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
4 Agenda
VO Authorization experience in NC Confirming the Basics CTCM Provider Relations Unit
VO Authorization experience in NC 5
# 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
6 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.
7 Confirming the Basics
All prior authorization requests must have: • • 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
8 Confirming the Basics
• • • • • • • • • Diagnosis (use DSM-IV axis) Use codes and words DD – minimum Axis II 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.
9 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.
10 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
11 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.
12 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
13 Community Alternative Program/Targeted Case Management Authorization Requests
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
14 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
15 Community Alternative Program/Targeted Case Management Authorization Requests
CTCM for
TCM
: If CAP eligible, include Plan of Care (POC) If not CAP eligible, include Person Centered Plan (PCP) must have the signature of the MD/DO, PhD, PA or NP on the last page for the Service Order
16 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
17 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
18 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.
19 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
20 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
21 CTCM FORM
SEE FORM AND INSTRUCTIONS
22 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.
•
Delayed auth letters, incorrect auths, auth issues between VO and EDS, authorization process questions and concerns, etc.
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The team is also responsible to develop and deliver provider trainings with DMA
To access these resources: call 1-888-510-1150
,
. or e-mail the team
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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