Service authorization process for EpSDT

1. Service authorization processfor EpSDT PERSONAL/ATTENDANT CARE (SERVICE TYPE 0091) Effective 09/01/2018-04/30/2019

2. New Health Coverage for Adults in Virginia • Beginning January 1, 2019, more adults ages 19-64, living in Virginia will have access to quality, low-cost health insurance. The new coverage includes hospital stays, doctor visits, preventive care, prescription drugs and much more! • The rules have changed! So, if you applied for Medicaid in the past and were denied, you may soon be eligible. Eligibility is based on income, with a single adult making up to $16,754, or a family of three making up to $28,677, qualifying for coverage. • Interested in learning more? • Check out the below resources or visit www.coverva.org for more information and details on eligibility. • Coverage for Adults Brochure (PDF) • Coverage for Adults Flyer (PDF) • FAQs - New Adult Eligibility for Health Coverage (PDF) • Coverage for Adults Poster (PDF)

3. Methods of submitting service authorization requests to kepro • All requests for service authorization must be submitted to KEPRO via Atrezzo Provider Portal Connect effective September 1, 2015. • https://atrezzo.kepro.com/Account/Login.aspx • Reference DMAS Medicaid Memo dated June 15, 2015. • Notification that KEPRO is converting to an electronic process for submitting Service Authorization Requests – Effective September 1, 2015

4. Resources for submitting service authorization requests to kepro • KEPRO Website: https://dmas.kepro.com/ • DMAS Website portal:https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ • For any questions regarding the submission of Service Authorization requests please contact KEPRO at 888-827-2884 or 804-622-8900.

5. Provider manual/Medicaid memorandums • DMAS publishes electronic and printable copies of its • Provider Manuals and Medicaid Memoranda on the DMAS Web Portal at https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/. • This link opens up a page that contains all of the various communications to providers, including Provider Manuals and Medicaid Memoranda. • The Internet is the most efficient means to receive and review current provider information. • If you do not have access to the Internet or would like a paper copy of a manual, you can order it by contacting: • Direct Mail Works at 1-804-303-1442. A fee will be charged for the printing and mailing of the manual updates that are requested.

6. Service Authorization information and responsibility

7. Service authorization information specific to personal care/attendant care • EPSDT Personal Care/Attendant Care: Service Type 0091 • Providers must submit a request to the designated preauthorization contractor within 10 business days of initiating care or within 10 business days of receiving verification of Medicaid eligibility from the local DSS, unless otherwise specified in the DMAS Provider Manual. Please note that some services can not be retro authorized and must be submitted by the SOC date requested. Refer to the specific Provider Manual for the submission requirements for each service/procedure code.

8. Service authorization information specificto personal care/attendant care continued • EPSDT Personal/Attendant Care: Service Type 0091 • EPSDT services are available to Medicaid members under 21 years of age. Personal care may be provided exclusively through EPSDT to eligible persons who have demonstrated a medical need for personal care that is not covered under an existing Medicaid program for which the individual is enrolled. • Procedure/Service Codes that Require Service Authorization: • T1019 (Agency Directed Personal Care)‏ • S5126 (Consumer Directed Personal Care)‏

9. Service Authorization information specific to personal care/attendant care continued • Eligible Members include individuals who are: • Under 21 years old and enrolled in Medicaid FFS, Medicaid MCO, or FAMIS Plus on dates of services requested. • Under the age of 19 years old and enrolled in FAMIS FFS on the dates of services requested.

10. Service authorization information specific to personal care/attendant care continued • Timeliness Requirements for Submission: • Providers must submit documentation to KEPRO within 10 business days of start of care. • Continuation of service reviews must be submitted prior to the end of the current authorization period. • If the request is not submitted within the required timeframe, the service must be authorized beginning with the date of submission to KEPRO.

11. Service authorization information specific to epsdt personal care/attendant care • Provider will be required to complete the questionnaire utilizing the information found on the following forms: • DMAS 7 EPSDT Personal Care Services Functional Status Assessment (signed and dated by physician, physician’s assistant, or nurse practitioner and must be updated every year) • DMAS 7-A from provider EPSDT personal care Program Agency and Consumer Directed Plan of Care (must be updated every year) • DMAS 99 Community Based Care Recipient Assessment Report (must be updated every year) • Back-up plan documented • Detailed Schedule of current services available to individual • NOTE*** If additional information is needed from the provider, the case is pended for five business days to allow provider time to submit additional documentation to KEPRO for review.

12. Service authorization information specific to personal care/attendant care continued • In addition to medical necessity, the following criteria must be met in order for personal care services to be determined as appropriate: • The member must have a plan of care developed by a currently enrolled personal care provider or service facilitator • The plan of care (DMAS-7A) should be consistent with the findings on the (EPSDT functional assessment) DMAS-7 and demonstrate the need for personal care. • The member must have a viable back-up plan, such as a family member, neighbor, or friend who is willing and able to assist the individual on very short notice in case the personal care aide does not report for work as expected. • Individuals who do not have a viable back-up plan are not eligible for services until a backup plan as has been established. • Individuals receiving EPSDT personal care must have a physician referral due to health conditions documented during an EPSDT medical exam

13. Service authorization information specific to epsdt personal care/attendant care continued • Medical Necessity • Health conditions must cause the individual to be functionally limited in performing three or more activities of daily living (ADL) • Health conditions may be medical or behavioral and include Autism Spectrum and other Developmental Disorders • Requiring prompting, verbal cuing, multiple reminders, or supervision during an ADL is considered a dependency in that particular ADL for EPSDT related requests

14. Service authorization information specific to epsdt personal care/attendant care continued • EPSDT Personal Care Services may be provided in a school setting if the service is not included in the member’s Individualized Education Program (IEP) and the services are deemed medically necessary. • Providers must document the medical need for coverage in the school setting and document that the services are not included in the member’s IEP. • EPSDT allows supervision hours when it is medically necessary for the member to receive supervision due to a health condition. • Disruptive behaviors such as aggression, self-injury, elopement/wandering, impulsivity, property destruction, etc. may require constant supervision from a personal or attendant care aide to maintain the child’s safety inaddition to the hours required for ADL/IADL supports.

15. Continuity of care • Should a member transition from CCC Plus to Medicaid FFS, the provider must submit a request to the Service Authorization contractor that the request is for a CCC Plus transfer within 60 calendar days. This will ensure honoring of the approval for the continuity of care period and waiving of timeliness requirements. • The Service Authorization Contractor will honor the CCC Plus approval up to the last approved date but no more than 60 calendar days from the date of CCC Plus disenrollment under the continuity of care provisions. For continuation of services beyond the 60 days, the Service Authorization contractor will apply medical necessity/service criteria.

16. Continuity of care continued • Should the request be submitted to the Service Authorization Contractor after the continuity of care period: • The dates of service within the continuity of care period will be honored for the 60 day timeframe; • The dates of service beyond the continuity of care period, will be reviewed for medical necessity, all applicable criteria will be applied on the first day after the end of the continuity of care period. Timeliness will not be waived. • For CCC Plus Waiver Services, Cap hours will be approved the day after the end of the continuity of care period up to the date of request. The continuation of service units will be dependent upon service criteria being met and will either be authorized or reduced accordingly as of the date of the request.

17. Continuity of care continued • Once member is FFS, only Medicaid approved services will be honored for the continuity of care. • If a member transitions from CCC Plus to FFS, and the provider requests an authorization for a service not previously authorized under CCC Plus, this will be considered as a new request. The continuity of care will not be applied and timeliness will not be waived. • When a decision has been rendered for the continuity of care/transition period and continued services are needed, providers must submit a request to the Service Authorization Contractor according to the specific service type standards to meet the timeliness requirements. The new request will be subject to a full clinical review (as applicable).

18. Ccc plus exceptions • The following exceptions apply: • If the service is not a Medicaid covered service, the request will be rejected; • If the provider is not an enrolled Medicaid provider for the service, the request will be rejected. (In this situation, a Medicaid enrolled provider may submit a request to have the service authorized; the Service Authorization Contractor will honor the CCC Plus approved days/units under the continuity of care period for up to 60 calendar days. The remaining dates of services will be reviewed and must meet service criteria but timeliness will be waived as outlined above.) • If the service has been authorized under CCC Plus for an amount above the maximum allowed by Medicaid, the maximum allowable units will be authorized.

19. Service authorization information specific to epsdt personal care/attendant care continued • The Following Services are Covered based on age appropriateness: • Assistance with activities of daily living (ADLs): bathing, dressing, toileting, transferring, eating/feeding, ambulation, and bowel and bladder continence • Assistance with IADLs related to the individual such as light housework, laundry, meal prep, transportation, grocery shopping, using the telephone, and money management • Medically Necessary Supervision related to a health condition • Special Maintenance tasks including monitoring health status and physical conditions; assistance with self administration of medication (not to include determining the dosage or the direct administration of medication) and other tasks such as range of motion, wound care and bowel programs as allowed in accordance with the Virginia Administrative Code

20. Service authorization information specific to epsdt personal care/attendant care continued • The Following Services are NOT Covered: • General Supervision • Respite • Performance of tasks for the sole purpose of assisting with the completion of job requirements • Assistance provided in hospitals, other institutions, assisted living facilities, and licensed group homes • Services included in the member’s Individualized Education Program (IEP)

21. Out of state providers • Out of state providers must be enrolled with Virginia Medicaid in order to submit a request for out of state services to the Contractor. If the provider is not enrolled as a participating provider with Virginia Medicaid, the provider is still encouraged to submit the request to the Contractor, as timeliness of the request will be considered in the review process. These providers will not have a NPI number but may submit a request to the Contractor. • The Contractor will advise out of state providers that they may enroll with Virginia Medicaid by going to https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/. (At the toolbar at the top of the page, click on Provider Services and then Provider Enrollment in the drop down box. It may take up to 10 business days to become a Virginia participating provider.)

22. Virginia Medicaid web portal • DMAS offers a web-based Internet option to access information regarding Medicaid or FAMIS member eligibility, claims status, check status, service limits, service authorizations, and electronic copies of remittance advices. • Providers must register through the Virginia Medicaid Web Portal in order to access this information. The Virginia Medicaid Web Portal can be accessed by going tohttps://www.virginiamedicaid.dmas.virginia.gov.  • If you have any questions regarding the Virginia Medicaid Web Portal, please contact the Web Portal Support Helpdesk, toll free, at 1-866-352-0496 from 8:00 a.m. to 5:00 p.m. Monday through Friday, except holidays. • The MediCall audio response system provides similar information and can be accessed by calling 1-800-884-9730 or 1-800-772-9996. Both options are available at no cost to the provider. • Providers may also access service authorization information including status via KEPRO’s Atrezzo Provider Portal Connect at https://dmas.kepro.com/.

23. Dmas helpline information • The “HELPLINE” is available to answer questions Monday through Friday from 8:00 a.m. to 5:00 p.m., except on holidays. • The “HELPLINE” numbers are: • 1-804-786-6273 - Richmond area and out-of-state long distance • 1-800-552-8627 - All other areas (in-state, toll-free long distance) • Please remember that the “HELPLINE” is for provider use only. • Please have your Medicaid Provider Identification Number available when you call.

24. THANK YOU THANK YOU!