Automated Peer Review Organization (PRO) Certifications

1. Automated Peer Review Organization (PRO) Certifications Cabinet for Health and Family Services – DCBS Training Branch – December 2009

2. PRO Certifications • PRO Certifications are used to verify the admission date and date “level of care” is met for a Long Term Care or Waiver recipient. • Information from the PRO is used to determine Medicaid effective dates.

3. KAMES Automation • Workers can access PRO certifications on KAMES Inquiry, option “P”. • Supports for Community Living (SCL) and Acquired Brain Injury (ABI) certifications are excluded from this automated process until further notice.

4. Verification for the Case Record • Certification notices are required to be placed in the case file. • Workers may print the screen from KAMES inquiry for verification. • ALWAYS include a screen print of the confirmation notice in the case record to avoid QC or M&E errors!!

5. Information Found on KAMES The following information is found on KAMES inquiry, including: • Facility/provider number • Admission date, and • Date level of care met

6. The KAMES Process • A SSN matching function will search KAMES for an active or pending member. • If a match is found, KAMES will post a spot check to the worker’s DCSR with the message, “Pending PRO Certifications”. • Supervisors also receive the spot check for probationary workers, and for non-probationary workers if no action is taken after 10 days.

7. No SSN Match? • If no MA case is found on KAMES, the member name, SSN and facility number will appear on the RDS report titled, “PRO Certifications Not Matched to KAMES”, sorted by county code. • Supervisors are responsible for monitoring this report daily and ensuring that vendor payments are issued for SSI recipients.

8. “PRO Certifications Not Matched to KAMES” RDS Report • This is the location of the “spot check” for SSI individuals and individuals that are not active Medicaid recipients on KAMES at the time the file is received. • Workers can then access the PRO Certification file for identified clients on item “P” of the KAMES Inquiry Menu.

9. Deleting PRO Spot Checks • When a worker adds the LTC segment to KAMES, matching the provider number and SSN of a pending PRO Certification, the spot check will disappear when the batch cycle is run overnight. • Only the supervisor will have the capability to manually delete the PRO Spot Check.

10. Verification Source on KAMES Use verification source of “PR” on the LTC screen on KAMES for the following types of care: • “01”- Nursing Facility (NF) • “02”- HCBS • “07”- ICF/MR/DD • “08”- Mental Health/Psychiatric • “09”- PRTF • “10”- Adult Day Care • “12”- IMD KAMES

11. How to Find Your PRO Cert There are 3 ways to search for your client’s confirmation notice on KAMES! The following slides demonstrate these options...

12. Option “P” in KAMES inquiry allows workers to search for confirmation notices.

13. This screen allows the worker 3 ways to search for the PRO Certification on KAMES.

14. When option A is selected, the worker may search for client information using their SSN. Enter the SSN, then press Enter...

15. Results for the SSN entered are shown on this screen. The worker would then select the corresponding line number and press Enter to access the certification.

16. Enter the line number corresponding with your client’s information. In this example, we are using line # 8.

17. “Date Received”- This is when the certification was received. “Initial”- Tells the worker if this is the first certification for this client. If NOT, the worker must find the initial certification to ensure the client is given the correct Medicaid effective date. Also, the provider name, type, and number are shown.

18. The “date level of care met” and “admission date” are at the bottom of the PRO Certification screen, shown here.

19. The second search option is to search for client info by entering either client name or facility provider number or you can enter both facility provider number and client name, to narrow your search.

20. Here, KAMES shows matches for a search where both provider number and client’s name were entered. We would then choose the line number which corresponds with our client’s info to obtain the certification verification.

21. The third search option on KAMES allows workers to search using county number and date range (the date KAMES received the confirmation record).

22. This search option matches all PRO certifications which were completed for that county in that specific date range.

23. Conclusion • When an applicant comes in to apply for a vendor payment, access KAMES inquiry to locate the confirmation notice. • Always include a screen print of the confirmation notice in the case record.

24. Thank you for utilizing this learning session. We hope you found it helpful. Comments or suggestions regarding this training product should be directed to: Sue.Woodard@ky.gov Cabinet for Health and Family Services DCBS Training Branch - December 2009