healthy louisiana appendix acher dampier [email protected] phone: 959-299-6527 fax: 844-227-9205...
TRANSCRIPT
Healthy Louisiana Appendix A Updated January 2021
MCO Contacts for Support Coordinators
Referral to
Healthy
Louisiana Case
Management
Forms
Fax: 844-634-1109
Single Point of Contact:
Lance Miguez [email protected]
Phone:959-299-6433
Fax: 225-397-4522
Single Point of Contact:
Kathryn Cox [email protected]
Phone: 843-414-3149
Fax: 844-839-9307
Single Point of Contact:
Danielle Hutson [email protected]
Phone: 877-440-4065
(Ext. 106-103-5145)
Fax: 877-668-2079
Single Point of Contact:
Nichole D. Tate Nichole.d.tate@louisianahealthconnect.
com
Phone: 225-666-4151
Fax: 877-590-8096
Single Point of Contact:
Kimberly Auger [email protected]
Phone: 800-377-5105 ext. 5
MCO
Prior
Authorization
Liaison
(PAL)
DeAndranee Emery
Phone: 959-299-6412
Fax: 844-227-9205
Sherri Chairs
Phone: 959-299-6581
Fax: 844-227-9205
Kathryn Cox
RN Prior Authorization Nurse
Phone: 843-414-3149
Fax: 866-397-4522
Kursten Munson
Interim Utilization Management
Manger [email protected]
Phone: 225-300-9588
Sumer Kohler
Utilization Management Supervisor
phone: 225-300-9229
Danielle Hutson,
Medical Management Specialist II
Phone: 877-440-4065 (Ext 106-103-
5145)
Fax: 844-839-9307
Marcia Olivia
Outreach Care Specialists
Phone: 877-440-4065 (Ext. 106-103-
5145\)
Fax: 877-839-9307
Carolyn Mather, RN
Senior Prior Authorization Nurse
carolyn.mather@louisianahealthconnec
t.com
Phone: 225-201-8465
Fax: 877-668-2079
Ashley Arnold, RN
Prior Authorization Nurse II
(Back-up PAL)
Ashley.n.arnold@louisianahealthconne
ct.com
Phone: 225-201-8501
Fax: 877-668-2079
Joshua Abshire, RN
Senior Manager, Utilization
Management
(Back-up PAL)
Phone: 337-417-8181
Fax: 877-668-2079
Latrell Fisher, RN
LA Prior Authorization
Liaison (PAL)
(Primary PAL)
Phone: 800-377-5105 Ext 6
Fax: 866-311-3754
Christal Achord, RN
LA Prior Authorization
Liaison (PAL)
(Back-up PAL)
Phone: 800-377-5105 ext. 4
Fax: 866-311-3754
Healthy Louisiana Appendix A Updated January 2021
MCO Behavioral
Health Prior
Authorization
Liaison (PAL)
DeAndranee Emery
Phone: 959-299-6412
Fax: 844-227-9205
Sherri Chairs
Phone: 959-299-6581
Fax: 844-227-9205
Jenna Aucoin, Care Connector
Phone: 855-285-7466
Fax: 225-757-8629
Brittany Bowens
UM Technician, Behavioral Health
Utilization Management
Phone: 225-300-9631
Fax: 855-301-5356
Faye Colbert Jenkins
BH UM Supervisor
Phone: 855-285-7466
Fax: 225-301-5366
Taylor Ross
Behavior Health UM Reviewer [email protected]
Phone: 225-300-9256
Danielle Hutson,
Medical Management Specialist II
Phone: 877-440-4065 (Ext 106-103-
5145))
Fax: 844-839-9307
Marcia Olivia
Outreach Care Specialists [email protected]
Phone: 877-440-4065 (Ext. 106-103-
5145)
Fax: 877-839-9307
(Primary PAL)
Melanie Roum, LCSW
Senior Prior Authorization Nurse
Melanie.M.Roum@louisianahealthcon
nect.com
Phone: 225-666-4134
Fax: 888-735-0101
(PAL Backup)
Danielle Solieau
Behavioral Health Referral Specialist
m
Phone: 225-929-8359
Fax: 877-668-2079
(PAL Backup)
Summer Chaves, LPC-S
Clinical Manager, Utilization
Management
Phone: 337-417-8103
Fax: 877-668-2079
Kioka Broussard Guillot, LPC
General BH PA
Prior Authorization Liaison
(PAL)
Phone: 800-548-6549 (Ext
63723)
Fax: 844-368-4466
Stephanie Widoe, ABA
ABA PA
Prior Authorization Liaison
(PAL)
Phone: 800-548-6549 (Ext.
67732)
Craig Woodsmall, PsyD
Psych Testing PA
Prior Authorization Liaison
(PAL)
[email protected] Phone: 763-321-2685
Fax: 877-697-7795
Erin Breuleux, MS, LPC
MHR PA
Phone: 800-548-6549 (Ext:
65225)
Fax: 855-858-0504
Case
Management
Lance Miguez [email protected] Phone: 959-299-6433
Fax: 844-227-9205
Cher Dampier
Phone: 959-299-6482
Fax: 844-227-9205
Suconda Smith
IHM Manager [email protected]
Phone: 225-300-9210
Fax: 225-757-8629
Brooke Deykin,
Manager I HCM [email protected]
Phone: 877-440-4065 (Ext 106-122-
4051)
Fax: 844-839-9307
Walthena Gosa
Manager Behavioral Health Services
Nichole D. Tate
Phone: 225-666-4151
Fax: 877-668-2079
Kimberly Auger
Main POC [email protected]
om
Phone: 800-377-5105 ext. 5
Fax: 877-590-8096
Healthy Louisiana Appendix A Updated January 2021
Phone: 877-440-4065 (Ext 106-123-
9050)
Fax: 844-839-9307
Upper
Management
Contacts for
Resolution of
Issues
Escalation
Jodi Carter-Jones
Phone: 504-667-4507
Fax: 844-227-9205
Richard Born
Phone: 504-667-4580
Fax: 844-227-9205
Peggy McCurry
504-667-4519
Fax: 844-277-9205
Rachel Weary
Director of Integrated Healthcare
Management
Phone: 225-300-9198 Cell: 225-910-2538
Fax: 225-757-8629
Beth Rasch
Manager II HCM
Phone: 877-440-4065 (Ext 106-123-
9021) Fax: 844-839-9307
Brenda Tompkins,
Director I HCM [email protected]
Phone: 504-836-8873
Fax: 844-839-9307
Gina Rabalais, RN
Senior Director, Medical
Management
m Phone: 225-663-5772
Fax: 877-668-2079
John Kight, DNP, RN
Senior Vice President, Clinical
Operations
john.j.kight@louisianahealthconnect.
com
Direct: 225-666-4150
Fax: 1-877-668-2079
Jennifer Barker RN, BSN,
CCM
Phone: 800-377-5105 Ext. 3
Fax: 855-880-0650 Specialty Program Manager
Chisholm Denial
Point of Contact
Ingrid Jones Carter
Phone: 959-299-6423 Cell: 504-487-0172
Fax: 844-227-9205
Kursten Munson
Interim Utilization Management
Manager Health [email protected]
Phone: 225-300-9588
Faye Colbert Jenkins
BH UM Supervisor
Phone: 855-285-7466
Fax: 225-301-5366
Sumer Kohler
Utilization Management Supervisor
Phone: 225-300-9229
Robin Labranche
Clinical Compliance
[email protected] Phone: 877-440-4065 (Ext, 106-122-
4015)
Fax: 844-839-9307
Justin Massicot
Manager II Health Services
Programs, Operations
Phone: 225-763-2178
Fax: 844-839-9307
Sandy Weinman, RN
Supervisor, Utilization Management
om
Phone: 225-929-8366
Fax: 1-877-668-2079
Latrell Fisher, RN
LA Prior Authorization
Liaison (PAL)
(Primary PAL)
[email protected] Phone: 800-377-5105 ext. 6
Fax: 866-311-3754
Christal Achord, RN
LA Prior Authorization
Liaison
(Back-up PAL)
[email protected] Phone: 800-377-5105 Ext. 4
Fax: 866-311-3754
*Note: These contacts may change periodically. The toll free number provided in Healthy Louisiana Appendix can be utilized as well to reach out to case managers and MCO PALs.
Aetna Customer Service: 1-855-242-0802
AmeriHealth Caritas Customer Service: 1-888-756-0004
Healthy Blue Customer Service: 1-844-521-6941
Louisiana Healthcare Connections Customer Service: 1-866-595-8133
United Healthcare Customer Service: 1-866-675-1607
Medicaid Managed Care Appendix B
Revised 3.13.19
Medicaid Managed Care Services DME, Transportation, Therapy, Behavioral Health, Applied Behavioral Analysis,
EPSDT Personal Care Services and Home Health Services (including Extended Skilled Nursing Services also known as Extended Home Health)
Managed Care Organizations must provide services in the same scope, range and duration as Legacy Medicaid; however, the Managed Care Organizations have the flexibility of offering services beyond those provided by Medicaid. For this reason, support coordinators will need to reach out to each the Managed Care Organizations for additional information regarding obtaining services for Managed Care Organization enrollees. Such details as the prior authorization process and length of the prior authorization vary from Managed Care Organization to Managed Care Organization. Contact information for each Managed Care Organization is listed below:
Managed Care
Organizaiton
Phone Number Website Link Transportation
Aetna Better
Health
1-855-242-0802 www.aetnabetterhealth.com/louisiana
1-877-917-4150 (Reservations)
1-877-917-4151 1-866-288-3133 (TTY)
AmeriHealth
Caritas Louisiana 1-888-756-0004 www.amerihealthcaritasla.com 1-888-913-0364
Healthy Blue 1-844-521-6941
TTY: 711 www.myhealthybluela.com
1-866-430-1101
Louisiana
Healthcare
Connections
1-866-595-8133 TTY: 711
www.louisianahealthconnect.com
1-855-369-3723 (Reservations)
1-855-369-3724 (Ride Assistance)
1-866-288-3133 (TTY)
United Healthcare 1-866-675-1607 www.uhccommunityplan.com 1-866-726-1472
Medicaid Managed Care Appendix C
Medicaid Managed Care
PCS Provider Changes within an Existing Prior Authorization Period
Enrollees have the right to change PCS providers at any time; however, approved authorizations are not transferred between agencies. If an enrollee elects to change providers within an authorization period, the current agency must notify the Managed Care Organization of the enrollee’s discharge, and the new agency must obtain their own authorization through the usual authorization process. If the discharge notice is not provided, the support coordinator should contact the MCO PAL.
NOTE: Members may contact their Managed Care Organization directly for assistance in locating another provider.
Revised 3.13.19
Medicaid Managed Care Appendix D
Revised 10.5.20
Medicaid Managed Care - PCS and EHH Prior Authorization
Timeframes
Prior Authorization Timeframes
Amerihealth Caritas
Louisiana
Aetna Better Health of Louisiana
Healthy Blue
Louisiana Healthcare
Connections
United Healthcare Community
Plan
EHH
Regular 1 month 60 days 30 days / 1 month unless the provider requests less
8 weeks 60 days
Chronic Needs 3 months 60 days 30 days / 1 month unless the provider requests less
8 weeks 60 days
PCS
Regular 3 months 60 days 180 calendar days or a rolling 6 months
6 months Up to 6 months
Chronic Needs 6 months 60 days 180 calendar days or a rolling 6 months
6 months Up to 6 months
*Renewal Submission
Timeline
10 days 10 days 14 calendar days prior to the expiration date of the authorization
14 days prior to the end of the approved authorization period
EHH= 14 days PCS= 21 days
*Number of days prior to the end of a PA that the renewal documents need to be submitted to avoid a lapse in services. Beneficiaries who have been designated by BHSF as a “Chronic Needs Case” are exempt from the standard prior authorization process. A new request for prior authorization shall still be submitted every 180 days; however, the EPSDT PCS provider shall only be required to submit a PA-14 form accompanied by a statement from the beneficiary’s primary practitioner verifying that the beneficiary’s condition has not improved and the services currently approved must be continued. The provider shall indicate “Chronic Needs Case” on the top of the PA-14 form. This determination only applies to the services approved where requested services remain at the approved level. Requests for an increase in these services will be subject to a full review requiring all documentation used for a traditional PA request. NOTE: Only BHSF or its designee will be allowed to grant the designation of a “chronic needs case” to a beneficiary.
MCO PAL PROCESS Medicaid Managed Care Appendix E
NOTE: All communications and actions taken during the MCO PAL process should be documented into the MCO and/or LDH tracking systems. Revised 3.13.19
Prior Authorization Requested Submitted
Request does not contain sufficient information to
fully approve hours requested
Refer to MCO PAL
Complete phone call to Provider/Enrollee/Support
Coordinator to explain needed documentation
Information obtained within 10 days from initial
contact
If yes and request is medically necessary
Send Approval notice to the Enrollee, Provider and Support Coordinator
If yes and request is not medically necessary
Send denial notice to the Enrollee, Provider and Support Coordinator
If no, Send PAL letter to Enrollee, Provider and
EPSDT Support Coordinator
If information is not received w/in 30 days of letter and appt is not scheduled and attended
Send Denial letter to the Enrollee, Provider and
EPSDT Support Coordinator
If information is received w/in 30 days of letter or
appt is scheduled and attended and servies are determined not medically
necessary
Send Denial letter to the Enrollee, Provider and
EPSDT Support Coordinator
Information is received w/in 30 days of letter or
appt is scheduled and attended and services are
determined medically necessary
Send Approval letter to the Enrollee, Provider and
EPSDT Support Coordinator
Request is complete and services deemed Medically Necessary
Send Approval letter to Enrollee, SC, and Provider
Medicaid Managed Care Appendix F
Revised 9.2.2020
EPSDT Timeline & Documentation for Medicaid Managed Care Appeals
Medicaid Managed Care enrollees have appeal rights with their Managed Care Organization (MCO). In addition to appeal rights with the MCOs, enrollees may also file a grievance. A grievance is an expression of dissatisfaction about any matter other than an action. An “action” is the denial or limited authorization of a requested service, including the type or level of service, the reduction, suspension, or termination of a previously authorized service. If the enrollee is seeking reversal of a denial of a service, they should file an appeal, not a grievance. The grievance and appeals process differs from MCO to MCO; however, each MCO must meet certain contractual guidelines regarding grievances and appeals. All Medicaid Managed Care enrollees are allowed 60 calendar days from the date on the MCO’s notice of action or inaction to file an appeal. Within that timeframe the enrollee or a representative acting on their behalf and with the enrollee’s written consent may file an appeal or the provider may also file an appeal on behalf of the enrollee, with the enrollee’s written consent. The appeal may be filed either orally or in writing. If the initial request is made orally and is not an expedited appeal, it must be followed with a written confirmation within 15 days of the notice from the MCO to send the written confirmation. All Medicaid Managed Care enrollees are: provided a reasonable opportunity to present evidence, testimony, and arguments about fact or law, in person, as well as in writing regarding their appeal; notified of any deadlines for doing so; and provided an opportunity before and during the appeals process to examine the case file and documents considered during the appeals process. The MCO must acknowledge receipt of each grievance and appeal in writing and provide enrollees with assistance with the appeals process as needed. Specific details regarding each MCO’s grievance and appeal processes can be located in the MCO’s enrollee handbook. Support Coordinators are encouraged to familiarize themselves with the enrollee handbooks for each MCO. Enrollee handbooks can be accessed at:
http://LDH.louisiana.gov/index.cfm/page/1212.
Timeframes for MCOs to Make an Appeal Decision MCO Aetna Better
Health of Louisiana
AmeriHealth Caritas Louisiana
Healthy Blue Louisiana Healthcare Connections
United Healthcare
Appeal Timeframe (includes 14 day extension)
30-44 days 30-44 days 30-44 days 30-44 days 30-44 days
Expedited Appeal Timeframe
72 hours 72 hours 72 hours 72 hours 72 hours
Once the appeal rights with the MCO are completed, enrollees may request a state fair hearing with the Division of Administrative Law (DAL). See Appendix L. Enrollees must complete the MCO appeals process before asking for a state fair hearing. A state fair hearing must be requested within 120 days from the date of the MCO’s Notice of Adverse Benefit
Medicaid Managed Care Appendix F
Revised 9.2.2020
Determination unless an extension is requested. A state fair hearing may be delayed at the request of the claimant/appellant or authorized representative, but cannot be delayed for more than 30 days without good cause. Enrollees may request a state fair hearing by mail, phone, fax or online. The timeframes for the state fair hearing process are below:
State Fair Hearing Timeframe
120 days from the date of the MCO’s Notice of Adverse Benefit Determination *An additional 30 days extension can be requested.
Expedited State Fair Hearing Timeframe
3 working days (after the DAL received the case file and documentation)
EPSDT Support Coordinators will need to follow the guidelines outlined in Medicaid Managed Care Appendix T-1 for both appeal processes for Chisholm Medicaid Managed Care enrollees. A list of Managed Care Organization contacts is located in Medicaid Managed Care Appendix A.
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Medicaid Managed Care Appendix H
Revised 3.13.19
Opting In and Disenrolling from Medicaid Managed Care
for Physical Health Services for Chisholm Class Members
Chisholm class members are children up to age 21 who currently receive or are eligible
for Medicaid, and who are on the Developmental Disabilities Request for Services
Registry (DD RFSR). Members included in the Chisholm class and Home and
Community Based Services (HCBS) waivers participants are required to enroll in a
Managed Care Organization for specialized behavioral health services and Non‐
Emergency Medical Transportation (NEMT). Members included in the Chisholm class
and HCBS waiver participants who do not have Medicare have the opportunity to
proactively opt‐in for physical health services or they can choose to stay with Legacy
Medicaid for their physical health services.
To Voluntary Opt-in to Medicaid Managed Care for Physical Health Services:
Members can call Medicaid Managed Care at 1-855-229-6848 or go online at
www.healthy.la.gov to enroll in a Managed Care Organization. Members have until the
2nd to last business day of the month to enroll with Medicaid Managed Care for the
effective date to be the first of the following month. For example, if you call Medicaid
Managed Care on April 8th, the effective date of enrollment for the Managed Care
Organization will be May 1st. If you call Medicaid Managed Care on April 30th, the
effective date of enrollment for the Managed Care Organization will be June 1st.
Disenrolling from Medicaid Managed Care for Physical Health Services:
Chisholm class members can return to Legacy Medicaid for their physical health services
at any time effective the earliest possible month that the action can be administratively
taken, but will have to stay enrolled in Medicaid Managed Care for their behavioral
health services and for non-emergency medical transportation. Members can call
Medicaid Managed Care at 1-855-229-6848 or go online at www.healthy.la.gov to
disenroll from Medicaid Managed Care. Members have until the 2nd to last business day
of the month to disenroll with Medicaid Managed Care for the effective date to be the
first of the following month. For example, if you call Medicaid Managed Care on April
8th, the effective date of disenrollment from the Managed Care Organization will be May
1st. If you call Medicaid Managed Care on April 30th, the effective date of disenrollment
for the Managed Care Organization will be June 1st. Members who have previously
disenrolled from Medicaid Managed Care may reenroll in Medicaid Managed Care only
during the annual open enrollment period effective the earliest possible month the action
can be administratively taken.
Medicaid Managed Care Appendix Q
4/7/15 Revised 3.13.19
Referral to Medicaid Managed Care Case Management EPSDT - Targeted Population
Date:
TO: ( ) Amerihealth Caritas Louisiana ( ) Aetna Better Health of Louisiana ( ) Healthy Blue
( ) Louisiana Healthcare Connections ( ) United Healthcare
Attn: Chisholm Case Management Fax # Case Manager’s Name:
FROM: Support Coordination Agency Provider #:
Support Coordinator’s Name:
Support Coordinator’s Phone#: Fax#:
Address: City: State/Zip:
RE: Provider:
Provider #: Phone #:
Address: City: State/Zip:
Service Type (if DME be specific):
Service Name: ( ) Initial ( ) Renewal
Amount/# of Hours of Service:
Participant Name: Responsible Party:
MID#:
Phone#:
Address:
City:
State/Zip:
This is to inform you that this individual is receiving EPSDT - Support Coordination Services and we are sending this notice to:
1. Make a referral for the above noted service. Please have the enrollee’s case manager assist with arranging these services. Please make sure the provider of choice includes our Provider #, Agency Name and Address on the request for Prior Authorization (PA). We are also requesting that the provider is informed to send us a copy of the PA request packet at the same time that it is sent to you for processing.
2. The enrollee has asked that their schedule for the above service be changed as per the attached Typical Weekly Schedule form. If this presents a scheduling problem, please contact the Support Coordinator so that we can all discuss this with the enrollee/family.
3. This is a reminder that the above named enrollee’s PA for the above service expires on / / and the renewal needs to be sent for continued services.
4. The enrollee wants to choose a new provider.
5. The enrollee has selected the new provider listed above. The previous provider was:
6. I am unable to find a provider that is willing to submit a request for a PA.
7. We have not received a notice of approval for the renewal approval and the previous PA expired on / / .
8. The provider is not providing the amount of services as per the CPOC and as prior authorized and we have been unable to resolve the issue.
9. Other:
Support Coordinator’s Signature Date
Medicaid Managed Care Appendix S-1
Revised 4.25.19
Instructions for Referrals to LDH Medicaid PAL for Services Authorized by Medicaid Managed Care
NOTE: The Referral to Medicaid Managed Care Case Management (Medicaid
Managed Care Appendix Q) should be sent prior to a referral being sent to the
Medicaid PAL. The MCO has 10 days to resolve the issue. Support Coordinators may
conduct both a phone/e-mail contact along with sending the form to the appropriate
Managed Care Organization contact. Submission of the form alone will not be
considered as one of the above contacts.
SC should make the initial contact to the appropriate MCO PAL or
Medicaid Managed Care Case Manager located in Medicaid
Managed Care Appendix A. Document your attempt on the MCO
PAL / Medicaid Managed Care Case Management Contact form
(Medicaid Managed Care Appendix S-3).
SC should make a second contact to the appropriate MCO PAL
located in Medicaid Managed Care Appendix A. Document your
attempt on the MCO PAL / Medicaid Managed Care Case
Management Contact form (Medicaid Managed Care Appendix S-3).
SC should make a third contact to the appropriate MCO PAL located
in Medicaid Managed Care Appendix A. Document your attempt
on the MCO PAL / Medicaid Managed Care Case Management
Contact form (Medicaid Managed Care Appendix S-3).
If the support coordinator is unsuccessful in resolving the issue with the MCO PAL or Medicaid Managed Care Case Manager then a Referral to the Medicaid PAL (Medicaid Managed Care Appendix S-2, S-3) should be sent.
Notify the Medicaid PAL if PA approval has not been received within 60 days of the Choice of Provider.
Notify the Medicaid PAL if the MCO has been unable to resolve the following issues within 10 days of the Referral to the Medicaid Managed Care Case Manager (MMCCM): unable to locate a willing provider, the PA renewal approval is not received, service is not provided in the amount in PA or service not delivered at times according to PA.
The Referral must include the completed MCO PAL / Medicaid Managed Care Case Management Contact form
(Medicaid Managed Care Appendix S-3) as well as all tracking and service logs, referral forms and e-mails related to resolving the issue with the MCO PAL.
Medicaid Managed Care Appendix S-2
Revised 9/23/20
Referral to Medicaid PAL for Medicaid Managed Care Enrollee EPSDT - Targeted Population
ONLY FOR USE AFTER SUBMITTING A REFERRAL TO MEDICAID MANAGED CARE CASE MANAGEMENT (MMC APPENDIX Q)
Medicaid Managed Care EnrolleeDate:
TO: Medicaid Prior Authorization Liaison (PAL) ۰ P.O. Box 91030 ۰ Baton Rouge, LA ۰ 70821-9030
Attn: Nancy Spillman Fax 225-389-2749
FROM: Provider #:
Support Coordinator’s Name:
Support Coordinator’s Phone#: Fax#:
Managed Care Organization: Medicaid Managed Care Case Manager:
Phone #:
RE: State Plan Provider:
Provider #: Phone #:
Address: City: State/Zip:
Service Type (if DME be specific):
Service Name: ( ) Initial ( ) Renewal
Amount/# of Hours of Service:
Participant Name: Responsible Party:
MID#:
Phone#:
Address:
City:
State/Zip:
This is to inform you that this individual is receiving EPSDT - Support Coordination Services and we are having/had the following problem with the Healthy Louisiana Plan Provider identified above (only those requiring PA): (Check the following that apply.)
1. We have not received an approval within 60 days from the Choice of Provider date.
2. The participant has been advised of their right to choose another provider and we are beginning the process again.
3. The participant has been advised of their right to choose another provider but has decided to stay with the same provider and wait until the PA packet is submitted.
4. The provider is not providing services at the times the participant requested and we have been unable to resolve the issue.
5. We have not received a notice of approval for the renewal approval and the previous PA expired on / / .
6. The provider is not providing the amount of services as per the CPOC and as prior authorized and we have been unable to resolve the issue.
7. The MCO has been unable to locate a willing provider within 10 days of the Referral to Medicaid Managed Care Case Management.
8. Other:
___ I certify that I have attached Medicaid Managed Care Appendix S-3 with all tracking and service logs, referral forms and emails to this form prior to submittal to the Medicaid PAL. All attempts to resolve the issue with the MCO PAL have been exhausted.
Support Coordinator’s Signature Date
Medicaid Managed Care Appendix S-3
Revised 9.23.20
MCO PAL / Medicaid Managed Care Case Management Contact Form
This form must be completed and sent along with all referrals to the Medicaid PAL for services authorized by
Medicaid Managed Care.
Initial Contact
Date: Reason for contact:
Type: _ Email (attach copy)
_ Phone# __________________________ Contact Name: _____________________________
_ Referral Form (attach copy)
_ Other (specify: )
Results of contact: (Describe in detail the results of the contact i.e. services approved, no reply, pending)
Second Contact
Date: Reason for contact:
Type: _ Email (attach copy)
_ Phone# __________________________ Contact Name: _____________________________
_ Referral Form (attach copy)
_ Other (specify: )
Results of contact: (Describe in detail the results of the contact i.e. services approved, no reply, pending)
Medicaid Managed Care Appendix S-3
Revised 9.23.20
Third Contact
Date: Reason for contact:
Type: _ Email (attach copy)
_ Phone# __________________________ Contact Name: _____________________________
_ Referral Form (attach copy)
_ Other (specify: )
Results of contact: (Describe in detail the results of the contact i.e. services approved, no reply, pending)
I certify that I have attached all tracking and service logs, referral forms and e-mails related
to resolving this issue with the MCO PAL. All attempts to resolve this matter with the MCO
PAL were exhausted without success prior to submitting a referral to the Medicaid PAL.
Support Coordinator Name: ___________________________________________________
SC Agency: _________________________________________________________________
Date of Medicaid PAL Referral: _____________________________________________________
Reason for Referral: __________________________________________________________
Medicaid Managed Care Appendix T-1
Revised 3.13.19
Medicaid Managed Care EPSDT Timeline & Documentation
Participant Contacts _______________________________________________________________________________________________________________
Support Coordination Referrals
Within 3 working days: Phone contact or face-to-face visit for Intake
(Document on EPSDT Service Log)
Within 10 calendar days: Face-to-face in-home visit for Assessment
(Document on EPSDT Service Log)
Within 35 calendar days: Complete and submit an approvable
CPOC to SRI (EPSDT Checklist)
Within 4 calendar days from notice of Appeal Denial from the Managed Care Organization:
Explain DAL State Fair Hearing (SFH) rights & offer assistance (Document on PA Tracking Log & EPSDT Service Log)
60 days from date SFH request filed: Check on SFH status and if additional assistance is needed
with the appeal. (Document on PA Tracking Log & EPSDT Service Log)
120 days from date SFH request filed: Check on final outcome of SFH
(Document on PA Tracking Log & EPSDT Service Log)
As Needed Follow up on obtaining information to submit or obtain approval of a PA request, determine service
start date after PA notice received, assist with identified needs and
problems with providers (Document on EPSDT Service Log
& PA Tracking Log as needed)
Monthly Contacts Assure implementation of
requested services listed on the CPOC
(Document on PA Tracking Log and EPSDT Service Log)
Quarterly Contacts Face-to-face visit review CPOC,
status of services & service needs (Document on LSCIS Quarterly Review / Checklist & Progress
Summary and Service Log)
Case Maintenance Appeals
See Medicaid Managed Care Appendix F for Appeals Info
After the Medicaid Managed Care appeal is exhausted, Division of Administrative Law (DAL) State Fair Hearing
(SFH)
Within 4 calendar days from notice of denial from the Managed Care Organization:
Explain appeal rights & offer assistance. Explain to the family that the provider can request a peer to peer review.
(Document on PA Tracking Log & EPSDT Service Log)
20 days from date appeal request filed: Check on appeal status.
(Document on PA Tracking Log & EPSDT Service Log)
Medicaid Managed Care Appendix T-2
4/7/15, Revised 6/19/15, 9/28/15, 3/14/16, 2/23/17, 3/13/19
Medicaid Managed Care EPSDT Timeline & Documentation
Medicaid Managed Care Case Manager (MMCCM) / Provider Contacts
Within 3 calendar days from date of service request:
Send referral to Medicaid Managed Care Case Management.
(Use Referral to MMCCM & Document on PA Tracking Log and EPSDT Service Log)
Within 15 calendar days from date of Referral to Medicaid Managed Care Case
Management: Contact MMCCM & check on status of referral /
COP & offer assistance if needed. (Document on EPSDT Service Log)
35 calendar days from date of Referral to Medicaid Managed Care Case Management
Contact MMCCM & check on status of referral / COP & offer assistance if needed.
(Document on EPSDT Service Log)
10 calendar days from date provider submitted packet to Managed Care
Organization (25 days if a DME
request) If PA or PAL Notice not received, contact the
MMCCM and/or Provider. Continue to follow up until PA is approved/denied based on
medical necessity. (Document on EPSDT
Service Log)
20 – 60 days prior to end of PA period:
Send reminder notice to MMCCM to renew PA
(Use Referral to MMCCM Form, Document on PA Tracking Log & EPSDT
Service Log)
Within 3 calendar days from date of Choice of Provider:
Send referral to Medicaid Managed Care Case Management.
(Use Referral to MMCCM Form & Document on PA Tracking Log)
15 calendar days from date of Referral to Medicaid Managed Care Case
Management: Contact Provider and/or MMCCM to check on status of referral & offer assistance if needed.
(Document on EPSDT Service Log)
35 calendar days from date of Referral to Medicaid Managed Care Case Management:
Contact Provider and/or MMCCM to check on status of referral & offer assistance if needed. If PA
packet has not been submitted to MCO seek assistance from MCO and continue to follow up
with provider and MMCCM until packet is submitted.
(Document on EPSDT Service Log)
If the service is requested and the family has
not made a Choice of Provider, start here.
If the date of service request and the Choice of
Provider date are the same, start here.
OR
Once you have a COP date, move to here.
Once PA packet is
submitted, move here.
4/7/15,
Revised 3.13.19 Medicaid Managed Care Appendix T-3
Medicaid Managed Care
EPSDT Timeline & Documentation PAL and Other Medicaid Managed Care Case Management Referrals
60 Day PAL Referrals* Other PAL* and MMCCM Referrals
60 calendar days from participant’s date of Choice of Provider:
If PA approval/denial not received, send referral to Medicaid PAL using Referral to Medicaid PAL – Medicaid Managed Care Form (Document on PA Tracking Log & EPSDT Service Log)
If PA renewal approval is not received: Complete Referral to MMCCM Form (Document on
PA Tracking Log & EPSDT Service Log) If the MCO is unable to resolve within 10 days of the Referral, the SC should submit a referral to the
Medicaid PAL. Complete Referral to Medicaid PAL Form.
(Document on PA Tracking Log & EPSDT Service Log)
If participant chooses a new provider: Complete Referral to MMCCM Form
(Document on PA Tracking Log & EPSDT Service Log)
If Service not provided in the amount in PA or service not delivered at times according to PA:
Complete Referral to MMCCM Form (Document on PA Tracking Log &
EPSDT Service Log) If the health plan is unable to resolve within 10 days of
the Referral, the SC should submit a referral to the Medicaid PAL.
Complete Referral to Medicaid PAL form. (Document on PA Tracking Log & EPSDT Service Log)
Unable to find a provider that is willing
to submit a request for a PA: Complete Referral to MMCCM Form
(Document on PA Tracking Log & EPSDT Service Log) If the MCO is unable to locate a willing provider
within 10 days of the Referral, the SC should submit a referral to the Medicaid PAL.†
Complete Referral to Medicaid PAL form. (Document on PA Tracking Log & EPSDT service log)
†Note: The MCO is contractually obligated to find a provider within 10 days of Referral to MMCCM. LDH will reach out to the MCO when a PAL referral is received to ensure that this is contractual obligation is met.
*Note: Service logs should be faxed with PAL referrals.