Provider Update: November 7, 2018

Subject:Internal Processes for ADvantage Administration in Harmony

In an effort to provide additional clarity for Providers of what action is taken after your Service Plan submissions arrive at the AA, we have outlined our general processes in Harmony below. We have also included some important tips for you to follow to make these processes flow smoothly for your Member.

Clinical Review Internal Process

Step 1 – Clinical Reviewer opens ticklers in date order, oldest to newest (note: Filters must be applied to identify requests for Priority Review – an additional step is required to determine whether justification for priority processing has been submitted and meets criteria. The CM agency is notified when the request does not meet criteria; otherwise, the request is processed within 24 hours and forwarded to Service Plan Authorization (SPA) for final authorization);

Step 2 – Clinical Reviewer reviews all services that require clinical level of review;

Step 3 – Clinical Reviewer navigates the system to identify whether or not all required documentation has been entered/uploaded;

Step 4 – Clinical Reviewer updates Clinical Review field with the appropriate outcome of review;

Step 5 – Clinical Reviewer adds a plan note as needed;

Step 6 – Clinical Reviewer sets the plan status to SPA Review – Note: It's not an automatic that SPA will apply an authorization as there may be other issues that SPA identifies unrelated to Clinical;

SPA Review Internal Process

Step 1 – Team Lead assigns ticklers to the SPA unit (note: Filters must be applied to identify requests for Priority Review – an additional step is required to determine whether justification for priority processing has been submitted and meets criteria. The CM agency is notified when the request does not meet criteria; otherwise, the request is processed within 24 hours);

Step 2 – SPA Reviewer opens tickler in date order, oldest to newest;

Step 3 – Determine what the review request is for, i.e. plan, addendum, response to condition, etc.;

Step 4 – SPA Reviewer navigates the system to identify whether or not all required documentation has been uploaded;

Step 5 – SPA Reviewer reviews services and updates the SPA Review field for all ADvantage services with the appropriate outcome of review;

Step 6 – SPA Reviewer sets all services that require Clinical Review to In Progess status for both the SPA Review and Clinical Review field(s;)

Step 7 – SPA Reviewer adds plan note as needed;

Step 8 – SPA Reviewer sets the plan status as appropriate to one of the following:

Open=all services authorized,
Partially Open=at least one service is not authorized or short-term authorized,
Clinical Review,
CD-PASS Review,
Denied=unable to review as submitted and plan note added to notify reason of denial;

Step 9 – SPA Reviewer creates authorization for all approved services;

Important Tips for Speedier Submission

1. The comments box located within each individual service area should be kept as brief as possible and used only to clarify the service.

For example:

Product Description:

For service E1399 - hand held shower, reacher, hip kit, etc.
For T1999 - Ensure, Boost, Glucerna

Provider, when "Other" is the selected provider, such as for pharmacy or informal supports:

Daughter, Lisa Brown
Walmart Pharmacy

Other:

Location, such as for multiple grab bars: shower wall, next to toilet

This box is character limited and MSU must also utilize this space.
If a lengthy response/description is required, please add a Service Plan Note. Information regarding multiple service lines can be addressed in one Service Plan Note.

2. When attempting to resolve Health and Safety conditions, please add a Service Plan Note explaining what action has been taken to resolve the condition. We are experiencing difficulty discerning what has changed in the plan upon receipt.

3. When the plan has been submitted to/approved by the Case Manager Supervisor (CMS), plan validation has been run, and the Plan status has been set to the appropriate review type, please do not change that status again. When doing so, it places the request for review further out.

a. Ex. On 10-8, CMS sets the plan status to SPA Review. On 10-12, CMS changes the plan status to Clinical Review. Then on 10-22, CMS changes the plan status back to SPA Review. This has essentially moved the review date from 10-8 to 10-22, resulting in a loss of 14 days!

If the Plan was incorrectly set for the wrong review type by the CMS, it will be routed appropriately by MSU-AA staff.

b. Actions applied to the Service Plan as it routes through the various departments within MSU-AA (CD-PASS, Clinical Review) will be visible to the Case Manager. However, until SPA has completed the final review and added the relevant authorizations, the Plan should not be modified by the Case Manager.

4. If a plan requires priority review, check the Priority Review box, add a plan note with a Note Type of Priority Review, and select a note Status of Communication so MSU Staff may respond. This helps us with identification. Please also be sure to add specific, detailed justification in the Plan Note for priority processing.

5. All services must be added to the Member's Plan, which includes all non-ADvantage services as well.

6. PA's – If a plan falls outside of the dates of service that were converted into the Harmony system (before 8-27-18) you must contact OHCA to resume billing for this PA. The PA is not available in Harmony.

7. The Signature Page acts as the signature for all documents that once required a wet signature; however, all Medical Order forms, the Request for Grab Bar form, and Environmental Modification forms continue to require the necessary wet signatures as identified on the document.

8. For all CM unit adjustments and requests for additional CM units, refer to the Bulletin sent/dated 10-16-18, as submissions outside of the directions given in this bulletin will not be considered.

Please note: If you have any questions regarding the information provided above, please send questions through the PQ chapter in Harmony.