reviews?

To make the transition easier for the provider community, ACS will retain the same toll free phone number, (800) 766-0686, and fax number, (573) 634-4262, used by HCE. The phones are staffed from 8 am to 5 pm, Monday – Friday, except for holidays. If providers call during off hours or the line is busy, you may leave a message and ACS will return your call by the next business day.

ACS
Attn: Tammy Brandes
205 Jefferson St., 10th floor
Jefferson City, MO 65101 OR

ACS
PO Box 105110
Jefferson City, MO 65110-5110

Do we need to purchase the Milliman criteria to submit our certification requests?

No, the new process will apply the Milliman criteria through the review tool in our system.

If we want to request a reconsideration, can we use Interqual criteria as justification?

Any substantial information showing that Interqual criteria may have resulted in an approval may be sent to the physician reviewing the reconsideration. The physician’s review will be based on his/her professional experience, knowledge and judgement.

Are reconsiderations reviewed based on Milliman’s criteria?

No, the physician reviewing the reconsideration is evaluating the medical necessity based on his/her professional experience, knowledge and judgement.

How will concurrent days be added to a certification which HCE started?

Any portion of a certification that HCE has completed will be honored and any additional days will be reviewed based on Milliman criteria by ACS. When additional days are required and added to the certification, ACS will issue a new certification number to encompass the whole stay.

Will claims pay using the certification number HCE issues?

Any claim billed using the HCE certification number must have dates of service that match the days certified under HCE’s certification number, otherwise it may deny.

Will the certification numbers be available electronically as they are presently through the Case Inquiry System used by HCE?

At the beginning period of the ACS contract, certification and denial letters will be mailed. If an approval is given over the phone, the certification will be given to the provider at that time. At a later date, the web based process used by ACS will provide electronic access to the certifications. ACS will provide the certification number at the time of the notification of certification.

Who do I contact after 12/28/09 in order to add days or to change admit or discharge days on an approved certification?

Changes to any certifications will be done by ACS. Historical information on past certifications will be available to ACS.

Who do I contact after 12/28/09 regarding a reconsideration requested prior to 12/28/09 on a pre-admission or initial admission that HCE started?

HCE will be completing any reconsiderations on pre-admission or initial admission requests if the reconsideration was requested prior to 12/28/09.

Who do I contact after 12/31/09 if a reconsideration was requested on a retrospective review?

ACS will need to be contacted regarding reconsiderations not completed by HCE.

Will ACS be tracking certifications scheduled to end based on discharge dates or checking with providers about the need for additional days?

ACS will be sending out a Daily Discharge/Expired Certification report to each facility so that discharge dates can be updated on certifications or additional days can be requested via a concurrent review.

Must the Daily Discharge/Expired Certification report be faxed back to ACS daily or can we save them up and fax all back at the end of the week or whenever it is convenient for our staff?

The necessary information concerning a discharge date or additional information to complete a concurrent review should be submitted to ACS by phone or fax as soon as the information is available. This will help to close out certifications with discharge dates and eliminate repeated information on the next day’s report. This will also facilitate the timeliness of concurrent reviews and decrease the number of retrospective reviews needed. If multiple areas of the hospital (i.e. psych and acute care) should receive this information, please provide the correct contact information (person’s name and fax number) to ACS.

Adding all dual eligible (Medicare/Medicaid) participants to the Daily Discharge/Expired Certification report in addition to the discharge information on each patient is quite labor intensive. Is this information required? What is its purpose? Will it affect our payment if we do not add the dual eligibles to the report?

At this point, the information is not required but is requested. This information will help MO HealthNet assist providers in improving patient care during and after discharge. The information does not affect your reimbursement in any way.

If I have a scheduled time to do certifications with HCE, will ACS be honoring this process?

ACS is willing to work with providers and either honor the time allotted or set up a new time that is mutually agreeable. You may contact ACS via phone at 1-888-581-9797 or e-mail at CyberAccessHelpdesk@acs-inc.com.

Can medical records be sent on a CD to ACS?

Yes, a copy of medical records may be sent via a CD to the ACS address starting 12/28/09.

ACS has "closed" my certification request due to insufficient information. Do I resubmit the records as a "Request for Reconsideration" or as an "Admission" request?

ACS will not "deny" any certification request based on insufficient information. They will simply "close" the request and a letter will be issued to the provider to let them know this has been done. When the records are sent again with the missing information, it is not a "Reconsideration" because the previous request was not denied. The form must indicate the correct request type.

Where will the Inpatient UR Certification Request Form be located?

The form will be located on the following website: http://manuals.momed.com/manuals/ Click on the FORMS link on the black toolbar in the middle of the page. This will bring up a list of forms.