Provider Services and Resources Hospital Contact Information Submitting Prior Authorization Requests Review Requests and Determinations Utilization Review Process Reconsideration Process Notifications of Review Outcome HFS Attachment F – Procedures Subject to Review Forms and Instructions Overview of eQSuite™ and Summary of Provider Reports I. Getting Started – Certification at a Glance Healthcare and Family Services IMPORTANT: Providers must read and be familiar with HFS’ policies and procedures located at . Before submitting any request to eQHealth, providers must check the Participant’s Medicaid eligibility and service limit information through Healthcare and Family Services’ eligibility verification channels. Requests for Prior Authorization (PA) must be submitted to eQHealth Solutions with the following information Participant name and 9-digit Medicaid ID number. Admitting physician (surgeon) 9-digit IL Medicaid ID and phone number The ICD9CM admitting diagnosis code The ICD9CM procedure code associated with CPT codes The hospital’s 12-digit IL Medicaid Provider ID where participant will have procedure performed Clinical information related to proposed procedure To assist hospitals, a template is available for surgeon (office) to provide you with information needed for utilization review. The templates are available in Section IV of this document. Prior authorization review is strictly for certification (prior authorization) of specific procedures. This is not an inpatient admission (concurrent) review. Prior authorization is required regardless of reimbursement type (DRG or Per Diem).
section of our homepage. Submitting Prior Authorization Requests Prior authorization (PA) review requests are submitted electronically using eQHealth’s proprietary Web-based software, eQSuite™. Thousands of healthcare professionals submit review requests and receive certification responses via the Web. eQHealth’s HIPAA secure, Web-based system – eQSuite ™ provides 24/7 access to: Submit review requests Check status of your Web submitted review Provide additional information when requested by eQHealth Submit online helpline queries View or print provider-specific notification/determination letters Run provider-specific reports with review data For more information on the Web system, see Section V of this manual. Web Administrator The Web Administrator will have rights to create a Provider profile for each user to grant access to eQSuite™ and maintain User IDs and passwords. If the hospital does not currently have a Web Administrator, you must appoint one. Managing system access and users is a non-technical process. A Hospital Contact Form is available on our Website. Review Requests and Determination Timeframes Description Request Method Requirements/Timeframe Determination Mandatory prior authorization of non-emergent, CABG and back surgery procedures. Prior authorization is required for elective procedures subject to review on HFS Attachment F that are scheduled on and after April 1, 2014. The hospital must obtain prior authorization of procedures subject to review by submitting requests online through eQHealth’s Web system, eQSuite™. DO NOT send requests or inquiries to HFS. Requests must be submitted to eQHealth via the Web: Up to 30 calendar days prior to procedure date No later than 3 business days prior to procedure date (more, if requested before a holiday). eQHealth will render a medical necessity determination in 2 business days from the receipt of all necessary information. A reconsideration of a medical necessity denial may be requested a) prior to the procedure date and b) requested no later than 10 business days from the date of the denial. IMPORTANT: The prior authorization number (TAN) will be valid for 60 calendar days from the date of the eQHealth approval notice: If a TAN is issued and the admission date changes but remains within those 60 days, the hospital can change the admission date on eQSuite (Utility) or call the eQHealth Helpline with the new admission date. The TAN is still valid.
Second Level Reviewers (Physicians) Make certification or denial determinations. The determination is: Based on hospital documentation that supports medical necessity and appropriateness of setting. Sensitive to the local healthcare delivery system infrastructure. Based on the physician reviewer’s clinical experience, judgment and generally accepted standards of healthcare. Only physicians may render an adverse determination for medical necessity. Note: See the Reconsideration Process section of this manual Pended Review for Additional Information Review Type If the review cannot proceed because ... Then Timeframe for submission Prior Authorization of Elective Procedure Clinical information is needed by the first level nurse reviewer to satisfy criteria. The hospital Liaison is faxed a Request for Additional Information and status shown as pended on eQSuite™. The hospital will supply additional information within 1 business day from the date on notice or the request will be canceled. Submitting Additional Information Prior Authorization requests may require additional information to help meet medical necessity: The hospital should check all Prior Authorization requests online within 24 hours of submission. The status will display as, at nurse, at physician or pend. For pended reviews, a notice of “Request for Additional Information” will be faxed to the hospital Liaison and is available for view online. You may submit the additional information needed through eQSuite™ under the Request for Addt’l Info tab. Please download the eQSuite™ User Guide from our Web site. All prior authorization information is available under the PriorAuthResources tab. Reconsideration Review Process If the hospital or physician disagrees with the adverse determination made by eQHealth, a request for reconsideration may be submitted. The hospital or treating physician/clinician may request an expedited reconsideration request using the eQHealth Prior Authorization Reconsideration Request form (included in Section IV of this manual). This request for reconsideration must be submitted within 10 business days from the date of the denial notice. A second eQHealth physician reviewer, who is board certified, and not involved in the initial decision, will review the reconsideration request and make a determination. The following apply to reconsideration requests: If the reconsideration request in untimely with no good cause, a notice is sent that the request is invalid. Upon reconsideration review, if the denial is upheld a notice is sent and there is no other course of action from eQHealth.
TEMPLATE - Medicaid Prior Authorization for Elective CABG (Use this template to gather information from Surgeon and enter into eQSuite™ Web system. Do not fax to eQHealth.) Request Date: _______________________ Elective CABG MEDICAID PARTICIPANT INFORMATION Participant Name: Last, First, Middle ___________________________________________________ Date of Birth: // Medicaid ID #: Sex: Age: HOSPITAL/REQUESTOR INFORMATION PHYSICIAN’S INFORMATION Hospital’s Name: ___________________________________________________ Medicaid 12-Digit Provider ID #: Requestor: ___________________________________________________ Phone #: () - Attending(Surgeon) Physician’s Name: Last, First, Middle Initial Street Address: ______________________________________ City: _______________________________________________ State: ______________________________________________ Zip Code: -
INSTRUCTIONS Section I: Participant Information Recipient Identification # – Enter the Participant’s number that appears on the IL Medicaid identification card. Participant Name – Enter the Participant’s first name, middle initial, and last name as it appears on the IL Medicaid identification card. Sex – Indicate the sex of the Participant. Age – Enter the age of the Participant at the time service (is to be) was rendered. Date of Birth – Enter the month, date, and year of the Participant’s birth. Use two-digit numbers, e.g., 01/04/64. Section II: Provider Information Medicaid # – Enter the hospital’s Illinois Medicaid provider number. Hospital Name – Enter the name of the hospital that (will render) rendered the treatment. Physician IL Medicaid # – Enter the physician’s Illinois Medicaid provider number. Physician Name – Enter the first name, middle initial, and last name of the attending (Surgeon) physician. Section III: Request Information Request Date – Record the date of the request. Request Method – Indicate whether request submitted by fax, mail or telephone. Requested By – Indicate whether the physician or hospital made the request. Requestor Name – Enter the name of the individual requesting the review. Requestor Telephone # – Enter the telephone number of the requestor including area code. Section IV: Reconsideration Information Date of Denial Notification – Enter the date medical necessity denial letter was issued. Date of Admission – Enter the date the patient was admitted to the hospital. Rationale for Request – Enter the medical basis/rationale for disagreement. Additional information submitted – Indicate whether additional information is submitted with the request.