Exciting Changes to Outpatient Surgery Prior Authorization Requirement; DRG Grouper Billing Guidelines; Change to Utilization Management’s Medicaid 800 Line and Change to Utilization Management’s Process for Voicemail Messages; Change to Medicaid Related Readmission Policy

IMPORTANT INFORMATION ABOUT

Change to Outpatient Surgery Prior-Auth Requirement!

Gateway Health Plan^® recognizes that medical practices are faced with tremendous challenges. At Gateway, we are committed to continuously look for opportunities to lessen the administrative burden on our network of participating physicians. With our mission to provide quality healthcare that is accessible and efficient and our commitment to our physicians in mind Gateway will implement the following changes to its Utilization Management (UM) Prior-Authorization requirement for Outpatient Surgical Procedures:

Gateway is very pleased to announce that Outpatient Surgical Procedures provided on or after October 1, 2008 for our Gateway PA Medicaid members will no longer require prior-authorization when rendered in either the Outpatient Hospital (POS 22) setting or Ambulatory Surgical Center (POS 24) within a hospital or freestanding facility!

Medical Necessity Reviews will only be required by calling Gateway’s UM Department for the short list of surgical procedures (including any related procedures) listed below. Please note ALL other prior-authorization requirements (inpatient stays, DME>$500, SNF, etc.) remain in place including those requests that are managed by National Imaging Associates (NIA).

If you have any questions on which services require Prior-Authorization vs. a Referral please contact Gateway’s Provider Services Department is available to assist with any questions by calling 1-800-392-1145, Monday through Friday from 8:30 am to 4:30 pm.

DRG GROUPER BILLING GUIDELINES

Gateway Health Plan^® requires claims to be billed with the correct DRG code based on the grouper which is in effect for the DOS and Line of Business for which you are submitting a claim.

PA Medicaid – We have not received any indication from DPW that they have updated groupers. Medicaid is currently pricing off of Grouper 23. All claims should continue to be billed with the appropriate DRG code from Grouper 23. We do not crosswalk DRG codes. If you bill with a DRG code from any other Grouper, the claim will deny as “Invalid DRG” and you would have to re-submit the claim with the appropriate DRG from Grouper 23 in order to receive payment. All corrections would be held to the timely filing limitation of 120 days from the date of the original remit.

Medicare Assured^® – We are currently using MS-DRG 25. We will update to Grouper 26 when Medicare makes their update to Grouper 26.

PLEASE NOTE: The information above applies to the submission of DRG codes only. As required by HIPAA, diagnosis Codes are updated annually for both Lines of Business and claims must be submitted with the most current, valid, DX codes for BOTH lines of business.

CHANGE TO UTILIZATION MANAGEMENT MEDICAID 800 LINE

In order to better service our providers, the UM department has made menu changes to the Medicaid 800 line effective October 1, 2008. These changes include options to reach someone in Pharmacy, Provider services and Medicare Assured^®.

CHANGE TO UTILIZATION MANAGEMENT PROCESS FOR VOICEMAIL MESSAGES

Based on feedback received from the provider community, beginning 10/1/2008 nurses in the UM department will be able to accept clinical information via voicemail. If you are calling a nurse in the department with an inpatient review or information related to a specific request, you may leave the clinical information on the voice mail of the nurse you are working with to obtain approval. The nurse will call you back if additional information is needed and you will be notified of the outcome of your request. This change applies to both Medicaid and Medicare Assured^® lines of business.

CHANGE TO MEDICAID RELATED READMISSION POLICY

In accordance with Act 44 of 2008 and the related Medical Assistance Bulletin 01-08-10, Gateway is revising its inpatient hospital payment policy related to readmissions paid through DRG’s within fourteen days of the date of discharge. This statutory change under Act 44 of 2008 was effective September 2, 2008. Effective with dates of discharge on and after September 2, 2008, Gateway will review inpatient hospital admissions within fourteen days of the initial admission’s date of discharge. Readmissions related to initial discharges prior to September 2, 2008 will be handled according to the prior MA Bulletin 1163-88-02.

This MA Bulletin supersedes the readmission policy set forth in MA Bulletin 1163-88-02; all other aspects of MA Bulletin 1163-88-02 remain in effect.

Link to the MA Bulletin 01-08-10 http://www.dpw.state.pa.us/PubsFormsReports/NewslettersBulletins/003673169.aspx?BulletinId=4388