MaineCare McKesson Interqual Criteria Sheet and ICD-10 Code Set Updates - November 4, 2016

Update to 2016 McKesson InterQual Criteria Sheets, CR 58167 

Effective November 14, 2016, please begin using the 2016 McKesson InterQual Criteria Sheets. They have been updated on the Health PAS Online Portal and will be used as guidelines to approve or deny Prior Authorization (PA) requests. 

Previous McKesson InterQual Criteria Sheets 

From November 14, 2016 to December 14, 2016: MaineCare will continue to accept PA requests with the previous versions of the McKesson InterQual Criteria Sheets concurrent with the newer versions; however, the PA Unit will have the option to issue a deferral letter and request the provider to complete, sign, date, and submit a 2016 McKesson InterQual criteria sheet, as well as any other needed supporting documentation identified in the deferral letter. The PA Unit will be reviewing requests using the 2016 criteria. 

On or after December 15, 2016: You must submit the appropriate 2016 McKesson InterQual criteria sheet along with your PA request. If you submit a previous version of the McKesson InterQual criteria sheet, your PA request will be deferred and you will receive a letter requesting the 2016 version. 

Accessing the 2016 McKesson InterQual Criteria Sheets 

The 2016 McKesson InterQual Criteria Sheets can be accessed by logging into your Trading Partner Aaccount on the Health PAS Online Portal and following the pathway: Prior Authorizations > Manuals, Forms and Criteria Sheets. The McKesson sheets are posted and sorted by MaineCare Benefits Manual policy section number. You may also call Provider Services at 1-866-690-5585 to request a criteria sheet. 

Other PA Criteria Sheet Updates 

• The MaineCare Criteria Sheets have also been updated to reflect current MaineCare Benefits Manual (MBM) policies and citation numbers. Dates of revision are indicated in the footer of the criteria sheets. MaineCare Criteria Sheets for MBM policies that remain unchanged have not been revised. 

• Some MaineCare Supplemental Criteria Sheets have been updated and are now available on the Health PAS Online Portal. 

A Few Reminders

• Please go to the Health PAS Online Portal to access the McKesson InterQual Criteria Sheets, the MaineCare Criteria Sheets, and the MaineCare Supplemental Criteria Sheets. All of the sheets are available on the same page at the Health PAS Online Portal and following the pathway: Prior Authorizations> Manuals, Forms and Criteria Sheets.  

• Some McKesson InterQual Criteria Sheets and MaineCare Supplemental Criteria Sheets are meant to be reviewed as a “combo” criteria set. MaineCare policy and criteria will supersede McKesson InterQual criteria. For example, this is applicable if deciding when it is appropriate to replace a durable medical equipment item or when a second opinion is required. 

• For the McKesson InterQual criteria sheets, the provider submitting the PA does not need to include the full McKesson InterQual criteria sheet in the submission to MaineCare. Instead, the provider may print, sign, date, and submit the first page of the criteria sheet, indicating the relevant clinical scenario number, and print only the completed clinical scenario pages for the scenario that applies. 

• There may be procedure codes listed on the McKesson InterQual Criteria Sheets that are not covered by MaineCare. To be covered, a procedure code must be open and active in MIHMS. 

• When submitting a criteria sheet, please submit a completed Prior Authorization Request form with it. You can access the Prior Authorization Request form by going to the Health PAS Online Portal and following the pathway:  Provider Home Page > Provider Documents > Forms > Authorizations and Referrals. 

If you have questions about the PA process, McKesson InterQual Criteria Sheets, or to verify which codes are covered, please contact Provider Services at: 1-866-690-5585. 

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ICD-10 Changes for FY 2017 Reminder 

As a reminder, the Centers for Medicare & Medicaid Services (CMS) routinely makes updates to the ICD-10-CM and ICD-10-PCS code set. The latest update, effective 10/01/2016, contained both additions and deletions to the code set. 

Providers should review these changes regularly in order to ensure you are billing appropriately. Information on these changes can be found on CMS’s ICD-10 Provider Resource webpage. Click on the appropriate code set link for changes. 

Claims submitted with deleted codes will deny and a new claim will need to be submitted with the correct code. 

If you have questions about this message, please contact your Provider Relations Specialist.