Medicaid Services System (MSS) Prior Authorization (PA) for County Boards & COGS

1. Medicaid Services System(MSS)Prior Authorization(PA) forCounty Boards & COGS Medicaid Development and Administration Jeanne Gregory-Kaeppner Prior Authorization Manager

2. Content • Brief Overview & History • Transition • The New Process • Know your dates • Demonstration • Q&A

3. Brief Overview and History Rule 5101:3-41-12 Since 2005, the prior authorization process has allowed individuals who exceed their Ohio Developmental Disabilities Profile (ODDP) range to receive medically necessary waiver services. Completion of forms/checklists and documentation sometimes lengthened this process. With the introduction of MSS (Medicaid Services System), advances were made to help simplify the process and better serve the individual, families, county boards and providers.

4. Transition Simplification of processes can only occur when the individual has been transitioned into MSS.

5. The New Process The on line pa process will abbreviate the review, examples are: • Attachment A—Prior Authorization Budget Information is now the Cost Projection Tool (CPT) in MSS --Reduces budget errors --Clarifies ratio’s and staffing • Appendix 7 Criteria Checklist and Rationale are now on page 2 of the IRF. • County boards can enter the Individual Request Form( IRF) into MSS Automatic IRF submittal allows instant review by county boards of the prior authorization status • Reviewers can access MUI’s and the ODDP from IDS, no need to send this to DODD • Tool tips will assist you in only submitting necessary information (ISP, pertinent assessments, estimates) • Tool tips will prompt you to briefly explain unusual circumstances reducing reviewer inquiries to county boards

6. Know your dates: The new MSS/Manage PA process went live December 10, 2011. The existing PA mailbox, prior-authorization@list.dodd.ohio.gov, was inactivated on: December 10, 2011. Starting December 10, 2011, supporting documentation must be either emailed to PADOC2@dodd.ohio.gov and include the PA# in the file/attachment name OR… faxed to DODD at to 6147525303@faxmaker.com and include the PA# on the coversheet

7. Demonstration • Participants will view completion of : • original prior authorization • budget adjustment • withdraw.

8. Search for Site by Name & Click Search PA is site specific Search for Site

9. Search by Site Defaults to Manage Individuals Screen Select Manage Unscheduled Services for One Person to add services if applicable

10. Click Manage Cost Projections on the left columnIn the center of your screen click “Get Cost Projection Details” Click to get Cost Projection Details. Please note that the individual is over their ODDP range (in red at right.

11. Finalization • Finalization Success • Finalization Amount: _____ • Warning: The finalized amount is over the individuals DDP range. A PA may be required. • Record your finalization total because you will need to enter the total amount on page 1 on the IRF. • If you are ready to create a PA now: • Click the “Create PA” or “Create Budget Adjustment” link below and complete the IRF. • If you are NOT ready to create a PA – exit now. When you are ready: • Go to Manage Individual PA • Click “Create PA” or “Create Budget Adjustment” link and complete the IRF. • Once you have completed the IRF: • Click the “Manage Versions” link • Click “Save New Version” • Name the version to indicate a PA request. Example: • “PA# 100032 John Smith” • Create PA

12. What Does “Ready” Mean? • You have admin/team approval to proceed with the prior authorization • A signed IRF by the individual/guardian • County Board rationale • An ISP • Correlating assessments • Necessary documentation If you are NOT Ready • Exit by clicking on the “x”. • Gather the information you need to proceed with the prior authorization at a later time.

13. When You Are Ready • Go to “Manage Individual PA” on the left • Click “Create PA” or “Create Budget Adjustment” button which will take you to the IRF for completion

14. Individual Request Form – Page 1

15. Individual Request Form – Page 1 Continued

16. Welcome to the 1st page of the IRF (Individual Request Form) • The individuals information will auto-populate from IDS • Under individual information go to “I live with: and select the appropriate option” • If applicable, enter guardian and authorized representative information. All fields must be completed • Under PA Contact Information you must enter all fields and select your county • Enter the dollar amount from the cost projection • Check the County Board attestation statement • Use the calendar to select the date the individual signed the IRF • DO NOT CHECK PAR RESUBMISSION WITHOUT AUTHORIZATION FROM THE PA MANAGER ; IT IS FOR SPECIAL CIRCUMSTANCES • Click update and continue.

17. Individual Request Form – Page 2

18. Individual Request Form – Page 2 Continued….

19. Individual Request Form – Page 2 • Please note as you saved and continued from page 1 a PA # was assigned at the top of page 2 of the IRF. • The PA# is key in documents sent to us and assisting in searches on the Manage PA Screen. • If the county board supports the request all the boxes numbered 1-4 must be checked “yes”. • If the county board does not support the request, check the numbered1-4 boxes accordingly. • Check “yes” under “Does CB support the pa request”? • If the CB does not support the request, check “no”. • Under Individual Rationale, enter the reasons the individual needs the pa request.

20. Individual Request Form – Page 2 Continued….. • The CB must select at least one criteria if the CB is in agreement with the par. Enter brief specifics under each criterion checked. • The CB must enter it’s rationale for support or non-support. • If a CB does not support the pa, the CB needs to create an alternative cost projection and save and name the version accordingly. • Click “Submit PA” which will give you tool tips on the information needed for the par and how to send it to us. • Click “OK” to complete submittal

21. The Giant Tool Tip

22. Manage Individual PA

23. Creating a PA from the Manage Individual Screen

24. Creating a PA from the Manage Individual Screen If you are ready to create a PA now: - Click “OK”  and complete the IRF. Once you have completed the IRF: 1)  Click the “Manage Versions” link. 2)  Click “Save New Version.” 3)  Name the version to indicate a PA request. Example:  “PA#10033 for John Smith.”

25. Saving and Naming Versions • Once you have submitted the IRF either through Finalization or Manage Individual Screen then: • Click the ‘Manage Versions” link. • Click “Save New Version”. • Name the version to indicate a PA request. • Example: • PA#10033 for John Smith”

26. Saving & Naming Versions

27. Manage Individual Screen • You can view the PA#, waiver span, top DDP amount, projected amount requested and STATUS of your request at any time. • Click on “View IRF” if you need to make modifications (locks down after DODD decision) • Click on “View Details” for overview of your request which includes your submittal date.

28. View PA Details

29. Manage PA Screen

30. Status Definitions • New – A new PA has been submitted • Incomplete – IRF is not complete (will not be assigned) • Assigned – PA assigned to a reviewer • In Review – Reviewer is currently working on this PA • Need CB Info – Need additional information • Withdrawn – PA not needed • DODD Approved – PA has been approved • Sent To JFS – DODD not supported, sent to JFS • JFS Approved – JFS decides to approve the PA • JFS Denied – JFS decides to deny the PA • Approval letter sent- DODD or JFS issues approval letter

31. Budget Adjustment • Additional prior authorization requests for the same individual within the same span are called budget adjustments. • Budget adjustments are created just like an original pa, either through finalization on the Manage Cost Projection screen or on the Manage Individual Screen. • A budget adjustment will be highlighted in red with a “B” after the PA #. An ISP is not required. The reviewer will contact you if additional information is needed.

32. Q&A Jeanne.Kaeppner@dodd.ohio.gov for prior authorization issues. MSSSupport@dodd.ohio.gov for MSS issues

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