Transcript Overview of the Virginia Medicaid Program

DMAS and KePRO
Your Key to PA
Program Changes and Updates
Check out the Medicaid Memos and
line
Manuals on
It’s easy:
Go to the DMAS website at www.dmas.virginia.gov and click on the
link to Providers Services
or
Go to the KePRO website at http://dmas.kepro.org
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PA SERVICE TYPE SELECTION
SELECT ONE OF THE SERVICE TYPES WHICH APPLY TO YOUR PA REQUEST:
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9999 INTENSIVE IN-HOME
0050 OUTPATIENT PSYCH SERVICES
0092 ORTHOTICS(EPSDT)
0093 EPSDT INPATIENT PSYCH
0100 DME
0200 INTENSIVE REHABILITATION
0201 CORF
0204 OUTPATIENT REHAB
0401 INPATIENT PSYCHIATRIC
0450 MRI
0451 CAT
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0452 PET
0500 HOME HEALTH
0625 ELDERLY CASE
MANAGEMENT
0700 TREATMENT FOSTER CARE
0750 CSA RESIDENTIAL
TREATMENT
0751 NON-CSA RESIDENTIAL
TREATMENT
0900 EDCD WAIVER
0902 DD WAIVER
0920 AIDS WAIVER
0960 TECH WAIVER (EXCLUDING
PDN AND RESPI)
0400 INPATIENT ADMISSION
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Submitting PA Requests via
iEXCHANGE
The preferred method of submission for
PA requests is through iEXCHANGE at
http://dmas.kepro.org
Providers can use iEXCHANGE to submit requests 24 hours a
day, seven days a week
Registration is required and once completed, providers can
expect to receive their iEXCHANGE user login and
password by email within 10 business days
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Submitting PA Requests via
iEXCHANGE
Need Help?
A step-by-step iEXCHANGE user manual, an on-line prerecorded training presentation with iEXCHANGE demo,
and other helpful resources are available on the KePRO
website at:
http://dmas.kepro.org/default.aspx?page=iexchange
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Submitting PA Requests
Requests also may be submitted via
 Telephone: 888-827-2884 or 804-622-8900 (local)
 Fax: 877-652-9329
or
 Mail to:
KePRO
2810 North Parham Road, Suite 305
Richmond, VA 23294
Do not send duplicate requests via multiple faxes, iEXCHANGE,
etc. unless specifically instructed by KePRO to re-send. This
only clogs up the system and slows the process
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Submitting PA Requests via Fax
Updated PA request fax forms are now
posted on the DMAS and KePRO websites
The forms have been updated based upon provider feedback,
and are available in two formats:
(1) a PDF version that providers can download and
complete manually; and,
(2) an editable Word version, that allows providers to
save the form and input responses directly. Use of editable
version of the PA request form will expedite processing
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Submitting PA Requests via FAX
When submitting by fax and/or mail, providers
must use the updated fax forms and should
include all relevant clinical information in the
Severity of Illness (SI) and Intensity of Service
(IS) boxes
Please do not state “see attached” or “meets criteria,” and do not
send attachments with the fax forms, except as noted in fax
form instructions
KePRO is unable to alter any information submitted on PA
requests
Providers are responsible for providing accurate and correct
information on their PA requests
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Submitting PA Requests for Waivers
The preferred method of submission for PA requests for waiver
services is through iEXCHANGE; however, requests may be
submitted via fax, telephone, or mail
Please note that PA requests for waiver enrollments must be submitted by fax or mail
and must include a thoroughly completed copy of the individual’s Uniform
Assessment Instrument (UAI) screening form
PA requested “from” and “through” service dates are required for all PA submissions.
However, for certain waiver services, an “open” through date (12/31/9999) is no
longer acceptable
Under KePRO, all dates entered must be “valid” and the new open through date format is
equal to six (6) years beyond the “from” date of service. The through date for “open”
waiver PAs will be systematically auto-renewed by KePRO prior to the PA expiration
date. This new “open” end-date change applies to newly added and/or updated prior
authorizations. Providers are not required to change existing waiver prior
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authorizations (e.g., those on file with a “12/31/9999” authorized through date)
Submitting Additional Information
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To submit additional information on an
open case
iEXCHANGE
Providers may submit additional information through iEXCHANGE by
choosing "add to comments." (NOTE: The "extend case" feature is
to be used when requesting additional days of coverage except for
inpatient med/surg admissions.). Whenever a provider adds to
comments, this puts the case back in the nurse review queue
FAX / PHONE
Providers may receive a notice from KePRO requesting additional
information. Providers should submit additional information by
following the instructions received from KePRO on the "fax-back"
notice
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Receiving a PA Number
Providers may obtain the PA number from the
following sources:
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iEXCHANGE – go to http://dmas.kepro.org
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Fax received from KePRO for requests faxed or phoned in
(except full authorizations for EDCD/AIDS waiver services)
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DMAS web-based ARS at http://virginia.fhsc.com
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Medicall (1-800-884-9730 or 1-800-772-9996)
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PA notification letters sent to the provider address on file
with DMAS
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Receiving a PA Number
Once your PA request has been submitted, a
case ID number will be generated.
The case ID number is used to track this specific case
through KePRO’s system
Please note that the case ID number is not your PA number
The PA number will also be posted on iEXCHANGE (and
sent via fax for telephone and fax PA submissions.)
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Receiving a PA Number
Reading numbers in iEXCHANGE
Medicaid ID numbers consists of 12 digits
KePRO Case ID number is 9 digits with dashes
PA Number generated by the VAMMIS is 11 digits
Without the correct number of digits, it will take longer to
process the request
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Retro Reviews
PA requests for retroactively eligible recipients
or “retro-reviews”
Requested start of care date should be entered as the first day
hands-on service was provided to the individual once
Medicaid eligibility was effective
These “retro reviews” can also be submitted via iEXCHANGE,
phone, or fax, and should include only the required clinical
documentation (i.e., do not submit the entire medical record)
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Overlapping Dates
Overlapping dates with the same provider
For on-going prior authorizations, check your files and
verify the dates that you already have authorized or
denied before submitting your request
Submit your request using the correct begin and end dates
If your new PA request overlaps with an approved or
denied PA that we already have on file (same recipient,
same provider, same service, same or overlapping dates),
your PA request will be rejected back to you to correct the
begin and/or end dates
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Overlapping Dates
Overlapping dates with another provider
If your PA request overlaps with a PA from a different provider
(same recipient, same service, same or overlapping dates),
your PA request will be delayed. Therefore, be sure to
request the correct begin and end dates
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ICD-9 Codes
ICD-9 Diagnosis Codes
For ALL prior authorization submissions, the primary ICD-9
diagnosis code (include all 5 digits, where applicable) relative to the
PA requested service(s) is required unless otherwise directed.
For inpatient PA requests, the admission or “working” diagnosis ICD-9
code is sufficient. (The diagnosis code provided with the inpatient
PA request is not required to match with the diagnosis code billed on
the inpatient claim)
iEXCHANGE provides a search feature for ICD-9 and procedure codes.
These codes are also available in an Excel format on the KePRO
website at http://dmas.kepro.org/default.aspx?page=faq
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Procedure Codes
Procedure Codes
For inpatient admissions, procedure codes are not required as
part of the PA submission. If the recipient is being admitted
for a planned, elective, surgical procedure, the provider must
specify the procedure to be performed as part of the
severity of illness or intensity of service documentation
For Outpatient Services providers must identify the PA
requested service(s) using the most appropriate procedure
code (CPT, HCPCS, Revenue codes etc)
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Procedure Codes
Procedure Codes
When entering a HCPCS Procedure Code through
iEXCHANGE, capitalize the leading alpha character, such as
"E1399"
Additionally, the maximum number of procedures that can be
submitted per PA is 18 (this is not a change). Therefore, any
PA request (i.e., specialized wheelchairs, etc.) having over 18
lines must be submitted via a separate PA request
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Procedure Codes
Procedure Codes
For non-emergency outpatient (NEOP) scans including MRI, PET, and CAT
scans, provide the CPT code(s) that most closely matches with the
physician’s order, particularly with the body part/location of scan
While the CPT code requested at the time of PA is not required to match with
the CPT code billed on the claim, it should match the location (body part)
scanned. The number of CPT codes requested will be reflected as units on
the letter from First Health Services along with the PA number.
Additionally, for those scans not yet scheduled at the time of PA submission,
submit the PA request with a “through date of service” up to 90 days
beyond the requested service begin date. (For scan claim submissions, the
provider must bill using the CPT code that matches the scan service
rendered. Claim payment is based upon the CPT code billed)
Please note: Imaging requests will be authorized for 90 days beginning
the date KePRO is notified (unless it is a retro request)
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Revenue Codes
Revenue Codes
For Home Health and Outpatient Rehabilitation providers, continue
using the existing revenue codes; however, for PA submissions, a
prefix of “R” is needed, i.e., revenue code 0421 must be entered
as R0421.
Please note that the R prefix is only required for the PA submission;
continue to submit claims without the “R” prefix
The appropriate revenue codes are listed in the DMAS Home Health
Provider Manual and Rehabilitation Provider Manual (Chapter 5)
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Verifying Eligibility
Eligibility verification avoids unnecessary delays
associated with PA submissions to an incorrect payer
source
Providers should submit PA requests for the dates that the recipient is
Medicaid Fee-For-Service eligible. Requests that are submitted for
dates outside of the recipient's eligibility coverage (except for
future dates where the recipient has on-going coverage) will be
rejected back to the provider for correction
How do I verify recipient eligibility?
DMAS web-based ARS at
http://virginia.fhsc.com
Medicall (1-800-884-9730 or 1-800-772-9996)
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Questions
Should you have any questions regarding the prior
authorization process, please send your inquiries via
e-mail to [email protected] or
[email protected]
Remember, do not send PHI by email unless it is sent via a secure
encrypted email transmission
The most up-to-date PA information is posted on the DMAS Website
at http://www.dmas.virginia.gov/pr-prior_authorization.htm and
the KePRO website at http://dmas.kepro.org
A pre-recorded Web-Ex training that provides an in-depth PA overview
and an iEXCHANGE demo is available on the KePRO website at
http://dmas.kepro.org/default.aspx?page=iexchange Providers
may view this web-cast training at their convenience
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