VA InsiderVirginia Medicaid Service Authorization Fall 2016

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ATTENTION ELDERLY OR DISABLED WITH CONSUMER DIRECTION PROVIDERS:**Please Note:** If you are requesting aide/attendant supervision, the hours of the request MUST match the hours the homeowners or family are outside of the home. The hours the aide/attendant is in the home must match the requested daily hours on the plan of care.

If you are requesting supervision for more than five days per week and the patient does not live alone, please upload employment letters from the employer of every adult individual that lives in the home with the patient. The employment letters MUST clearly state what days and hours the person works and his/her travel time to and from work.

If you are requesting more than two hours/day of Instrumental Activities of Daily Living (IADL) on the plan of care, please provide specific examples to justify the reason for the excessive IADL hours. This information can be documented within the questionnaire or in the additional clinical section of Atrezzo. When you are creating a request for services in Atrezzo, please DO NOT enter a rate for the following procedure codes. Rates are not applicable and should not be entered for submission to KEPRO.

• T1019 - Agency Directed Personal Care• T1005 - Agency Directed Respite Care• S5126 - Consumer Directed Attendant Care • S9125 - Skilled Respite• S5150 - Consumer Directed Respite Care • S5160 - PERS Installation• S5161 - PERS Monitoring• S5185 - PERS Medication Monitoring• S5102 - Adult Day Health Care• H2021 - PERS Nursing• H2015 - Transition Coordination

Please remember if you are requesting a continuation of services, you must submit a request to KEPRO justifying the need for the services. If the request is not received prior to the end date of the current authorized period, you may receive a denial for dates of service up to the date the request was received by KEPRO. Please reference the EDCD Waiver Manual, on Appendix D, page 5.

In this Edition

Submission of Condensed Summary for Review. . 2

Outpatient Rehabilitation Submission Requests. . 2

Requirements for Non-Emergent Outpatient Imaging Results. . . . . . . . . . . . . . . . . . . . . . . . . . 3

Move of Transplant and Imaging Requests. . . . . . 4

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In an effort to streamline the information submission process, we are providing a guide for the mandatory information that is required with each outpatient rehabilitation submission. The following items are required:

1. Long term goals with the specific time frames for completion: The date given cannot extend past the service authorization request time frame.

2. Short term goals with the specific time frames for completion: The date must be within the date range of the service authorization request time frame.

3. Frequency and duration: The frequency and duration must match the number of units that are being requested.

Ex. Two times per week for six weeks. The total requested should equal 12 if you are a hospital provider or 48 if you are a freestanding facility providing care for an hour each visit.4. Functional deficits must be documented.

If any of the listed items are missing, the case will be pended back to the provider for inclusion and/or clarification. The provider will have three business days to supply the requested information. If the required information is not received within that time frame, the case will be submitted for physician review.

Outpatient Rehabilitation Submission Requirements

DMAS requires that all information submitted for clinical review be in the form of a Condensed Summary. Submission of voluminous amounts of information copied and pasted from the chart cannot be accepted for review. Additionally, the clinical review must be legible and include only information that is pertinent to the service being requested. Typically, what is required is a brief list of chronic medical conditions, a current physical examination with abnormal findings noted, any failed outpatient treatment, abnormal laboratory results, intravenous medications and fluids (inpatient requests), any conservative treatment failure (for imaging scans) and what is expected to be learned.

This is not a comprehensive list of requirements, but is meant as a general guide to assist in obtaining an expeditious service decision.

Submission of Condensed Summary for Review

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KEPRO will be adding an imaging questionnaire to assist providers when submitting service authorization requests. Providers risk a denial determination when this information is missing.

When submitting clinical information for outpatient imaging requests be sure to include the following information:

1. Provider contact name and phone number.2. Please include the type of scan and the reason the scan is being ordered. It is helpful to document

what is expected to be learned or what is suspected.3. Please include a brief summary of the history related to this request. This should include

symptoms, duration of symptoms and clinical findings.4. Is there a history of trauma? Yes/No a. If yes, what was the date of the injury? b. What was the type of trauma?5. Previous x-rays, US, CT, MRI, or PET scans done with result of the studies.6. Any pertinent lab results.7. For advanced spinal imaging, please include medications that were tried and the length of time

the patient has been on medications, as well as, all other conservative management tried (PT/HEP/activity modification and length of time tried). Also, include motor and sensory exam findings and symptoms.

8. If the diagnosis is seizures, please indicate if it is a new onset, if the frequency has changed, or if medications with adequate blood levels are not controlling seizures.

9. Is the diagnosis neoplastic or malignant? Yes/No a. If yes, is the requested study for initial staging, or for periodic assessment during treatment or after completed treatment (enter current treatment regimen and/or surgery). If treatment is completed, enter the completion date.10. If the diagnosis is a headache, please state whether it is new onset or chronic with increasing

symptoms. Describe the current symptoms and include neurological exam findings and neurological symptoms.

11. Is there any other pertinent information regarding this request?12. Is this a retro review? Yes/No

**Note: An urgent imaging scan service authorization request must be submitted to KEPRO within one business day of the scan being performed.**

Requirements for Non-Emergent Outpatient Imaging Requests

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Attention all providers participating in the Virginia Medicaid and FAMIS programs. As of Nov.1, 2016 KEPRO will no longer receive organ and stem cell transplants (in state and out of state) and non-emergent outpatient out of state MRI, PET, and CAT scan requests. All requests received on Oct. 31, 2016 will be processed by KEPRO. For the purposes of this change, out of state is defined as any facility or provider not within the state of Virginia. If you have a case that was pended by KEPRO, you must respond to KEPRO via phone, fax, or the web portal Atrezzo, by the required timeframe noted on the pend request.

As of Nov. 1, 2016 the Department of Medical Assistance Services (DMAS) Medical Support Unit (MSU) will begin accepting all organ and stem cell transplants (in state and out of state) and non-emergency, outpatient, out of state MRI, PET, and CAT scan requests.

All requests for services submitted on or after Nov. 1, 2016 must be faxed to the DMAS MSU at 804-452-5450. Please refer to the DMAS memo dated 10/19/2016, for information pertaining to this change.

For questions and all other inquiries regarding this change you may also contact the DMAS MSU at 804-786-8056 or the DMAS Helpline at 1-800-552-8627 or 804-786-6273.

2810 North Parham Road, Suite 305Henrico, VA 23294

Toll-free: 888.827.2884Tel: 804.622.8900Fax: 877.652.9329

http://dmas.kepro.com

Organ and Stem Cell Transplants and Out of State Imaging Requests

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Transplants and Requests will be handled by DMAS Medical Support Unit

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