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Welcome to the 2008 NC Medicaid and Provider Education Seminar For Developmental Disabilities . NC PSD Provider Relations. Speeding up the process for requesting Authorizations. FAX TO AUTHORIZATION. Agenda. VO Authorization experience in NC Confirming the Basics CTCM
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Welcome to the 2008 NC Medicaid and Provider Education Seminar For Developmental Disabilities NC PSD Provider Relations
Agenda • 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
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.
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
Confirming the Basics • 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. CTCM 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.
Confirming the Basics How to submit Authorization Requests to ValueOptions: • MAIL: P.O. BOX 13907RTP, NC 27709-3907 • FAX:919-461-0669 for CAP/TCM only919-461-0599 for all MH/SA services • PHONE: 1-888-510-1150
Confirming the Basics How to view authorization letters • Go to www.ValueOptions.com • Select Providers; select ProviderConnect Login 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.
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
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.
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) • Discrete Services • Plan Revisions
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.
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.
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 “Discrete 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
Community Alternative Program Discrete Services Discrete 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
Community Alternative Program Discrete Services When an authorization request is submitted for any of the Discrete 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 be submitted 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.
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
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.
CTCM FORM SEE FORM AND INSTRUCTIONS
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. • 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.