Provider Notice issued 06/30/12

Changes to Utilization Reviews/Inpatient Detoxification Readmissions

As a result of Public Act 097-0689 (pdf), referred to as the Save Medicaid Access and Resources Together (SMART) Act, the department is implementing the following utilization review changes specific to inpatient level of care for detoxification readmissions.

Effective with admissions on or after July 9, 2012, HFS will implement a review of inpatient detoxification admissions 60 days prior to July 9, 2012, for the detoxification diagnosis codes that currently require mandatory concurrent review and are identified below. Inpatient detoxification admission stays will not be approved for reimbursement if there has been a previous inpatient detoxification stay within the last 60 days. The admitting inpatient facility should contact eQHealth within 24 hours or the next business day of the admission to begin the concurrent review process.

Effective July 9, 2012, a Detoxification Look-Up utility will be available to providers to check inpatient detoxification admission status. This utility will be available solely through eQHealth’s Web system, eQSuite™, as it offers 24/7 availability and a majority of providers already have access to eQSuite™. If hospital staff needs access to eQSuite™, they should contact their eQHealth Web Administrator.

• eQHealth Look-Up Utility

If there was an admission within the past 60 days, the message will read:

Participant is not eligible for a detox admission for the proposed admit date due to a previous inpatient detoxification stay within 60 days.

If there was no admission with the past 60 days, it will read:

Participant is eligible for a detox admission for the proposed admit date. Submit your review request via the Web or Certification line within 24 hours of admission or the next business day.

The applicable message will be shown in a pop-up that also contains the beneficiary ID entered in the look-up and the last detoxification admission date as shown below:

Bene ID: 1234567

Last detox admission date: 6/15/2012

Participant is not eligible for a detox admission for the proposed admit date.

A provider notice from eQHealth will be sent next week with instructions/screen shots to use this new utility. eQHealth will also offer 15-minute Webinars throughout the day on July 5th and 6th, for those who prefer a quick tutorial. Hospitals may register for the eQHealth tutorial under the Announcement section of the eQHealth Web site or e-mail eQHealth.

When a diagnosis code is subject to review and ICD-9-CM coding guidelines mandate a coding change requiring a 4th or 5th digit code extension, the 4th and 5th digit code extension will automatically be subject to review.

The following diagnosis codes are currently part of the Mandatory Concurrent Review Process that is administered by HFS and its Quality Improvement Organization, eQHealth:

This informational notice also provides notification of changes to diagnosis codes subject to admission/concurrent inpatient utilization review.

• Changes in Diagnosis Codes on Attachment B

Effective with admissions on and after August 1, 2012, the following Diagnosis Codes are subject to mandatory concurrent review and will be added to Attachment B and will be subject to the 60 day readmission policy for detoxification:

• Exceptions to Mandatory Concurrent Review Will Apply

The department will allow limited exceptions to mandatory concurrent review in the following circumstances:

• A participant’s eligibility was backdated to cover the hospitalization.

• Medicare Part A coverage exhausted while the patient was in the hospital, but the hospital was not aware that Part A exhausted.

• Discrepancies associated with the patient’s Managed Care Organization (MCO) enrollment at the time of admission.

• The patient remains unresponsive or has a physical or mental impairment during the hospitalization that prevents the hospital from identifying coverage under one of the department’s medical programs.

• Other – the hospital must provide narrative description.

Attachments A through D can be downloaded from the department’s Peer Review Organization (PRO) / Quality Improvement Organization (QIO) Web site.

Any questions regarding the review process may be directed to eQHealth at the toll-free Helpline at 1-800-418-4045. Any questions regarding this notice may be directed to the Bureau of Maternal and Child Health Promotion at 217-557-5438.

Theresa A. Eagleson, Administrator

Division of Medical Programs