KePRO Quality Improvement Organization (QIO)

Attention Providers:

KePRO authorizations in effect August 1.

Contact the Provider Service Center: (888) 289-0709

Q. Who is the new Quality Improvement Organization for SC Medicaid?
A. Keystone Peer Review Organization (KePRO).

Q. When will KePRO begin operating as the new QIO?
A. June 1, 2012.

Q. What is the process for a obtaining a PA for a recipient who receives retrospective Medicaid?
A. Please refer to your current Medicaid policy manuals for complete instructions regarding Retroactive Eligibility policies.

Q. If Medicare is the primary payor, is a Medicaid PA required for an admission?
A. If Medicare makes a zero payment and Medicaid becomes primary payor, the PA is required.

Q. If a patient has a private insurance, is a prior authorization from KePRO required.
A. Yes.

Q. Are the surgery codes the same as was required for the previous QIO?
A. A list of surgical procedures that require a PA has been revised. Please refer to your Medicaid manual.

Q. Will the PA specify a certain number of days for an inpatient admission?
A. No

Q. If the physician initiates the PA request, can the rendering hospital see the request in the system.
A. Yes, as long as the rendering hospital was listed in the web portal by the initiating physician.

Q. If a patient is transferred from Hospital A to Hospital B and then back to Hospital A, is a PA required for each transfer?
A. Yes. Each admission requires a new claim and a new PA number.

Q. If a newborn is transferred to NICU within the same hospital, is a PA required?
A. No. If the newborn is not discharged from the hospital after birth, only transferred to another unit within that same hospital, no PA is required.

Q. Will KePRO prior authorize services for a patient who is a member of an MCO?
A. KePRO will only authorize a transplant for members in an MCO.

Q. What is the time frame to obtain a PA for a patient who is admitted to the hospital directly from the physician's office?
A. If the admission is an emergency, you have 2 business days to submit a PA request. If the admission is not an emergency, you will have 1 business day to submit your authorization request.

Q. If an inpatient is going home and requires DME, should the hospital case manager or the DME provider obtain the PA?
A. The DME provider will obtain the PA.

Q. If a hospital provider uses InterQual internally, is it necessary to submit the documentation?
A. Yes. You are still required to submit a PA request.

Q. If a Skilled Nursing Facility (SNF) patient is sent to the hospital for admission, who should request the PA?
A. The PA can be submitted by either the SNF or the hospital. Providers will need to communicate with each other regarding who will request the PA.

Q. If a patient is admitted to the hospital with premature labor, but does not deliver, is a PA required?
A. Yes, a PA is required.

Q. Is a PA required for an observation stay?
A. No. Observation is an outpatient service and does not require a PA.

Q. If a patient is admitted for a surgery that requires a PA, is a PA needed for the inpatient admission and the CPT code?
A. KePRO will issue an authorization number for the inpatient stay that must be shared with the rendering physician for payment of the surgery .

Q. If a patient is seen and treated in the ED and is discharged, is a PA required?
A. No

Q. What is the age requirement for therapy prior authorizations?
A. Prior authorizations are required for patient age 21 and over.

Q. Is the prior authorization for therapy required for Dr's office?
A. Prior authorization is only required for adults in the outpatient hospital setting.

Q. Will an acute inpatient rehabilitation admission require a PA?
A. Yes if it is an admission to an acute care facility.

Q. On a 1500 physician claim, for a recipient in a Medical Homes Network (MHN), does the MHN approval # go on the claim?
A. The MHN's referral number and the prior authorization number must appear on the claim form.

Q. If a patient is in a MHN, will a provider need to obtain PA # from the MHN and from KePRO?
A. Yes. The MHN referral number is not documented on the UB claim but it must be on file for audit purposes.

Q. Can a provider view the Interqual criteria?
A. InterQual criteria is proprietary and must be purchased by each user. Each denial letter will however, include the reason for the denial.

Q. In terms of timeliness, when does the clock start, if a provider calls or faxes the information?
A. The clock starts when the information is received and entered into the KePRO system.

Q. If an observation stay turns into an admission, is a PA required?
A. Yes

Q. How does the hospital let the patient know that their admission has been denied when they are already an inpatient?
A. KePRO will also issue a letter to the patient if the admission is denied. The hospital may issue the patient a letter notifying them that their admission is not covered.

Q. Can a patient appeal a decision?
A. Yes, the beneficiary will receive a copy of any denied service. The denial letter will include the right to request an appeal.

Q. Is there a peer-to-peer review in the appeals process?
A. Providers may request a peer to peer review when applicable.

Q. If a patient is admitted, can it be changed to an observation stay?
A. Yes, if the hospital has an order from the physician to admit to observation.

Q. Can you bill for "ancillary only" services if an inpatient claim is denied?
A. Medicaid will accept an outpatient claim (bill type 131) for covered ancillary services.

Q. If a patient is in observation for four days, will Medicaid pay?
A. Yes

Q. What should you do when you do not know the diagnosis code at the time of admission?
A. A diagnosis code must be entered and submitted for the PA request. The initial diagnosis code provided may not be the same as the discharge diagnosis. The review is focused on the clinical documentation, not the diagnosis code.

Q. If a patient is discharged and re-admitted within 72 hours or less than 30 days, is a new PA required?
A. Yes. Each new admission requires a new PA #.

Q. What is required if a planned admission is postponed?
A. Providers should contact KePRO customer service center.

Q. Will the PA's issued by DHHS be honored?
A. Yes. KePRO will re-issue an authorization number via fax for services authorized on or after June 15th.

Q. What is an acceptable response time for a request from KePRO for additional documentation?
A. The documentation must be submitted within 48 hours.

Q. What is the difference in reconsideration and appeal?
A. Providers may request a reconsideration of a denial made by the QIO within 30 days of the date of the letter of denial. If the decision is upheld, the provider may exercise their option to request an appeal to SCDHHS's office of Appeals and Hearings.

Q. Are PA's required for a wound center?
A. If the wound center is an acute care facility, yes a PA is needed.

Q. Will KePRO price custom orthotic codes?
A. No. KePRO is not responsible for pricing services.

Q. Can a provider go in the web portal and see the previous admission dates?
A. Yes

Q. Is there a field in the web portal for the provider to enter their case ID#?
A. No, not at this time.

Q. Will KePRO provide an immediate approval?
A. No, not at this time.

Q. Can you print the PA request screen in the web portal?
A. Yes

Q. Can a provider delete a case in the portal once it is submitted?
A. No

Q. Is the KePRO web portal ICD-10 ready?
A. Yes

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