NC PSD Provider Relations

1. Welcome to the 2008 NC Medicaid and Provider Education Seminar For Developmental Disabilities NC PSD Provider Relations

2. Speeding up the process for requesting Authorizations

3. FAX TO AUTHORIZATION

4. Agenda • VO Authorization experience in NC • Confirming the Basics • CTCM • Provider Relations Unit

5. 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

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 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.

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 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

11. 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.

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) • Discrete Services • Plan Revisions

15. 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.

16. 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.

17. 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

18. 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

19. 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.

20. 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

21. 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.

22. CTCM FORM SEE FORM AND INSTRUCTIONS

23. 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.

24. Q & A