Provider Manual State of Alaska Department of Health and Social Services Division of Health Care Services September 2021 Table of Contents SECTION 1: CARE MANAGEMENT PROGRAM OVERVIEW .....................................................................6 Purpose of the Care Management Program .....................................................................................6 Definitions of Utilization Management and Case Management ........................................................6 Comparison of Utilization Management and Case Management ......................................................6 SECTION 2: COMMUNICATING WITH COMAGINE HEALTH ...................................................................8 Business Hours ...............................................................................................................................8 Contact Information .......................................................................................................................8 Voice Mail ......................................................................................................................................8 Submitting UM Reviews via the Internet .........................................................................................8 SECTION 3: COMPLIANCE WITH URAC UTILIZATION REVIEW STANDARDS .......................................... 10 Frequently Asked Questions About Utilization Review Decisions ................................................... 10 SECTION 4: HIPAA ............................................................................................................................ 13 Business Associate Standing ......................................................................................................... 13 DHCS Letter to Alaska Medicaid Providers ..................................................................................... 13 SECTION 5: PROVIDER BILLING CONCERNS ........................................................................................ 15 Claim Discrepancies ...................................................................................................................... 15 Certification Modifications ........................................................................................................... 15 Contingency for Payment ............................................................................................................. 15 SECTION 6: MEDICAID ELIGIBILITY AND THIRD PARTY LIABILITY ......................................................... 17 Eligibility Categories ..................................................................................................................... 17 Eligibility Verification ................................................................................................................... 17 ID Cards and Coupons ................................................................................................................... 17 Eligibility Verification System........................................................................................................ 17 Third Party Liability and Dual Eligibility ......................................................................................... 18 SECTION 7: UTILIZATION REVIEW PROCESS OVERVIEW ..................................................................... 19 Submission Modes ....................................................................................................................... 19 Eligibility Verification ................................................................................................................... 19 First-level Non-physician Review .................................................................................................. 19 Second-level Peer Review ............................................................................................................. 20 SECTION 8: WEB-BASED UTILIZATION REVIEW SUBMISSIONS ............................................................ 21 Purpose ....................................................................................................................................... 21 Responsibility............................................................................................................................... 21 Requirements .............................................................................................................................. 21 Process and Procedures ................................................................................................................ 21 Provider Manual Alaska Medicaid – Health Care Services |Page 2 Submission ...................................................................................................................................... 21 Required Review Documentation ..................................................................................................... 21 Medical Necessity Screening ............................................................................................................ 23 Second-level Peer Review ................................................................................................................ 23 Non-certifications ............................................................................................................................ 23 Questionnaires ................................................................................................................................ 24 Submitting Retrospective (Retro) Reviews ........................................................................................ 24 Time Frames .................................................................................................................................... 24 SECTION 9: PRE-SERVICE UTILIZATION REVIEWS ................................................................................ 26 Purpose ........................................................................................................................................... 26 Responsibility .................................................................................................................................. 26 Requirements .................................................................................................................................. 26 Late Notification .............................................................................................................................. 26 Processes for the Select Diagnoses and Procedure Review Guidelines ............................................... 27 SECTION 10: CONCURRENT UTILIZATION REVIEWS ............................................................................ 32 Purpose ....................................................................................................................................... 32 Responsibility .................................................................................................................................. 32 Requirements .................................................................................................................................. 32 Late Notification .............................................................................................................................. 32 Process and Procedures ................................................................................................................ 33 SECTION 11: RETROSPECTIVE UTILIZATION REVIEWS ......................................................................... 38 Definition and Purpose ................................................................................................................. 38 Responsibility............................................................................................................................... 38 Requirements .............................................................................................................................. 38 Retrospective Review Submission When Eligibility is Established during the Inpatient Admission ... 38 Late Notification .......................................................................................................................... 38 Process and Procedures ................................................................................................................ 39 SECTION 12: PHYSICAL REHABILITATION UTILIZATION REVIEWS ........................................................ 42 Purpose ........................................................................................................................................... 42 Responsibility .................................................................................................................................. 42 Requirements .................................................................................................................................. 42 Late Notification .............................................................................................................................. 42 Process and Procedures ................................................................................................................... 42 SECTION 13: OUTPATIENT IMAGING UTILIZATION REVIEWS .............................................................. 48 Purpose ......................................................................................................................................