Transcript Document

Welcome to the
2007 NC Medicaid and
Provider Education Seminar
For Developmental
Disabilities
Jane Harris, LCSW
Provider Relations Director, PSD
Speeding up the process
for requesting
AUTHORIZATIONS
JANE HARRIS, LCSW
Director of Provider
Relations
North Carolina Medicaid
FAX TO AUTHORIZATION
JANE HARRIS, LCSW
Director of Provider
Relations
North Carolina Medicaid
Agenda
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VO Authorization experience in NC
Confirming the Basics
CTCM
Provider Relations Unit
VO Authorization experience in NC
 # auth requests received in a week –
Just over 7000 or 1400 a day
 # auth requests returned to providers
weekly because of incomplete/missing
information- About 750 a week
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Confirming the Basics
 Prior authorization is required for all
services
 Exceptions (limits for no auth required):
• TCM gets 32 units (8 hours) the first month
 Consumer transfers: to your agency and
has already had the pass through units
TCM, you need PA before delivering
services.
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Confirming the Basics
All prior authorization requests must have:
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Level of care being requested
Member Medicaid number
Provider Medicaid number, and this will
be the LME number if it is for TCM
Check for completeness, accuracy and
clarity before submitting – speeds the
process
Confirming the Basics
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Diagnosis (use DSM-IV axis)
Use codes and words
DD – minimum Axis I, II or II will be accepted
Specify “units”, “hours”, or “days” for each service; this
needs to be consistent. CTCM form must match Cost
Summary.
If you put units and the service is billed in days, this will be a
problem. VO authorizes what you put on the form, units,
days, etc.
Specify the duration requested – Start date and End date
Include PCP or POC that identifies the need and purpose of
each requested service. CTCT must match Cost Summary.
Signed Service Order per DMA guidelines
CTCM, Cost Summary and POC/CNR have to match for you
to get an accurate authorization.
Confirming the Basics
 Missing information/incomplete forms will be
returned to the requesting provider.
 Currently DD Coordinators will contact you by
phone for missing or incomplete information
and this must be submitted within 10
business days.
 In the future, if the 10 day turnaround time is
not met, a denial will be issued.
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Confirming the Basics
How to Send Authorization Requests to
ValueOptions
 MAIL:
P.O. BOX 13907
RTP, NC 27709-3907
 FAX:
919-461-0669 for CAP/TCM only
919-461-0599 for all MH/SA services
 PHONE: 1-888-510-1150
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Confirming the Basics
How to view authorization letters
 Go to www.ValueOptions.com
 Select Provider; select Provider Connect log-in site.
 Use your Medicaid ID number to register the first time
you visit the site
 If you bill through the LME you will not be able to use
this function
 Call 888-247-9311 if you have problems
 COMING IN 2007: ValueOptions will be testing an
option to allow providers to complete the various
authorization forms on line.
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Reminders
 Piedmont Cardinal Health Plan
If a recipient's eligibility is in Cabarrus,
Rowan, Stanley, Union or Davidson counties,
please call Piedmont Behavioral Health at :
1-800-939-5911
 All other questions call ValueOptions at:
1-888-510-1150
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Community Alternative Program/Targeted
Case Management Authorization Requests
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Use ValueOptions CTCM form and
instructions
Located at www.ValueOptions.com (Select
provider; select network specific; select NC
Medicaid or NC Health Choice)
NC Health Choice does authorize TCM for
children
Available in PDF and Word format
Instructions last updated on 3/30/07
Community Alternative Program/Targeted
Case Management Authorization Requests
The CTCM form is used to request:
• Plan of Care (POC) initial review
• Continued Need Review (CNR)
• Targeted Case Management (TCM)
• Discreet Services
• Plan Revisions
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Community Alternative Program/Targeted
Case Management Authorization Requests
CTCM for TCM:
With each request for a Non-Waiver recipient submit:
 Person Centered Plan (PCP)
 Service Order, properly signed QP until new TCM
definition is approved then one of the approved four
disciplines will need to sign the PCP for non-Waiver
consumers.
 Requests must be submitted no less than every 90
days. See Timeline Grid
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Community Alternative Program/Targeted
Case Management Authorization Requests
With each TCM request, for Waiver Recipients, submit:
 For TCM, a request will be submitted with your
annual CNR (starts with November birthday
month requests)
 Service Order, properly signed and
 CTCM must be submitted
 This will be an annual authorization.
 If all units are used prior to the next CNR, you should
submit a Revision Request using the CTCM
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Community Alternative Program/Targeted
Case Management Authorization Requests
 CAP Waiver Equipment and Modifications
• VO only approves/denies the need for the equipment or
modification
• Case Manager & LME select vendor
 CAP Plan of Care/CNR
• VO approves/denies the Plan; unless cost summary is over
$85,000. In these cases, the POC/CNR is sent to the
Division for review and decision
• Revisions to POC/CNR: VO approves or denies all revisions
 CAP “Discreet Services” & Targeted Case Management
• VO approves/denies the need for the service & authorizes
the provider, if approved
• VO makes initial POC and Continuing Need Review (CNR)
decisions
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Community Alternative Program Discreet
Services
Discreet Services are those services which are
Provider specific (not equipment or
modifications) and include:
 Home and Community Supports
 Residential Supports
 Respite
 Personal Care
 Day Supports
 Supported Employment
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Community Alternative Program Discreet
Services
When an authorization request is submitted for any of
the Discreet Services, the following applies:
 A separate CTCM form must be submitted for each
service if different providers are delivering the
services. If same provider delivers multiple services,
up to 3 requests can go on one form.
 The Case Manager submits the original or initial
request along with the Plan of Care/CNR
 The individual provider can submit JUST the CTCM
on the concurrent request if there are no changes. In
these cases the POC/CNR is not required to be
resubmitted.
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CTCM Authorization Requests
Use the CTCM form for submitting Plan of Care/
Continuous Need Review (POC/CRN). Include with
each request
• Plan of Care
• Service Order
• MR2 form with LME signature. MR2 can not be
signed after the date the POC is signed (see CAP
Manual)
• Supporting Assessments
• SNAP index score
• Cost Summary
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CTCM Authorization Requests
CTCM for Targeted Case Management
(TCM) must also have the following
submitted:
 Person Centered Plan (if not CAP; if
CAP use POC)
 Service Order, properly signed
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CTCM FORM
SEE FORM AND INSTRUCTIONS
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Provider Relations Team for the NC
Medicaid Account
 ValueOptions’ Customer Service Team can answer most
routine questions and address many requests
 ValueOptions also has a Provider Relations Team to
address more complex auth related issues and questions.
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Delayed auth letters, incorrect auths, auth issues between VO
and EDS, authorization process questions and concerns, etc.
• The team is also responsible to develop and deliver provider
trainings with DMA
 To access these resources: call 1-888-510-1150,
 If you have multiple authorizations issues that need to be
researched, please complete the template found on our web
page. Follow the directions for sending it by e-mail as a
password protected document.
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Q&A
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