Informational Packet

Transcription

1 Pennsylvania Department of Public Welfare Office of Developmental Programs Informational Packet Supplemental Habilitation (SH) and Additional Individualized Staffing (AIS) Services: IMPORTANT Reminders for Prior Authorization Requests ODP Communication Number: Packet AUDIENCE: Individuals and Families, Supports Coordinators (SCs), Support Coordinator Supervisors, Supports Coordination Organizations (SCOs), Administrative Entities (AEs), and Consolidated Waiver-Funded Licensed Residential Habilitation providers. PURPOSE: DISCUSSION This Office of Developmental Programs (ODP) communication is intended to inform the audience above about critical information to remember when making prior authorization (PA) requests and billing for SH and AIS services. On September 1, 2010, PROMISe TM prior authorization for SH or AIS services was implemented. During the post-implementation period, ODP monitoring efforts have identified the following issue areas: Information reviewed in the SH/AIS ISP Checklist (DP 1035) has not been adequately documented in the Individual Supports Plan (ISP). Critical pieces of information have either been missing or entered incorrectly on the Outpatient Service Request Form (MA 97). Claim denials resulting from inadequate units found on the ISP. In order for the ODP Regional Office to make a prior authorization determination, to prevent the denial of you re SH or AIS prior authorization request in PROMISe TM, and to ensure SH or AIS service claims are paid, AEs, SCOs, and Waiver-Funded Licensed Residential Habilitation providers should review the information contained in this communication. This communication also provides clarification and additional information regarding: What occurs when SH or AIS Prior Authorization requests are denied in PROMISe TM Mailroom screening procedures Importance of prompt response time Immediate Need Requests ODP Communication Number: Packet pages 1 of 9

2 THE SH/AIS CHECKLIST (DP 1035), PROVIDER INFORMATION SECTION Consolidated Waiver-Funded Licensed Residential Habilitation providers should accurately complete the Provider Information section of the DP 1035 and send it to the AE with their SH/AIS prior authorization requests. It is critical that the provider enters an accurate 13-digit MPI # on the DP Please remember that the 13-digit MPI number consists of a 9-digit provider ID number and 4-digit service location code. On the DP 1035, there is a space to the right of the field named 13-digit MPI # that is reserved for the 9-digit provider ID number and the field named Service Location Code is reserved for the 4-digit service location code. AEs use the information contained in the Provider Information section of the DP 1035 to complete the MA 97 and Prior Authorization Additional Information form (DP 1031). If the information is not entered correctly on the DP 1035; there is a risk that the AE will copy incorrect information onto the MA 97 and DP Invalid 13-digit MPI numbers cause prior authorization requests to deny. When the service location code is missing, the MPI number is considered invalid and the prior authorization request will deny. Providers will not be paid for SH or AIS services when a prior authorization request is denied in PROMISe TM. THE SH/AIS CHECKLIST (DP 1035), NUMBER 3, The purpose of the intensive staffing/support is adequately described This section must be detailed sufficiently in the ISP in order for the ODP Regional Office to make a determination. SCs are responsible for ensuring that the information entered into the ISP contains adequate detail to support the SH or AIS prior authorization request. SCs should answer all the questions listed under this specific review area on the DP 1035 and document the answers in the ISP with sufficient detail. The AE and ODP reviewer intentionally examine the ISP and look for evidence that the SH or AIS service will support an individual s assessed need. Also in this section of the ISP, ODP Regional Staff expect to see documented evidence that alternate supports have been attempted and have been found to inadequately support the individual s assessed needs. For example, would the receipt of Behavior Therapy services, Behavior Support services, or medication management better support the individual s assessed need rather than SH or AIS services? If not, the ISP should indicate what specific alternate supports were investigated and what factors led to the ISP Team s determination that the alternate supports did not meet the individual s assessed needs. ODP Communication Number: Packet pages 2 of 9

3 The SH/AIS CHECKLIST (DP 1035), NUMBER 4, The ISP includes the plan for eventual discontinuance or reduction of the intensive staffing/support A large volume of SH and AIS prior authorization requests have been found to lack appropriate detail. In order for the ODP Regional Office to make a determination and to prevent the denial of your SH or AIS prior authorization request in PROMISe TM, this section must be sufficiently completed. One example of possible language that could be included in the ISP, to support this section of the DP 1035, would be the following: In order for the ISP Team to feel comfortable in reducing the intensive staffing/supports, Jennifer must have no more than 5 incidents or situations when [enter behavior] took place during a 6 month period. This example defines specific criteria that will be evaluated within a specific timeframe to determine whether a reduction in supports should be made based on the occurrence of a specific behavior. DIRECT SERVICE PROVIDERS: REVIEW SERVICE AUTHORIZATION NOTICES ODP has been monitoring SH and AIS claims submitted for dates of service September 1, 2010 through the present. Many of the claim denials are a result of insufficient units on the individual support plan (ISP). When PROMISe TM determines there are insufficient units found on the ISP, your claim will deny and error status code (ESC) 971 will set. The short description for ESC 971 is SERVICE INDICATED, BUT NO UNITS AVAILABLE IN HCSIS. Before a provider submits a claim for either SH or AIS services which have been prior authorized in PROMISe TM, they should first review their Service Authorization Notices and confirm all the data present on the Service Authorization Notices (including units) are consistent with the data found on the Notice of Prior Authorization Decision letter. If the units found on the Service Authorization Notice are less than what has been approved in PROMISe TM, the provider should contact the individual s SC entity and request additional units are added to their ISP. The units added to the ISP should not exceed what is found on the Notice of Prior Authorization Decision letter. Once the provider has received confirmation that the units have been corrected on the ISP, they should resubmit the claim detail line or lines that denied on ESC 971. ADMINISTRATIVE ENTITIES: ENSURE ISP ACCURATELY REFLECTS DATA FOUND ON THE NOTICE OF PRIOR AUTHORIZATION DECISION LETTER Before the AE authorizes either SH or AIS services on an ISP, it is the AE s responsibility to confirm that all the SH or AIS data on the individual s ISP exactly matches the data found on the Notice of Prior Authorization Decision letter. If the units and begin and end date of service do not exactly match what is found on the Notice of Prior Authorization Decision letter, the provider will not be paid for services rendered. ODP Communication Number: Packet pages 3 of 9

4 THE FOLLOWING DESCRIBES WHAT OCCURS WHEN SH OR AIS PRIOR AUTHORIZATION REQUESTS ARE DENIED IN PROMISe TM 1. The Notice of Prior Authorization Decision letter, which will detail the reason for the denial, will be generated from PROMISe TM and mailed, via the United States Postal Service, to the Individual/Family, provider, AE, and SCO. 2. At the same time, the ODP Regional Office will contact the AE, via , and include the following information in their An electronic copy of the ISP Checklist (DP 1035) so the reason for the denial is understood by the AE. Inform the AE that they can expect to receive the Notice of Prior Authorization Decision letter in the mail which will detail the reason for the denial. An explanation to the AE that the ISP did not sufficiently support the ISP Team s request for SH and AIS services and once the additional information requested has been updated in the ISP; the ODP Regional Office will consider a prior authorization resubmission. MAILROOM SCREENING PROCEDURES AEs should note the following information regarding the mailroom screening procedures for the MA97 and DP 1031 forms. a. Before the MA97 and the DP 1031 form are scanned into the PROMISe TM prior authorization subsystem, SH and AIS prior authorization requests must pass the mailroom screening process. Requests that fail the screening process are returned to the sender (AE) with the applicable reason(s) checked on the Return to Prior Authorization Letter. b. It is critical that the AE includes a return address on the envelope that is used to the mail the MA 97 and DP If the AE s return address is missing on the envelope, any requests that fail the mailroom screening process will be returned to the ODP Regional Office instead of the AE, causing a delay in processing. c. SCOs and Waiver-Funded Licensed Residential Habilitation providers should verify their Mail To address is correct in PROMISe TM. Incorrect Mail To addresses cause the Notice of Prior Authorization Decision letter to be returned to ODP Central Office located in Harrisburg, Pennsylvania. SCOs and Waiver-Funded Licensed Residential Habilitation providers can verify and make any corrections to their Mail To address using epeap (electronic Provider Enrollment Automation Project), which is accessible through the PROMISe TM Internet. Please use the following links to access epeap and the epeap online Instruction Manual: epeap is accessed from the My Home page on the PROMISe TM Internet. Please go to to access the PROMISe TM Internet Home page. If ODP Communication Number: Packet pages 4 of 9

5 MAILROOM SCREENING PROCEDURES (continued from previous page) you are currently a registered user on the PROMISe TM Internet, enter your User ID in the space provided, which is located on the top left hand side of the Home page. After logging in, the user will be directed to the My Home page. Click on epeap which is located in the top horizontal menu bar located close to the top of the My Home page screen. Once you select epeap, you should see the epeap Menu screen. Select the Enrollment Information link located in the Provider Options list. Next, select the Address Information link to go to the screen used to update the Mail to address currently on the PROMISe TM provider file. Hyperlink for the epeap online Instruction Manual: pdf d. AEs with incorrect addresses in PROMISe TM, will not receive their Notice of Prior Authorization Decision letters. These letters are returned to ODP Central Office. AEs that are aware that they have incorrect mailing addresses in PROMISe TM, can not use e-peap to make a correction. If an AE would like have their address changed, they should contact the appropriate ODP Regional Office assigned to their region. The ODP Regional Office will coordinate the address correction in PROMISe TM with ODP Central Office. e. The AE should also correct any error(s) indicated on the Return to Prior Authorization Letter and r the corrected MA 97 and DP If the AE chooses to handwrite the information into the MA 97, it is important that your handwriting is legible. The following fields on the MA 97 must be completed accurately in order to pass the mailroom screening process: 1. Field 1 (MA97) Prior Authorization box must be checked 2. Field 3 (MA97) Recipient Number (RID) must be present and be 9 or 10 digits in length. 3. Field 9 (MA97) Provider ID must be 13 digits. A 13-digit Provider ID number consists of a 9-digit MPI and a 4-digit service location code. This is the most common error that causes the MA97 to be returned to the sender. 4. Field B (MA97): Procedure Code must be present and be 5 digits in length. 5. The words Signature Exception or Signature on File must be found in fields 33 and 35 on the MA The DP 1031 must be sent with the MA 97. If it is missing, the prior authorization request will be mailed back to the sender. f. AEs should note that although the MA 97 and DP 1031 may pass the mailroom screening process, other data contained on these forms may be missing or invalid and cause your ODP Communication Number: Packet pages 5 of 9

6 MAILROOM SCREENING PROCEDURES (continued from previous page) prior authorization request to be denied. A large of number of MA 97s have been found to contain invalid 13-digit MPI numbers that are not recognized by PROMISe TM. This may be caused by a transposition error. After completing the MA97, AEs should review the data entered and ensure the numbers have not been transposed. Please remember that the 13- digit MPI number consists of a 9-digit provider ID number and 4-digit service location code and must be included on the MA 97 or your request will fail the mailroom screening process and be returned. g. AEs are required to complete both the MA 97 and the DP 1031 when a prior authorization request for SH or AIS services is made. The AE should mail both documents to the following address: DPW, Office of Developmental Programs P.O. Box Harrisburg, PA h. AEs should note that the 2-digit County Code where the AE s office is located should be entered in the License Number field (Block 13) on the MA 97. This field is important because the system uses it to determine the AEs address so that the AE may receive the Notice of Prior Authorization Decision letter. A list of county codes can be found in Informational Packet , Appendix B, on page 24. i. AEs should note that if the number of units requested exceeds 9,999 units, please use separate lines on the MA 97 and divide up the number of units requested. Each line completed on the MA 97 should not exceed 9,999 units of service. IMPORTANCE OF PROMPT RESPONSE TIME The SH/AIS prior authorization request process is structured as a team process where every participating entity has an important role that is associated with a specific timeframe for completion. If anyone who has a role in the SH/AIS prior authorization request process fails to respond or complete their tasks within the established timeline, the prior authorization determination decision is delayed which has a direct impact on the services rendered to the individual and the provider s ability to get paid for those services. Waiver-Funded Licensed Residential Habilitation providers should be mindful of their response time when additional information is requested by the AE. The AE is dependent on the Waiver- Funded Licensed Residential Habilitation provider to obtain certain pieces of information in order to complete a SH/AIS prior authorization request. If information is missing or not accurate when it is sent to the AE, the AE will either request the information from the Waiver- Funded Licensed Residential Habilitation provider or the AE has the option to mail the prior authorization requests to the appropriate address even if it is missing information or contains invalid information. Requests that are missing information or contain invalid information will ODP Communication Number: Packet pages 6 of 9

7 IMPORTANCE OF PROMPT RESPONSE TIME (continued from previous page) be denied. Providers will not be paid for SH or AIS services when a prior authorization request is denied in PROMISe TM. Please review Informational Packet , Appendix A, Prior Authorization Timeline for SH and AIS, to understand the expectation regarding timing, order, and dependency of action steps in the prior authorization request process. The ISP Team meeting should occur after the provider has ed the SH or AIS prior authorization request to the AE, which includes completing the Provider Information section of the ISP Checklist (DP 1035). The ISP Team meeting does not replace the provider s prior authorization request to the AE. The timing, associated with the Prior Authorization Timeline for SH and AIS, begins once the provider s the SH or AIS prior authorization request to the AE. Failure to meet the timeline associated with the prior authorization request process does not guarantee your request will be approved. Retroactive approvals are not automatically granted when timely filing of a prior authorization request is delayed. ODP strongly encourages Supports Coordinators, Support Coordinator Supervisors, Supports Coordination Organizations, Administrative Entities, and Consolidated Waiver-Funded Licensed Residential Habilitation providers to follow the Prior Authorization Timeline for SH and AIS as it is documented in Informational Packet To view this communication, click on the following hyperlink: Informational Packet IMMEDIATE NEED REQUESTS One example of an immediate need request would include the need for additional staffing when there is less than 24 hours notice of a hospital discharge and a health and safety issue has been identified. This type of situation would warrant an immediate need request because the service is needed effective the day of the request. If there is a question about what constitutes an immediate need for staffing, please contact the ODP Regional Program Manager assigned to your area. When immediate need approval is requested, Waiver-Funded Licensed Residential Habilitation providers and AEs should keep in mind the following information: 1. If either SH or AIS services are needed effective the day of the request, the provider will indicate this in their to the AE and attach the DP 1035 with the Provider Information section completed. 2. The AE will forward the provider s to the ODP Regional Office no later than the next business day to confirm that SH or AIS services are needed immediately. 3. The AE will send the immediate need approval request to the appropriate regional SH/AIS mailbox using the following naming convention in the subject line of the AE_MCI#_Immediate Need ODP Communication Number: Packet pages 7 of 9

8 IMMEDIATE NEED REQUESTS (continued from the previous page) 4. Simultaneously, the AE should complete the MA97 and DP 1031 and mail both documents to: DPW, Office of Developmental Programs, P.O. Box 69027, Harrisburg, PA The MA97 and DP1031 should contain the Quantity requested, Begin Date, and Anticipated End Date for the entire period the SH or AIS service is being requested. If the ISP Team agrees that more than 14 calendar days of service are needed to meet the assessed need of the individual, then the MA97 and DP1031 should reflect the total length of time and units that the ISP Team agreed would meet the assessed need of the individual. The Regional Office will be reviewing the MA97, DP1031, and DP1035 and will use the timeframe and quantity requested on these forms to make a final determination for the continuance of services beyond the 14 calendar days. 6. The ODP Regional Office will determine whether the prior authorization for SH or AIS services will be made retroactive to the date of the immediate need approval request. 7. The AE is required to the SH/AIS ISP Checklist (DP 1035) to the ODP Regional Office within 14 calendar days starting from the day that the immediate need approval request was first ed to the ODP Regional Office. 8. If the decision is made by the ODP Regional Office to approve the request for immediate staffing, then this approval will only be up to 14 calendar days. The ODP Regional Office immediate need request decision will be communicated to the AE via If an initial verbal and approval was made to the AE by the ODP Regional Office, then the AE should authorize the SH or AIS service on the ISP for no more than 14 calendar days from the date the AE sent the initial immediate need request to the ODP Regional Office. 10. Once the SH/AIS ISP Checklist (DP 1035) has been received and thoroughly reviewed by the ODP Regional Office, a final determination will be made through the PROMISe TM prior authorization system. This final determination will confirm whether the immediate need request is approved or denied for the continuance of service beyond the 14 calendar day period and will be documented on the Notice of Prior Authorization Decision letter. 11. Providers should not begin billing for SH or AIS services until the prior authorization request has been approved in PROMISe TM. Providers may begin billing once they receive the Notice of Prior Authorization Decision letter in the mail confirming that the SH or AIS service has been approved in PROMISe TM. 12. If the SH or AIS service has been approved for continuance beyond the 14 calendar day period, the ODP Regional Office will: ODP Communication Number: Packet pages 8 of 9

9 IMMEDIATE NEED REQUESTS (continued from the previous page) the AE to indicate the units and length of time the service has been approved. The AE should adjust the units, begin date, and end date on the individual s ISP accordingly. The PROMISe TM prior authorization system will be updated accordingly with the approved units, begin date, and end date if more than 14 calendar days of service has been approved. 13. If the SH or AIS service is denied, the ODP Regional Office will: the AE to indicate that 14 calendar days of service has been approved but the continuation of services beyond the 14 calendar days has been denied. If the AE initially approved more than 14 calendar days of service, then the AE should adjust the units and end date on the individual s ISP accordingly. If no more than 14 calendar days of service are approved by ODP Regional Office, then the units and end date in the PROMISe TM prior authorization system will reflect 14 calendar days of service and units. Any units submitted for dates of service beyond the period reflected in PROMISe TM. will be denied. 14. Regardless of the decision rendered by ODP, the Notice of Prior Authorization Decision letter will be mailed, via the United States Postal Service, to the Individual/Family, provider, AE, and SCO and will detail the ODP determination decision. IMPORTANT ADDITIONAL INFORMATION Please ensure you have read the MA 97 block by block instructions found in Informational Packet , Appendix B, beginning on page 19. Click the following hyperlink to view this communication: Informational Packet The DP 1035, SH/AIS ISP Checklist, has been modified to allow the user to enter more information in those sections that require an explanation. The DP 1035 must accompany every new SH or AIS prior authorization request made to the ODP Regional Office. For immediate need requests, the DP 1035 must be sent to the ODP Regional Office within 14 calendar days starting from the day that the immediate need request was first ed to the ODP Regional Office. Click on the following hyperlink to access the DP 1035: DP 1035 If you have questions regarding any information contained in this communication, please contact the ODP Regional Office assigned to your area and request to speak with the individual responsible for responding to SH/AIS prior authorization inquiries. ODP Communication Number: Packet pages 9 of 9