DME-MEDICARE
What medical condition would qualify a Medicare patient for a home blood pressure monitor?
What is ESRD on Home Dialysis?
What is PPL?
Preferred Provider Listing
This is the preferred network for a site, pod or region.
PPL-capitated
PPL-employed
PPL-contracted
A patient is required to have this characteristic in order to qualify for home health.
What is homebound?
Medicare defines "homebound" status as being those patients that require assistance when leaving the home and that when they do, it requires a considerable, taxing effort.
A region 5 patient is in the region 1 area and visits an Optum contracted urgent care there.
True or False
The patient would have to pay a higher co-pay because the urgent care is not in Region 5's service area
False.
Copays are determined by the Health Plan.
A region 2 patient saw an in-network dermatologist for Acne but was not satisfied and requests a 2nd opinion at USC dermatology.
True or False
We would approve because USC is contracted and this is for a second opinion only
False
Acne is not a condition that requires specialized treatment. A second opinion is available in the community network setting.
What are the approvable condition(s) for a Medicare patient to receive supplemental nutrition, like ensure?
What is tube feeding for a permanent non-functioning GI tract?
The abbreviation(s) used by our referral system to indicate a provider is contracted but not preferred in a pod or site.
What is NLL (Non Listed List)?
EPL (Extended Provider List) is also an acceptable answer)
UNN (Unlisted Network) is not acceptable
A decision to exceed a member's covered benefits
What is a benefit override?
A region 1 Glendora IPA senior patient capitated to CVPP for orthopedics requests to see a contracted orthopedic surgeon in Pasadena because 25 miles is too far to drive from her home in Glendale
Which is the true statement?
1) This should be approved because 25 miles is too long a distance for us to redirect to Glendora.
2)This should be denied and redirected back to CVPP in Glendora because this is a capitated service and the patient choose a PCP in Glendora.
The true statement is 1) 25 miles is too far, so, we cannot redirect.
The maximum distance for a senior to drive to an Orthopedic surgeon is 20 minutes or 10 miles.
The HSD (Health Service Delivery) table is what Medicare uses to determine if we are directing a patient to an alternate provider within an acceptable distance and time from the patient's home.
A third opinion request is approvable for this reason.
What is when the patient has had two other opinions that do not agree?
One reason when Medicare would cover a commode?
What are:
1)Confined to a single room?
2)Confined to the home and there is no toilet facilities in the home?
3)Confined to one level of the home and there is no toilet on that level?
This abbreviation is used when a member is injured or becomes ill and there may be another party or insurer that may help cover the costs of care
What is TPL (Third Party Liability)
When the patient needs to have a referral addressed within 72 hours due to a clinical reason.
What is an urgent referral?
An employed PCP left the organization and the patient was reassigned to an IPA PCP. The patient has an established relationship with Cal Eye for glaucoma. Under the IPA the capitation is now with Foothill Eye.
True or False
A referral to continue with Cal Eye would be denied because glaucoma can be managed within the capitated Foothill Eye network.
False
The change in PCP network from Group to IPA was our assignment decision and not the patient's, therefore, we would continue to honor the prior specialist network.
one condition that would meet Medicare coverage requirements for a hospital bed?
What is?:
1)A medical condition which requires positioning of the body in ways not feasible with an ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require a hospital bed.
2)A condition that requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain.
3)A condition that requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease or problems with aspiration.
4)A condition that requires traction equipment, which can only be attached to a Hospital Bed.
5)For semi electric hospital bed approval, the patient must meet one of the above conditions and also requires frequent changes in body position and/or has an immediate need for a change in body position.
One condition that meets the ARL (adverse risk list) definition.
What is,
A new patient, effective with Optum w/in the last 60 days, AND any of the following
In the midst of treatment for an acute episode
High Risk Pregnancy
Chronic condition not being well-managed
High-dollar procedure, such as transplant, pending or in progress
Major surgery is urgently indicated or pending
Dialysis required
Cancer chemotherapy or radiotherapy that is in progress
Major diagnosis made within the past 30 days
Legal/regulatory issues and/or DMHC is involved
HCPs financial risk increased due to health plan expansion of benefits,
service area, products
Health plan has requested “goodwill” care
Patient is living “out of area”
High Cost DME or Infusible’ s
A patient has the right to file this if he/she disagrees with a referral denial
What is an appeal?
A region 1 patient with back pain wants to go to a contracted EPL (extended provider list) physical therapist in region 5 because they plan to stay out there with family while recuperating. Physical therapy is not capitated in region 1
Which is the correct statement?
1)We should deny because an EPL provider in another region is not considered in-network
2)We should approve because both PPL and EPL are considered in-network.
2) Approved, PPL and EPL are considered in network.
A referral can be approved when care is medically necessary and care is requested from any EPL or PPL provider contracted within or employed by the organization UNLESS:
1. The specialty is Hematology/Oncology
2. There is a capitated provider for the requested specialty
3. There are only employed providers within the patient’s assigned network
The qualified health care professional(s) who can deny a case for medical necessity
What is a licensed physician?
Which of the following equipment would be covered by Medicare if it was determined to be medically beneficial for the patient? Answer all that may apply.
A) Bathtub seat
B) Braille Teaching Texts
C) Grab Bars
D) Incontinent Pads
E) Raised Toilet Seat
F) Spare tanks of Oxygen
G) Surgical leggings
What is none of the above?
A) Bathtub seat-Deny-comfort or convenience item; hygienic equipment
B) Braille Teaching Texts-Deny-educational equipment
C) Grab Bars-Deny-self help device
D) Incontinent Pads-Deny-nonreusable supply, hygienic item
E) Raised Toilet Seat-Deny-Convenience item, hygienic equipment
F) Spare Tanks of Oxygen-Deny-convenience or precautionary supply
G)Surgical leggings-Deny-non-reusable supply; not rental-type item
What does OCN stand for?
Optum care network
The terminology that means this is an IPA network
A service that the health plan does not delegate to Optum -- Optum does not make the UM decision or pay for the service.
What is a carve out?
City of Hope was terminated 3/31/20.
COH oncology on 7/31/20 requests a follow up with a patient because the patient has had a cancer recurrence and is in need of active treatment.
Which is the true statement?
1) This is denied because the active treatment can be provided by the capitated oncology group and City of Hope is no longer contracted.
2) This is approved because it meets continuity of care guidelines for a serious chronic condition requiring active treatment
2) This is approved and meets continuity of care guidelines.
Continuity of care guidelines ensure the transition of patients from other medical groups to Optum or from a change in health plan affiliation or from provider terminations.
1) An ACUTE medical condition that requires prompt medical attention that has a limited duration. Coverage for duration of acute condition.
2) A SERIOUS CHRONIC condition, serious in nature and persists without cure or worsens over time and requires ongoing treatment. Will cover services to complete active treatment and to arrange for clinically safe transfer to a participating provider. The time period will not exceed 12 months
3)PREGNANCY-For the duration of pregnancy and the immediate post-partum period
4)TERMINAL ILLNESS-Condition with high probability of causing death within one year provided that the prognosis of death was made by the terminated provider prior to the agreement termination date
5)NEWBORN CARE-care for child between birth to 36 months. covered services not to exceed 12 months from termination date or extend beyond child's third birthday
6)SURGERY OR OTHER PROCEDURE-that was authorized to the terminated provider within 180 calendar days of the termination date
7)BEHAVIORAL HEALTH-a terminated mental health provider can continue services for a reasonable period of time to safely transition care to a contracted provider. This excludes commercial products where B.H. is provided by the health plan.
A phone number to the referrals department for referral questions?
Or the phone number to the U.M. Physicians for a peer to peer discussion or network questions.
What are?
REGION I- 626-254-8104
REGION II- 213-861-5890/626-254-8104
REGION V- 818-205-0900 OPT #1
North U.M. Physicians Peer to Peer line- 626-254-2245