Letter to Ohio Medicaid Providers

August 28, 2017

Dear Ohio Medicaid Providers,

The Ohio Department of Medicaid (ODM) recently completed the procurement process for the Program Integrity (PI) Hospital Utilization Review (UR) contract. The selected vendor, KEPRO, will begin processing the following review types on August 14, 2017:

  • Hospital Inpatient and Outpatient Retrospective Reviews
  • Focused Clinical Reviews and Bill Audits
  • Prior Authorizations to include:
    • Non-covered Hospital Services
    • Home Health Services >14 hours per week
    • Mental health and Substance Use Disorder (SUD) treatment (under limited circumstances specified below)

Key Information to Know

KEPRO Contact Information

Toll free line: 844.854.7281

Fax line: 844.262.8990

Email: OHMedicaid@KEPRO.com

Inpatient and Outpatient Medical-Surgical Hospital Prior Authorizations

Prior Authorizations for non-covered hospital services should be submitted in MITS.

Prior Authorization of Medicaid Home Health Services > 14 Hours per Week

Home Health Prior Authorizations can be submitted to KEPRO one of two ways:

  1. Via fax at 844.262.8990
  2. Via Atrezzo™ (see description below)

Prior Authorization of Certain Community Based Behavioral Health Services

With the July 1, 2018 “carve in” of community behavioral health services to Medicaid Managed Care, KEPRO’s main role will be to perform prior authorization of behavioral health services for Medicaid consumers who are not enrolled in managed care.  KEPRO will perform prior authorization for Assertive Community Treatment (ACT), Intensive Home Based Treatment (IHBT), SUD Partial Hospitalization and SUD Residential Treatment when requested for Medicaid beneficiaries who are NOT enrolled in Medicaid managed care plans.  KEPRO will also review requests for service continuation of MH and SUD treatment services which have annual utilization thresholds when a beneficiary has met that threshold of utilization. 

Prior Authorization of Certain Hospital Outpatient Behavioral Health Services

Effective August 1, 2017 qualified Ohio hospitals were given the opportunity to render outpatient behavioral health services. For the period August 1 through December 31, 2017 KEPRO will perform prior authorization for ACT, IHBT, SUD Partial Hospitalization and SUD Residential Treatment for Medicaid beneficiaries who are NOT enrolled in Medicaid MyCare plans.  KEPRO will also review requests for service continuation of MH and SUD treatment services which have annual utilization thresholds when a beneficiary has met that threshold of utilization.  Beginning January 1, 2018, Medicaid MCPs will take over the PA responsibility for their members and KEPRO will only perform PA for fee for service enrollees.

Prior Authorization Requests for CPST > 104 hours

Prior Authorization Requests for CPST > 104 hours for service dates 7/1/2017 – 1/1/2018 will continue to go to Permedion following the current process.  After the implementation of the new behavioral health benefit package on 1/1/2018, there will no longer be any benefit limits for CPST.

Prior Certification and Retro Reviews of Hospital Inpatient Psychiatric Admissions

Prior Certification and Retro Reviews of Hospital Inpatient Psychiatric Admissions will continue to be performed by Permedion using the current process EXCEPT for admissions to Institutions for Mental Disease (IMDs) for Medicaid managed care members ages 21 to 65. In this case the member’s managed care plan will conduct the precertification review.

Retrospective Reviews of Hospital Services

In addition to the service prior authorizations described above, KEPRO will also be performing Retrospective Reviews of inpatient and out-patient medical-surgical hospital stays and procedures.

KEPRO is launching an innovative web-based Provider Portal for retrospective reviews, called Atrezzo™. The Atrezzo™ provider portal is a new tool that providers can use to submit medical records, communicate with KEPRO, and check on the status of reviews. We have scheduled web-based trainings to introduce you to this new and helpful tool.

Introduction to the New Atrezzo™ Portal

How to Submit Retrospective Review Medical Records

Date

Time

Conference Line

Web Meeting URL

August 29, 2017

10:00 am

1-866-754-2932

Conference Code: 6815237722

http://KEPRO.adobeconnect.com/rb4dw5ydgs94/

August 30, 2017

1:00 pm

1-866-754-2932

Conference Code: 6815237722

http://KEPRO.adobeconnect.com/rb4dw5ydgs94/

August 31, 2017

1:00pm

1-866-754-2932

Conference Code: 6815237722

http://KEPRO.adobeconnect.com/rb4dw5ydgs94/

Have questions regarding the vendor transition to KEPRO? Reach out to the appropriate ODM Contact below:

Hospital Retrospective Reviews

Lowell Webb, RN - Medicaid Health Systems Administrator-1             

Email:  Lowell.Webb@medicaid.ohio.gov  

Phone: 614.752.5700

Behavioral Health Redesign

BH-Enroll@medicaid.ohio.gov  

Hospital Policy

Hospital_policy@medicaid.ohio.gov   

In-Patient Psychiatric Pre-certifications

Robert Johnson, Social Work Reviewer
robert.johnson@hms.com  
Phone: 614.918.5104

We look forward to our continued work together and hope you are able to join us for a training opportunity.