NC PSD Provider Relations

Welcome to the 2008 NC Medicaid and

Provider Education SeminarFor Developmental

Disabilities

Speeding up the process for requesting Authorizations

FAX TO AUTHORIZATION

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Agenda

VO Authorization experience in NC Confirming the Basics CTCM Provider Relations Unit

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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

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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.

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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

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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.

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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.

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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

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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.

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Reminders

Piedmont Cardinal Health PlanIf 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

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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.

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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

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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.

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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.

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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

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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

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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.

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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

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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.

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CTCM FORM

SEE FORM AND INSTRUCTIONS

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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.

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Q & A