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service definitions

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This USER GUIDE contains the prior authorization (PA) request process for

the provider, Administrative Entity (AE), and Supports Coordinator Organization

(SCO) to support the delivery of Supplemental Habilitation (SH) and Additional Individualized Staffing

Services (AIS)

SH/AIS User Guide

To Support the Prior Authorization Process

Version 6.0

Office of Developmental Programs

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2 CONTENTS

PURPOSE ............................................................................................................................ 3

SERVICE DEFINITIONS ....................................................................................................... 4

NEED IDENTIFIED ............................................................................................................... 5

PRIOR AUTHORIZATION REQUEST PROCESS: PROVIDER’S ROLE ..................................7

PRIOR AUTHORIZATION REQUEST PROCESS: SUPPORTS COORDINATOR’S ROLE .... 12

PRIOR AUTHORIZATION REQUEST PROCESS: AE’S ROLE ............................................ 15

MAILROOM SCREENING PROCEDURES ......................................................................... 20

ODP DETERMINATION PROCESS .................................................................................... 24

PROVIDER BILLING: ......................................................................................................... 28

IMMEDIATE NEED REQUESTS ......................................................................................... 31

CRITICAL REVISIONS ....................................................................................................... 34

FISCAL YEAR RENEWALS ................................................................................................ 36

DUE PROCESS, FAIR HEARING, AND APPEALS .............................................................. 39

APPENDIX A: COUNTY CODE LISTING (INCLUDES JOINDERS) ...................................... 41

APPENDIX B: MA97 INSTRUCTIONS .............................................................................. 42

APPENDIX B: MA97 FORM (HYPERLINK TO MA 97 FORM) .......................................... 48

APPENDIX C: DP1031 FORM .............................................................................................. 51

APPENDIX D: REASON CODES ON NOTICES .................................................................. 52

APPENDIX E: PRIOR AUTHORIZATION TIMELINE FOR SH AND AIS ............................. 53

APPENDIX F: DP1050, ISP REVIEW CHECKLIST .............................................................. 59

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3 PURPOSE

PURPOSE The purpose of this User Guide is to consolidate communications issued by ODP in the past regarding the prior authorization of Supplemental Habilitation (SH) and Additional Individualized Staffing (AIS) services. By combining information into one resource, stakeholders will be able to locate related information more easily. The publication of this User Guide obsoletes the following communications:

Informational Packet #125-10, issued August 31, 2010, provided Individuals and Families, AEs, SCOs, Supports Coordinators (SCs), and direct service providers with the PROMISeTM prior authorization implementation date. In addition, this communication introduced and instructed all applicable parties to use the SH/AIS Individual Support Plan (ISP) Checklist (DP 1035) when SH or AIS prior authorization requests are made. NOTE: The ISP Review Checklist (DP 1050) replaced the DP 1035 effective March 1, 2013.

Informational Packet #146-10 was issued on October 28, 2010. This communication emphasized important reminders to keep in mind regarding SH and AIS prior authorization requests.

Informational Packet #077-10 was issued on June 25, 2010. This communication announced: the prior authorization of SH and AIS, implementation phases, and the unit of service change.

Informational Packet #050-11 was issued April 14, 2012. This communication provided guidance regarding the handling of SH and AIS services in the FY 2011-2012 Renewal ISPs. It also introduced an abbreviated prior authorization request process for repeated AIS prior authorization requests that result from an individual’s retirement.

Informational Memo #0164-11 was issued on December 6, 2011. This communication reiterated the mailing address for individuals to send SH and AIS appeals.

Informational Packet #039-12 was issued on May 22, 2012. This communication provided guidance on existing SH and AIS prior authorization scenarios, overlapping fiscal years and new SH/AIS prior authorization requests during the FY 2012-2013 renewal period. It also announced to stakeholders that the prior authorization of SH and AIS would be centralized beginning July 1, 2012.

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4 SERVICE DEFINITIONS

SERVICE DEFINITIONS For the purposes of this User Guide, SH and AIS services fall under the category “Residential Enhanced Staffing” and are only available to individuals enrolled in the Consolidated Waiver. If base-funded SH or AIS is needed, the provider or SC should contact their AE to determine the steps required to render these services.

SH and AIS services were introduced in the Fiscal Year 2009-2010 service definitions and, effective July 1, 2010, ODP required that these services receive ODP prior authorization, via PROMISeTM) before they are authorized on an individual’s ISP. SH service: Used to temporarily supplement the licensed residential habilitation service to meet

the short-term unique behavioral or medical needs of an individual when the change in need cannot be met as part of the usual residential habilitation staffing pattern.

May be authorized for a maximum of 12 consecutive calendar months. SH Procedure Codes:

W7070 – The provision of 1:1 staffing for habilitation to supplement the Basic residential service to meet the unique needs of the individual, 15-minute units. W7084 – The provision of 2:1 staffing for habilitation to supplement the Basic residential service to meet the unique needs of the individual, 15-minute units.

AIS service: Is used to meet the long-term additional individualized staffing needs of an individual

who resides in a licensed residential habilitation setting when an individual experiences a change in need that is unable to be met with the current residential habilitation staffing pattern.

This service differs from the SH service in that the individual’s need for staffing is long-term and the individual’s staffing needs can no longer be met as part of the usual residential habilitation staffing pattern.

This service may be used to meet the additional long-term staffing requirements to ensure the health and welfare of the individual.

The individual’s ISP must reflect both the residential habilitation and the applicable AIS procedure code.

AIS Procedure Codes

W7085 – The provision of 1:1 staffing for habilitation to supplement the Basic residential service to meet the unique long-term needs of the individual, 15-minute units. W7086 – The provision of 2:1 staffing for habilitation to supplement the Basic residential service to meet the unique long-term needs of the individual, 15-minute units.

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5 NEED IDENTIFIED

NEED IDENTIFIED ISP Team Agreement: The ISP Team should convene to discuss the assessed need of the individual who resides in a licensed residential habilitation and evaluate whether the assessed need of the individual requires additional staffing for a short term or long term period or if another service will be more appropriate to meet the assessed needs of the individual. Add service to your Services and Supports Directory (SSD): When the ISP Team agrees that either SH or AIS services will meet the assessed needs of the individual, the provider who intends to render this service to the individual must first select and add the procedure code (service) to their SSD for each service location. Providers who intend to render SH and/or AIS services, should ensure they have selected and added the service offerings for SH and AIS in their SSD for each service location. This must be done through Provider Access in the Home and Community Services Information System (HCSIS). In order for the SC to select the provider who will render the service, the service must be available as a service offering on the SSD first. The next sections describe the process to request prior authorization of either SH or AIS services. It includes the roles of the provider, AE, SCO, and ODP.

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6

PROVIDER’S

ROLE

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7 PRIOR AUTHORIZATION REQUEST PROCESS – PROVIDER’S ROLE

PRIOR AUTHORIZATION REQUEST PROCESS: Provider’s Role The provider should review Appendix E to understand the timeline associated with each step in the prior authorization request process. STEP 1: ADD SERVICE TO SSD

When the ISP Team agrees that either SH or AIS services will meet the assessed needs of the individual, the provider who intends to render this service to the individual must first select and add the procedure code (service) to their SSD for each service location. The provider’s SSD is located in the Provider Access area of HCSIS. An SC cannot select a provider to render SH or AIS services, if the service is not available as a service offering in the SSD*.

* For more detailed instructions regarding how to add a service in the SSD, please visit the Learning Management System (LMS), which is found on the HCSIS Welcome screen. After clicking on LMS, go to “My Curriculum” found on the left-hand side of the screen. Please locate the heading titled “ODP PROV100I Provider Materials” then scroll to the tip sheet called “Provider Access Updates Tip Sheet v5.0 4/23/09”. Once the tip sheet is located, the provider should click on the download button and the document will appear on the screen. Detailed instructions on how to “Add a Service” in the SSD begins on page 14 of the tip sheet.

STEP 2: PROVIDER COMPLETES THE DP 1050 (ISP REVIEW CHECKLIST): Sample in

APPENDIX F (Form located on odpconsulting.net>Resources>ODP Forms)

A. To request prior authorization for waiver-funded SH or AIS services, the provider is responsible for completing several sections of the ISP Review Checklist (DP 1050) which include: 1. Checking off “Provider” in the “Initiator of checklist” section and

checking off “SH/AIS” in the “Activity” section of the ISP Review Checklist (DP 1050).

2. Completing the “Provider Information” section on page 1 and the “Provider to Complete (SH/AIS ONLY)” section on page 2.

3. Entering a “Reason for service need/justification of on-going service need” and an “Explanation of what type of support the staff will be providing”.

B. After the provider’s portion of the ISP Review Checklist has been

completed, the provider will e-mail the SC, SCO Director, and AE, attach the ISP REVIEW Checklist (DP 1050) to the e-mail and

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communicate the need for SH or AIS services within the body of the e-mail.

C. If either SH or AIS services are needed by the individual effective the day of the request, please follow the process for immediate need requests in the section of this User Guided titled “Immediate Need Requests”. See “Contents” found on page 2 of this User Guide for page numbers.

STEP 3: PRIOR AUTHORIZATION DETERMINATION PROCESS (No provider action required)

A. The AE Completes the Following Activities:

a. Reviews the provider’s prior authorization request (DP 1050), b. Completes the appropriate sections on the DP 1050 (see

Administrative Entity’s Role section of this guide for more specific details).

c. Sends ODP their determination recommendation, d. Completes all the appropriate forms and mails the forms to an

ODP specific location that is for SH or AIS prior authorization requests only.

B. ODP Makes Determination:

a. Once the AE e-mails the DP 1050 (ISP Review Checklist) to ODP at [email protected], ODP reviews the information specified in the DP1050, the MA97 and the DP 1031 then makes a determination.

a. ODP enters their determination in PROMISeTM. This action triggers the generation of the “Notice of Prior Authorization Decision”, which is automatically produced and mailed to the individual, provider, AE, and SCO.

b. Refer to the section of this User Guide titled “ODP Determination Process” for more specific details regarding the determination process.

STEP 4: PROMISeTM DETERMINATION NOTICE:

a. The provider, individual, AE and SCO will receive a PROMISeTM prior authorization determination letter in the mail which indicates ODP’s decision to approve, approve other than requested or deny the provider’s prior authorization request.

b. The PROMISeTM notification letter is titled “Notice of Prior Authorization Decision”.

mailto:[email protected]

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c. This letter includes the authorization decision and, if approved or approved other than requested, will also include the number of units authorized (Quantity), dates of service for which the authorization is valid (Authorization Period), the specific SH or AIS procedure codes (Billing Code) authorized and a prior authorization number (“PA Reference #”) to be used during billing.

d. The provider should review the service authorization notice in HCSIS and render the service per the authorization. If the service authorization notice is inconsistent with the information found in the “Notice of Prior Authorization Decision” letter, then contact the individual’s SC to discuss. If the service is denied by ODP, the SC will reconvene the ISP Team to discuss other service options.

e. A service authorization in HCSIS alone will not guarantee payment for service. If a provider renders and bills for SH or AIS services before receiving prior authorization from ODP, there is no guarantee the provider will be paid for the services rendered.

STEP 5: MISCELLANEOUS INFORMATION

a. Retroactive Approvals

Prior authorization requests for SH or AIS waiver funded services should be made in a timely manner. If ODP makes a decision to retroactively approve a prior authorization request for SH or AIS services, the approval will only be made retroactive for a period of no longer than 30 calendar days from the date ODP receives the request from the AE. Any ODP waiver funded provider who renders SH or AIS services for a period longer than 30 days without first obtaining ODP prior authorization is risking non-payment. For emergency situations, such as a medical or behavioral change in need, please follow the process for immediate need requests in the section of this User Guided titled “Immediate Need Requests”. See “Contents” on page 2 for page numbers.

b. Additional Units Needed If the ISP Team decides that more units are needed to meet the needs of the individual beyond what was originally approved by ODP, the provider should e-mail their AE, attach another DP 1050, and request the AE complete and mail a new MA 97 and

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DP 1031 to request additional units. See Appendix B and C of this User Guide for samples of the MA97 and DP1031 forms as well as instructions to complete the forms.

c. Change in Service Location SCENARIO 1: If the individual moves from one service location to another service location with their existing staff (using the same provider or a new provider), the new provider should:

Ensure the new service location is enrolled in PROMISeTM.

Request the AE complete and mail another MA 97 and

DP1031 to request prior authorization at the new service location.

Ensure that the DP1031 reflects only the new dates of service and units that apply to the new service location. The “Begin Date” (#15) should reflect the date the individual moved to the new service location and the “Anticipated End Date” (#16) is the last day the individual will need the service. Space #17 on the DP 1031 should include the number of units associated with the date span found in spaces #15 and # 16 on the DP 1031. If this is not done, then it will delay review of the prior authorization request which will delay payment to the provider.

SCENARIO 2: If an individual already receives either SH or AIS and moves to a new service location (with a new or existing provider) with a different staffing pattern and new staff, then the provider should:

Complete all the same actions found in SCENARIO 1 but also complete a new ISP Review Checklist (DP 1050). When completing the ISP Review Checklist (DP 1050), the provider should follow the instructions found in the section of this User Guide titled “STEP 2: PROVIDER COMPLETES THE DP 1050 (ISP REVIEW CHECKLIST)”.

Attach the completed DP 1050 to an e-mail that is sent to the SC, SCO Director, and AE. Within the body of the e-mail communicate the need for SH or AIS services.

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11 PRIOR AUTHORIZATION REQUEST PROCESS – SUPPORT COORDINATOR’S ROLE

SUPPORTS COORDINATOR’S

ROLE

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PRIOR AUTHORIZATION REQUEST PROCESS: Supports Coordinator’s Role The SCO should review Appendix E to understand the timeline associated with each step in the prior authorization request process. STEP 1: CONVENE ISP TEAM MEETING

After receiving an e-mail notification from the provider that they are serving an individual who has a need for SH or AIS services, the SC will convene the ISP Team to discuss the need for the SH or AIS services. SCs should take the ISP Review Checklist (DP 1050) with them to the ISP team discussion so that all items under Section D: Intensive Staffing of the ISP Review Checklist are discussed during the ISP Team discussion.

STEP 2: DOCUMENT IN THE ISP

a. All the information discussed at the ISP Team discussion should be documented in the ISP. If the ISP Team determines that the need for the service is aligned with the approved service definitions, then the SC will update the ISP by documenting the need for the service as specified in Section D: Intensive Staffing section of the ISP Review Checklist (DP 1050). SCs should complete the “Recommended ISP Section” area of the ISP Checklist by checking off the applicable areas of the ISP were the information was documented.

b. If the ISP Team is unsure whether the need for the service is aligned with the approved service definitions, the provider should still send a prior authorization e-mail request to the AE and attach a completed DP 1050 form to the e-mail. The AE is required to complete these steps in the process. ODP is ultimately responsible for making the final prior authorization determination.

c. The most current ISP should be updated. ODP will be reviewing the ISP that applies to the request. In other words, ODP will review the most current and approved ISP or may review an ISP that is pending approval depending on the period the request applies to.

d. The SC should attach the SH or AIS procedure code(s), in addition to the Consolidated Waiver-Funded Licensed Residential Habilitation procedure code(s), to the Service Details section of the ISP. If the service is not listed in the provider’s SSD, the SCO should contact the provider to request that the provider add the service to its SSD so it can be selected by the SC and added to the individual’s ISP.

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e. The SC should update the Service Details section of the ISP with the appropriate begin and end dates. The begin and end dates should accurately reflect the length of time the individual needs the service not to exceed a fiscal year. For instance, if an individual needs SH services from 7/1/11 to 7/15/11, these dates should be listed as such in the Service Details section of the ISP.

f. The SC should enter the appropriate units of service in the Service

Details section of the ISP to accurately reflect the units of service needed by the individual for the duration in which the service is needed not to exceed a fiscal year.

STEP 3: SCO SAVES CHECKLIST. The SCO should save the ISP Review Checklist using the

following naming convention: MCI#_ISPChecklist STEP 4: THE SCO WILL SUBMIT THE ISP TO THE AE. After the ISP Team discussion has

taken place and the ISP has been updated, the SCO should submit the ISP to the AE. This action should occur within 9 days from the date that the AE first e-mailed ODP regarding the prior authorization request.

STEP 5: MONITORING. When the SC conducts regular monitoring visits, as with any

service, it is essential that SH and AIS services are monitored too. The SC should make sure that the staff person is present and supporting the person as described in the ISP. The SC should also monitor to see if the enhanced support is still needed.

NOTE: SH or AIS services will remain in pending authorization status in HCSIS until

the AE receives the PROMISeTM notification letter, titled “Notice of Prior Authorization Decision”.

.

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14

ADMINISTRATIVE ENTITY’S

ROLE

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15 PRIOR AUTHORIZATION REQUEST PROCESS: ADMINISTRATIVE ENTITY’S ROLE

PRIOR AUTHORIZATION REQUEST PROCESS: AE’s Role Effective July 1, 2012, the SH and AIS prior authorization process has been centralized. ODP regional mailboxes previously used will no longer be effective. All AE communication sent to ODP regarding prior authorization for SH or AIS should be sent to the following e-mail address:

[email protected]

AE IDENTIFIES POINT PERSON(S) The AE should identify a point person(s) within their organization to receive the initial prior authorization request e-mail from the provider. The point person(s) will also maintain communication with the provider(s) who request prior authorization for SH or AIS. The AE will inform all providers, as well as ODP, of the AE point person(s) assigned to this task. The AE will use [email protected] to communicate to ODP who the assigned point person(s) are in their organization. AE E-MAILs ODP

The subject line of the e-mails sent from the AE to ODP should include the name of the AE and the MCI# of the individual who has been identified as in need of SH or AIS.

The chart below lists the subject line naming conventions ODP expects to receive as

part of the SH and AIS process.

The purpose of each “EMAIL SUBJECT” below is explained throughout this User Guide.

SUBJECT LINE NAMING CONVENTIONS

WHEN TO USE THE SUBJECT LINE DESCRIPTORS

AE Name_MCI#_Immediate Need Used when an immediate need has been identified

AE Name_MCI#_Auth. Recommend Used when the AE has made a decision regarding a provider’s SH or AIS prior authorization request

AE Name_MCI#_Forms Mailed Used when the AE mailed the MA97 and DP1031 to the ODP mailing address for prior authorization requests.

AE Name_MCI#_SLC Change Used when the individual changes service locations either to a completely new provider or another service location of the existing provider.



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STEP 1:

a. The AE will review the e-mail request and ISP Review Checklist (DP 1050) sent from the provider. The version from the provider will not show the areas that the SC populated in the ISP but it will alert the AE that the prior authorization request is with the SC. Receipt of the Checklist from the provider also alerts the AE that a prior authorization request is currently with the SC and the AE can expect to receive the Checklist from the SC once the SC has finished completing the appropriate sections.

b. The AE will ensure that the ISP Review Checklist (DP 1050) is completed appropriately by the provider and Supports Coordinator.

c. The AE will enter the appropriate information in the sections of the ISP Review Checklist (DP 1050). On page 1 of the ISP Review Checklist (DP 1050), the AE should enter their name, contact name and contact e-mail address. On page 2 of the DP 1050, the AE should complete the section titled “Administrative Entity To Complete”. In addition, the AE will complete “Section D: Intensive Staffing” by reviewing each item listed in the column called “Item to Discuss/Document in the ISP”. The AE should check off the appropriate selection in the column titled “Item Documented? AE to Complete” to affirm that the item listed has been reviewed and is sufficiently documented. See APPENDIX F of this User Guide for a copy of the DP1050.

d. The AE should confirm the units of service entered in the Service Details section of the ISP accurately reflects the timeframe requested and matches the provider’s request in the DP1050. If the AE does not receive the ISP by day 7 (7 days after the AE emailed ODP with the prior authorization request), the AE will follow-up with the SCO to ensure the SC convened the ISP Team and the AE will request the ISP be updated and completed within 2 calendar days.

e. After the AE receives the ISP indicating that SH or AIS services are needed, the AE will:

Review the ISP to ensure that the need for SH or AIS services is documented within the ISP and that all of the information identified above in STEPs 1 and 2 of the Support Coordinator’s Role is included. The AE will need to work with the SCO until all of the necessary documentation is included.

Ensure that the service(s) being requested are consistent with the service definition for SH or

AIS services.

Leave the SH or AIS service in “pending authorization status” in HCSIS until the AE receives the “Notice of Prior Authorization Decision” letter via United States Postal Service indicating ODP’s final decision.

f. If the AE determines that the individual’s ISP includes the required documentation to support

the need for SH or AIS services and the AE has completed the ISP Review Checklist (DP 1050) in its entirety, the AE will send an e-mail to [email protected] with their authorization recommendation for SH or AIS services and include the ISP Review Checklist (DP 1050) as an attachment, even if the AE recommends denying the prior authorization request. The AE will include the following naming convention in the subject line of the e-mail: AE_MCI#_Auth. Recommend. The AE should replace the word “Recommend “with their authorization recommendation. As an example, an approval would look like this: AE_MCI#Auth.Approve and a denial would look like this: AE_MCI#Auth.Deny


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g. Final SH or AIS prior authorization request determinations and communication of that determination is made by ODP. Please note, if the ISP Review Checklist (DP 1050) is not completed in its entirety or other information is missing from your e-mail request, ODP can not make a prior authorization determination until all the required documentation is received and complete. To avoid a delay in processing, ensure all information required is submitted to ODP when making a prior authorization request.

h. Once ODP makes a PROMISeTM prior authorization determination for SH or AIS services, the individual, provider, AE, and SCO will receive a “Notice of Prior Authorization Decision” letter via United States Postal Service. If the determination letter indicates an approval by ODP, the AE should authorize the service in the ISP and the provider will proceed with rendering the service. If the service is denied by ODP, the AE should remove the service from the ISP in HCSIS and inform the SC to reconvene the ISP Team to discuss other service options. In addition, when a denial determination is made, the “Notice of Prior Authorization Decision” letter will specify the individual’s right to a fair hearing. See the section of this User Guide titled “DUE PROCESS, FAIR HEARING, AND APPEALS” for more information. PLEASE NOTE: ODP will be responsible for communicating and coordinating fair hearing information with the individual and/or surrogate, if applicable.

STEP 2:

At the same time that the AE sends the e-mail to ODP indicating their prior authorization recommendation, the AE should complete the MA 97, Outpatient Service Authorization Request form, and the attachment titled “Supplemental Habilitation & Additional Individualized Staffing Prior Authorization Request” form (DP 1031), even if the AE recommends denying the prior authorization request. The begin and end dates of service on the MA97 should be based on the individual’s need for the service. No more than two (2) services (procedure codes) are permitted to be requested per MA 97 form. If two (2) services (procedure codes) are being requested on the MA 97 form, then two (2) separate DP 1031 forms will need to be completed.

IMPORTANT NOTE: AEs should note that if the number of units requested exceeds 9,999 units, please use separate lines on the MA 97 and divide up the number of units requested. Each line completed on the MA 97 should not exceed 9,999 units of service. The system is unable to process a single line that exceeds 9,999 units of service.

The MA 97, the DP 1031 attachment, and the instructions on how to complete each document are located in the Appendices section of this User Guide. These documents are also stored on www.odpconsulting.net. When you reach the odpconsulting.net homepage, locate “Resources”. Click on the arrow adjacent to it and select “ODP Forms” from the drop down menu. All SH and AIS forms related to the requesting prior authorization are also stored on the Provider Information Center (PIC) and the Administrative Entity Information Center (AEIC) under ODP Business Practice Information > Prior Authorization Processes. * If there are questions regarding the use of the ODP Consulting website, users can contact [email protected] to receive assistance.

http://www.odpconsulting.net/


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STEP 3:

After the MA 97 and DP 1031 forms have been completed and signed, the AE will: a. Mail the MA 97 Outpatient Service Authorization Request form and the DP 1031

Supplemental Habilitation & Additional Individualized Staffing Prior Authorization Request form via the United States Postal Service to the following address:

DPW, Office of Developmental Programs

P.O. Box 69027 Harrisburg, PA 17106-9027

b. ODP will retrieve the forms from the address above and validate the forms are complete. If

they are, the forms will be scanned into the prior authorization subsystem in PROMISeTM. If the forms are missing critical data elements, they will be returned to the AE with a request for additional information. See the next section of this SH/AIS User Guide, titled “MAILROOM SCREENING PROCEDURES”, for more information on what is screened. Once the forms are scanned into the system, ODP is alerted and conducts a review of the prior authorization documents. After a review has been completed, ODP makes a prior authorization determination and approves, approves other than requested or denies the prior authorization request in PROMISeTM.

c. After the AE has mailed the forms to the address indicated above, the AE will send an e-mail

to [email protected] and put AE_MCI#_Forms Mailed in the subject line of the e-mail. This e-mail should be sent the day the forms have been mailed and will include the providers 13-digit MPI and service location code in the body of the e-mail. This e-mail alerts ODP that the required documentation for the prior authorization request has been mailed and it will soon appear in PROMISeTM for review, assuming the documentation was determined complete.

d. Once the AE has received the “Notice of Prior Authorization Decision” letter in the mail

indicating that the prior authorization request was approved or approved other than requested, the AE may authorize the SH or AIS service(s) on the ISP.

NOTE TO AE: THE AE SHOULD NOT AUTHORIZE SH OR AIS SERVICES ON THE ISP UNTIL

THE AE HAS RECEIVED THE “NOTICE OF PRIOR AUTHORIZATION DECISION” LETTER THAT THE SERVICE HAS BEEN APPROVED. If the SH or AIS services are authorized on the individual’s ISP without prior authorization from ODP, the provider will not be paid for rendering this service.

If the request to prior authorize SH or AIS services are denied, the AE will either remove the service from the individual’s ISP or request the SCO removes the service from the individual’s ISP in HCSIS. The AE will inform the SC to reconvene the ISP Team to discuss other service options.


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19

MAILROOM SCREENING

PROCEDURES

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20 MAILROOM SCREENING PROCEDURES

MAILROOM SCREENING PROCEDURES

a. The AE mails the MA97 and DP1031 forms to a mailbox. Once the MA97 and DP1031 forms are picked up from the mailbox, they undergo a mailroom screening process and, if they pass this process, both forms are scanned into the PROMISeTM prior authorization subsystem.

b. Requests that fail the mailroom screening process are returned to the sender (AE) with the applicable reason(s) checked on the Return to Prior Authorization Letter.

c. It is critical that the AE includes a return address on the envelope that is used to the mail the MA97 and DP1031. If the AE’s return address is missing on the envelope, any requests that fail the mailroom screening process will not be returned to the AE, which will cause a delay in processing.

d. SCOs and Waiver-Funded Licensed Residential Habilitation providers should verify

their “Mail To” address is correct in PROMISeTM. Incorrect “Mail To” addresses cause the Notice of Prior Authorization Decision letter to be returned to ODP Central Office located in Harrisburg, Pennsylvania. SCOs and Waiver-Funded Licensed Residential Habilitation providers can verify and make any corrections to their “Mail To” address using ePEAP (electronic Provider Enrollment Automation Project), which is accessible through the PROMISeTM Internet. Please use the following links to access ePEAP and the ePEAP online Instruction Manual:

● ePEAP is accessed from the “My Home” page on the PROMISeTM Internet.

Please go to http://promise.dpw.state.pa.us/ to access the PROMISeTM Internet Home page. If you are currently a registered user on the PROMISeTM Internet, enter your “User ID” in the space provided, which is located on the top left hand side of the Home page.

● After logging in, the user will be directed to the “My Home” page. Click on

“ePEAP” which is located in the top horizontal menu bar located close to the top of the “My Home” page screen. Once you select ePEAP, you should see the ePEAP Menu screen. Select the “Enrollment Information” link located in the “Provider Options” list. Next, select the “Address Information” link to go to the screen used to update the “Mail to” address currently on the PROMISeTM provider file.

● Hyperlink for the ePEAP online Instruction Manual:

http://www.dpw.state.pa.us/ucmprd/groups/webcontent/documents/manual/s_001933.pdf

e. AEs with incorrect addresses in PROMISeTM, will not receive their Notice of Prior Authorization Decision letters. These letters are returned to ODP Central Office. AEs

http://promise.dpw.state.pa.us/



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that are aware that they have incorrect mailing addresses in PROMISeTM, cannot use e-PEAP to make a correction. If an AE would like to change their mailing address, they should send the request via e-mail to [email protected] and indicate in the e-mail that their address has changed and the new address should be stated.

f. The AE should also correct any error(s) indicated on the Return to Prior Authorization Letter and mail the corrected MA 97 and DP 1031 back to ODP using the same address that is used for the MA97 and DP1031. If the AE chooses to handwrite the information into the MA 97, it is important that the handwriting is legible.

g. The following fields on the MA 97 must be completed accurately in order to pass the

mailroom screening process: 1. Field 1 (MA97) – Prior Authorization box must be checked 2. Field 3 (MA97) – Recipient Number (RID) must be present and be 9 or 10 digits

in length. 3. Field 8 (MA97) – Provider ID must be 13 digits. A 13-digit Provider ID number

consists of a 9-digit MPI and a 4-digit service location code. This is the most common error that causes the MA97 to be returned to the sender.

4. Field B 20 – 25 (MA97): Procedure Code must be present and be 5 digits in length.

5. The words “Signature Exception” or “Signature on File” must be found in fields 33 and 35 on the MA 97.

6. The DP 1031 must be sent with the MA 97. If it is missing, the prior authorization request will be mailed back to the sender.

h. AEs should note that although the MA97 and DP1031 may pass the mailroom

screening process, other data contained on these forms may be missing or invalid and cause the prior authorization request to be denied. A large number of MA97s have been found to contain invalid 13-digit MPI numbers that are not recognized by PROMISeTM. This may be caused by a transposition error. After completing the MA97, AEs should review the data entered and ensure the numbers have not been transposed. Please remember that the 13-digit MPI number consists of a 9-digit provider ID number and 4-digit service location code and must be included on the MA97 or the request will fail the mailroom screening process and be returned to the return address on the envelope.

i. AEs are required to complete both the MA 97 and the DP 1031 when a prior

authorization request for SH or AIS services is made. The AE should mail both documents to the following address:

DPW, Office of Developmental Programs P.O. Box 69027

Harrisburg, PA 17106-9027


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j. AEs should note that the 2-digit County Code where the AE’s office is located should be entered in the License Number field (Block 13) on the MA 97. This field is important because the system uses it to determine the AEs address so that the AE may receive the Notice of Prior Authorization Decision letter. A list of county codes can be found in Appendix A located at the end of this User Guide.

k. IMPORTANT NOTE: AEs should note that if the number of units requested exceeds

9,999 units, please use separate lines on the MA97. The number of units requested must be divided up on separate lines not to exceed 9,999 per line. The system is unable to process a single line on the MA97 when the unit amount exceeds 9,999 units of service.

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23

ODP DETERMINATION

PROCESS

Page | 24

ODP DETERMINATION PROCESS 24

ODP DETERMINATION PROCESS STEP 1: ODP is alerted that the provider is requesting prior authorization for an SH or

AIS service when the AE sends ODP an e-mail with “AE Name_MCI#_Auth. Recommend” in the subject line and a completed DP1035 form is attached.

STEP 2: ODP will review the following information prior to making a determination1:

1. Service notes to ensure that a team meeting occurred to discuss the need.

2. All areas of the ISP that correspond to the 11 items listed in “Section D: Intensive Staffing” portion of the ISP Review Checklist (DP 1050).

3. Behavioral Support Plan section of the ISP: It is critical that the

behavioral support plan is adequately documented in the ISP. Stating only that a “Behavioral Support Plan has been developed” lacks sufficient detail. Instead, ODP is looking for plan details such as the specific behavior that requires support, how that behavior will benefit from a support plan, the expected outcome from utilizing the support plan, and planned monitoring schedule that will be used to evaluate the effectiveness of the behavioral support plan.

4. Reduction of Intensive Staffing/Support (#10 of DP1050): A large

volume of SH and AIS prior authorization requests have been found to lack appropriate detail while describing the plan for eventual discontinuance or reduction of the intensive staffing/support. This information should be documented in the Supervision Care Needs: Reasons for Intensive Staffing and Outcome Actions sections of the ISP. One example of possible language that could be included in the ISP would be the following: “In order for the ISP Team to feel comfortable in reducing the intensive staffing/supports, Jennifer must have no more than 5 incidents or situations when [enter behavior] took place during a 6 month period”. This example defines specific criteria that will be evaluated within a specific timeframe to determine whether a reduction in supports should be made based on the occurrence of a specific behavior.

1 Failure to provide this required information clearly and thoroughly may result in a denial of your prior

authorization request.

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5. Monitoring: A plan for monitoring service delivery and effectiveness of service delivery should be detailed in the Supervision Care Needs: Reasons for Intensive Staffing, Plan for Reducing Intensive Staff Support and the Outcome Actions sections of the ISP. Indicating that “a monitoring plan has been developed” is not enough information for this area of the ISP. The details of the monitoring plan must be entered as well. For example, a monitoring plan might consist of unplanned site visits that are conducted regularly. During the site visit, a confirmation of the delivery of service, service effectiveness, and a review of file notes will be documented.

6. Continuation of AIS or SH service requests (#11 on DP 1050): If the ISP Team determines that AIS or SH will continue to meet the needs of the individual in future fiscal years, it is ODP’s expectation that ISP documentation will demonstrate this. The assessment results, the second item on the ISP Review Checklist, should demonstrate the impact of service and progress made as a result of receiving the service. The information should be documented in the Outcome Summary, Medical: Health Evaluations, Non-Medical Evaluations, and Medical History areas of the individual’s ISP.

7. Documentation in the ISP: The documentation in the ISP should be

clear in describing that the continuous need request is warranted and will best meet the needs of the individual instead of another service. Ensure that evaluation criteria and an evaluation timeframe is documented in the ISP regarding when supports should be reduced. Before a final prior authorization determination is made, ODP will validate that specific evaluation criteria and a timeframe is present and that the information documented in the ISP demonstrates an intensive staffing need.

8. The ISP sections associated with Number 3 in Section D of the ISP

Review Checklist should contain current language that is consistent with and justifies the intensive staffing need. ODP reviews all the sections of the ISP that correspond to this item on the ISP Review Checklist to ensure the language documented is consistent with the prior authorization intensive staffing need request.

9. Incident information: Incident information should be documented in

the ISP if it is related to the intensive supports request.

10. ODP reviewers will validate that SH/AIS was not authorized on the ISP prior to an ODP determination being made.

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11. Missing Information: If ODP determines that information is missing on the ISP Review Checklist (DP 1050), ODP cannot complete the determination process for prior authorization. AEs should ensure the documents and information sent to ODP are complete. ODP thoroughly reviews ISPs during the prior authorization determination process. During this review, it should be clear to ODP that the request for SH or AIS services is warranted and will best meet the needs of the individual instead of the use of another service. A lack of required information documented in the individual’s ISP may cause a prior authorization service request to be denied.

STEP 3: ODP makes prior authorization decision and updates internal systems and

databases to reflect the determination.

STEP 4: The individual, provider, AE and SCO will be notified of ODP’s prior authorization determination when they receive the “Notice of Prior Authorization Decision” letter. PROMISeTM automatically generates and mails the “Notice of Prior Authorization Decision” letters to the individual, provider, AE, and SCO.

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27 Provider Billing

PROVIDER

BILLING

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28

PROVIDER BILLING:

NOTE: a. SH and AIS services are subject to existing ODP specific edits, audits, and Medical

Assistance billing rules. Base SH and AIS services do not require PROMISeTM prior authorization.

b. The individual must be actively enrolled in the Consolidated waiver in order for the provider to receive reimbursement for either SH or AIS services rendered.

STEP 1: Once ODP makes a prior authorization determination and it is entered in

PROMISeTM, the “Notice of Prior Authorization Decision” letter is automatically generated and mailed to providers. It is the official notification of the prior authorization number from PROMISeTM. This number will be identified as the “PA Reference #”.

STEP 2: When completing a claim, the PROMISeTM prior authorization number must be

entered into the “Prior Authorization Number” field, which is available on each of the different claim transaction methods (CMS1500, PROMISeTM Internet, Provider Electronic Solution Software (PES) or third party billing software).

STEP 3: When billing for a service that has been assigned a prior authorization number

in PROMISeTM, the SH or AIS service(s) are the only service or services permitted to be billed on one single claim. No other service detail lines unrelated to the authorized service are permitted on the claim with the authorized services. If a provider enters any service on the claim other than SH or AIS services, the claim detail line(s) for those service(s) will be denied and payment will only be disbursed for the SH or AIS services.

STEP 4: When the provider is billing for SH or AIS services, the accumulated units of

service and date span entered on the claim should never exceed what is shown as authorized on the “Notice of Prior Authorization Decision” letter or your entire claim will deny. PROMISeTM will not cutback units and pay when excess units have been billed.

STEP 5: The provider must also enter the 10-digit Medical Assistance (MA) Recipient

Identification Number, also known as the RID, on the claim in order to receive payment for SH or AIS services. PROMISeTM will not accept the 9-digit MCI number when processing claim transactions.

STEP 6: The SH or AIS billed amount on the provider’s claim should reflect the unit cost

of the eligible residential service found on the service authorization notice.

For billing inquiries, contact the ODP Claims Resolution Section: E-mail: [email protected] Phone: 1-866-386-8880 Mon-Thurs 8:30am - 12:00pm and 1:00pm - 3:30pm


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29

NOTE: UNITS IN EXCESS OF 9,999

Units authorized that exceed 9,999 are set up as two or more line items in the PROMISeTM prior authorization system because PROMISeTM can not process more than that per item. The units billed on a claim line item should not exceed the balance on each of the line items set up in the PROMISeTM prior authorization system. Please review your determination notices to identify the total units approved per line item and track any billings that deplete the units associated with each of the line items. If the units billed exceed the balance on a line item, the system will skip the line item if the balance is inadequate and go to the next line item and evaluate the balance. If the second line item balance in PROMISeTM is adequate to cover the units submitted on the claim, then PROMISeTM will deplete the second line item by the units billed. If you find that you have multiple line items with an inadequate unit balance in the PROMISeTM prior authorization system, e-mail [email protected] and request the units remaining are shifted to align with the units you intend to bill.


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30

IMMEDIATE

NEED

REQUESTS

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31 Immediate Need Requests

IMMEDIATE NEED REQUESTS

NOTE: Immediate need requests should only be submitted up to 48 hours after the immediate need has been identified. If an immediate need was identified but the request was not submitted within a 48 hour period, then the need is no longer considered immediate. In this situation, the prior authorization request should be submitted using the standard SH/AIS prior authorization request process. This request will be reviewed as a prior authorization intensive staffing need request instead of an immediate need request. When an immediate need approval is requested, Waiver-Funded Licensed Residential Habilitation providers and AEs should keep in mind the following information: 1. PROVIDER ROLE: If either SH or AIS services are needed effective the day of the

request, the provider will e-mail the AE, indicate that this is an immediate need, and attach the DP 1050 with the Provider Information section completed.

2. AE ROLE: The AE will forward the provider’s e-mail to ODP no later than the next

business day to confirm that SH or AIS services are needed immediately.

The AE will send the immediate need approval request to [email protected] using the following naming convention in the subject line of the e-mail: AE_MCI#_Immediate Need

Simultaneously, the AE should complete the MA97 and DP 1031. The MA97 and DP1031 should contain the “Quantity” requested, “Begin Date”, and “Anticipated End Date” that represents 14 calendar days of service. The original MA97 and DP 1031 should be mailed to: DPW, Office of Developmental Programs, P.O. Box 69027, Harrisburg, PA 17106

3. PROVIDER ROLE: The immediate need decision will be communicated to the AE by

ODP via e-mail. In addition, if ODP approves the immediate need prior authorization request, the PROMISeTM prior authorization system will reflect a total of 14 calendar days. After the approval is made in the PROMISeTM prior authorization system, the Notice of Prior Authorization Decision letter will be mailed to the individual, provider, AE and SCO also indicating the approval.

4. AE ROLE: If an immediate need e-mail approval was made to the AE by ODP, then

the AE should authorize the SH or AIS service on the ISP for no more than 14 calendar days from the date the AE sent the initial immediate need e-mail request to ODP.



Page | 32

32 Immediate Need Requests

5. ISP TEAM ROLE: The ISP Team has 14 calendar days to meet, discuss, and determine

the number of days that would meet the assessed need of the individual. Day one begins from the date the AE sent the initial immediate need e-mail request to ODP.

6. AE ROLE: After the ISP Team meeting has occurred, the AE is required to update the

ISP Review Checklist (DP 1050) and e-mail it to ODP ([email protected]).

The e-mail should also include the total units and begin and end dates agreed to by the ISP Team. This action should occur within 14 calendar days starting from the day that the immediate need approval request was first e-mailed to ODP.

7. ODP ROLE: ODP will review the ISP Review Checklist (DP 1050) and use the

timeframe and quantity requested on the form to make a final determination for the continuation of services beyond the 14 calendar days. ODP will determine whether the prior authorization for SH or AIS services will be made retroactive to the date of the immediate need approval request. If the additional units and time frame are approved by ODP, the PROMISeTM prior authorization system will be updated to reflect the new approved units and a second Notice of Prior Authorization Decision letter will be mailed to the individual, provider, AE and SCO with the updated units and effective dates.

8. PROVIDER BILLING: Providers should not begin billing for SH or AIS services until

the prior authorization request has been approved in PROMISeTM. Providers may begin billing once they receive the Notice of Prior Authorization Decision letter in the mail confirming that the SH or AIS service has been approved in PROMISeTM.

NOTE: Regardless of the decision rendered by ODP for immediate need requests, the

Notice of Prior Authorization Decision letter will be mailed, via the United States Postal Service, to the individual, provider, AE, and SCO and will detail the ODP determination decision.

EXAMPLE OF AN IMMEDIATE NEED REQUEST An example of an immediate need request would include the need for additional staffing when there is less than 24 hours notice of a hospital discharge and a health and safety issue has been identified. This type of situation would warrant an immediate need request because the service is needed effective the day of the request.


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33 CRITICAL REVISIONS

CRITICAL REVISIONS

Page | 34

34 CRITICAL REVISIONS

CRITICAL REVISIONS

CRITICAL REVISIONS

Entity Roles and Responsibilities

Provider

1. Initiate ISP Review Checklist (DP 1050) 2. Submit supporting documentation 3. Forward to SC 4. Maintain copy of ISP Review Checklist (DP 1050)

for files 5. Participate in ISP Team discussion

Supports Coordinator (SC)

1. Convene an ISP Team discussion 2. Document information discussed in ISP 3. Complete ISP Review Checklist (DP 1050),

identifying sections 4. Submit ISP Review Checklist (DP 1050) to AE 5. Maintain copy of ISP Review Checklist (DP 1050)

for files

Administrative Entity (AE)

1. Use ISP Review Checklist (DP 1050) to review ISP and to make an authorization recommendation

2. Complete ISP Review Checklist (DP 1050) 3. Forward ISP Review Checklist (DP 1050) and

authorization recommendation to ODP

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35

FISCAL YEAR

RENEWAL

PERIOD

Page | 36

36 Fiscal Year Renewals

FISCAL YEAR RENEWALS Unless otherwise communicated, during each fiscal year renewal period, ODP will manage the following SH and AIS prior authorization scenarios as specified in the chart below:

SCENARIO ACTION

AIS Resulting from retirement

ODP recognizes that individuals who are prior authorized to receive AIS services, as a result of a retirement, will likely continue to maintain a need for AIS services in future fiscal years. As a result, ODP uses an abbreviated prior authorization process for this specific situation. 1. ODP will automatically approve AIS as a result of retirement for the

next FY if it is used during the current fiscal year 2. The prior authorization number will be the same number that was

associated with the prior authorization in the previous fiscal year. 3. AE ACTION: Once the AE receives the "Notice of Prior Authorization

Decision" letter in the mail, the AE should verify the number of units authorized (Quantity), dates of service for which the authorization is valid (Authorization Period), the assigned SH or AIS procedure code (Billing Code) in the notice with the information in the ISP before the services are authorized. Next the AE should perform the following steps for services that are attached to the FY renewal ISP: a. Navigate to the Pending Approval/Review screen and click

[Approved]. b. When the Authorize Services screen is displayed, the

Authorization Status will be pre-populated with Pre-Authorized and the correct Funding Stream.

c. Click [Authorize Services].

SH or AIS that overlap fiscal years

PROVIDER ACTION:

Complete the appropriate section of the ISP Review Checklist (DP 1050) to initiate the prior authorization request process. Only one ISP Review Checklist (DP 1050) will need to be completed for this scenario. Enter the begin and end date for which the service is being requested in the Reason service for service need/justification of ongoing service need” section of the DP 1050 form and forward to the AE.

AEs ACTION:

Complete and mail two (2) MA97s and two (2) DP1031s; one for each

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37 Fiscal Year Renewals

SCENARIO ACTION

fiscal year. SCO ACTION: 1. SCs should only update the narrative of the FY renewal ISP to reflect

the reason for the need, the service, units requested and length of time service is needed.

2. Do not attach the SH or AIS service to the FY renewal ISP 3. For the current FY prior authorization requests, SCs should attach

the service to the current FY ISP.

SH or AIS prior authorization requests that apply to the following fiscal year only

Providers, AE, SCO and SC Action: When a draft FY renewal is created, services previously authorized in the current FY ISP will pre-populate into the FY renewal ISP. SH and AIS services MUST be removed from the draft FY renewal ISP, with the exception of AIS services that were given ODP prior authorization approval as a result of retirement. This action is necessary to ensure that the services are not placed in “pre-authorized” status in HCSIS. If the services are placed in “pre-authorized” status, there is a risk that the service will be authorized in HCSIS without first obtaining ODP prior authorization approval. AEs and SCOs should take the following action to remove SH and AIS services from the draft FY renewal ISP: 1. Navigate to the Service Details screen of the draft FY renewal ISP 2. Select the SH or AIS service from the table and delete the service

using [Delete]. Note the Confirm Deletion message. 3. Complete other necessary updates to the narrative of the ISP. 4. Submit ISP for approval as per usual protocol.

Note: If the individual already received SH service authorization for 12

consecutive calendar months, then any new SH prior authorization requests made for the same individual and same provider for a period beyond the 12 consecutive calendar month period will be denied. If the ISP team believes there is a continuing need for enhanced staffing support, a new prior authorization request for AIS must be submitted.

For SH or AIS prior authorization requests that apply to the following fiscal year only, Providers, AEs, and SCs should follow the prior authorization request process under the applicable section as specified in this User Guide.

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38

DUE PROCESS, FAIR HEARINGS AND

APPEALS

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39 Due Process, Fair Hearing, and Appeals

DUE PROCESS, FAIR HEARING, AND APPEALS

When a determination is made by ODP for a SH or AIS PROMISeTM prior authorization request, the Notice of Prior Authorization Decision Letter is mailed, via the United States Postal Service, to the Individual, AE, SCO, and ODP. On the last page of the decision Decision Letter, there is language that specifies where to locate the DP 458 form and where appeal requests are to be mailed. Below is a section of the decision letter that

specifies where appeals must be mailed (circled in red).

To ensure all parties are adequately represented at an appeal hearing, it is critical that

the completed Fair Hearing and Request Form, DP 458, is mailed to ODP Central Office only, located in Harrisburg, PA. DO NOT MAIL the DP 458 directly to the Bureau of Hearings and Appeals (BHA).

Review page two of the DP 458 form for instructions and notice of right to a fair

hearing. ODP will be responsible for communicating and coordinating fair hearing information

with the individual and/or surrogate, if applicable.

RESOURCES

1. Bulletin # 00-04-07, titled “Clarifying procedures for Individual and Provider Appeals”,

was issued on March 14, 2004.

2. Bulletin # 00-08-05, titled “Due Process and Fair Hearing Procedures for Individuals with Mental Retardation”, was issued on April 10, 2008 or current version.

http://documents.odpconsulting.net/alfresco/d/d/workspace/SpacesStore/82e159ba-521d-4d53-aadc-a62c366b80af/Fair_Hearing_Request_Form_DP_458.pdf

http://services.dpw.state.pa.us/olddpw/bulletinsearch.aspx?BulletinId=4032

http://services.dpw.state.pa.us/olddpw/bulletinsearch.aspx?BulletinDetailId=4326

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40

APPENDICES

Page | 41

41 APPENDIX A: LIST OF COUNTY CODES

APPENDIX A: COUNTY CODE LISTING (INCLUDES JOINDERS)

County Code

County Name County

Code County Name

1 Adams/York 27 Forest/Warren

2 Allegheny 28 Franklin/Fulton

3 Armstrong/Indiana 30 Greene

4 Beaver 31 Huntingdon/Mifflin/Juniata

5 Bedford/Somerset 35 Lackawanna/Susquehanna

6 Berks 36 Lancaster

7 Blair 37 Lawrence

8 Bradford/Sullivan 38 Lebanon

9 Bucks 39 Lehigh

10 Butler 40 Luzerne/Wyoming

11 Cambria 42 McKean

12 Cameron/Elk 43 Mercer

13 Carbon/Monroe/Pike 46 Montgomery

14 Centre 48 Northampton

15 Chester 49 Northumberland

16 Clarion 51 Philadelphia

17 Clearfield/Jefferson 53 Potter

18 Clinton/Lycoming 54 Schuylkill

19 Columbia/Montour/Snyder/Union 59 Tioga

20 Crawford 61 Venango

21 Cumberland/Perry 63 Washington

22 Dauphin 64 Wayne

23 Delaware 65 Westmoreland

25 Erie

26 Fayette

Page | 42

42 APPENDIX B: MA97 Instructions and Form

APPENDIX B: MA97 Instructions PURPOSE The purpose of this document is to provide a block-by-block

reference guide to assist Administrative Entities (AEs) in successfully completing the MA 97 Outpatient Service Authorization Request form to request PROMISeTM prior authorization for Supplemental Habilitation (SH) and Additional Individualized Staffing (AIS) services. The MA97 and instructions are posted on www.odpconsulting.net >Resources> ODP Forms: MA97 Form and Instructions

DOCUMENT FORMAT This document contains a table with four columns. Each column

provides a specific piece of information as explained below:

Block Number – Provides the block number as it appears on the MA 97.

Block Code – Lists a code that denotes how the claim block should be treated. They are:

M – Indicates that the claim block must always be completed. A – Indicates that the claim block must be completed, if

applicable. O – Indicates that completing the claim block is optional. LB – Indicates that the claim block should always be left blank.

Block Name – Provides the block name as it appears on the MA

97.

How To Complete Block - Details ODP-specific instructions on how to complete the block for the request to prior authorize Supplemental Habilitation (SH) or Additional Individualized Staffing (AIS) services.

Send completed MA97 and DP1031 to: DPW, Office of Developmental Programs

P.O. Box 69027 Harrisburg, PA 17106-9027


http://documents.odpconsulting.net/alfresco/d/d/workspace/SpacesStore/8b1634e0-712c-4fc8-8cdc-4eab37c7fe01/MA-97_Outpatient_Service_Auth_Request_Form_and_Instructions.pdf

Page | 43


BLOCK NUMBER

BLOCK CODE

BLOCK NAME HOW TO COMPLETE BLOCK

1 and 2 M Prior Authorization/1150 Waiver (Program Exception)

Place a check (√) in the box next to the words “PRIOR AUTHORIZATION”.

3 M Recipient Number Enter the 10-digit recipient identification number (RID) or 9-digit MCI number (also known as the MCI or MAID #). If this block is blank or contains less than 9 numbers, the entire MA 97 will be rejected and mailed back to the requestor.

4 M Patient’s Name (Last, First, M.I.)

Enter the individual’s last name, first name, and middle initial (if any).

5 M Birthdate (MMDDYYYY) Enter the individual’s birth date in an 8-digit format using MMDDYYYY. Do not enter any lines or other symbols between the month, day, and year.

6 O Sex Check the appropriate box, “M” (male) or “F” (female).

7 M Provider Name Enter the provider’s last name, first name, and middle initial (if any) or the organization’s name as it appears in PROMISeTM.

8 M Provider ID Enter the provider’s 13-digit MPI number and service location code.

9 LB Provider’s Own Reference NUMBER

This block does not apply to ODP service programs. Do not enter any information in this block.

10 LB GROUP NAME This block does not apply to ODP service programs. Do not enter any information in this block.

11 LB GROUP ID NUMBER This block does not apply to ODP service programs. Do not enter any information in this block.

12 M NAME OF REFERRING PRACTITIONER OR PRESCRIBER

Enter the name of the ODP region you are associated with. Valid ODP region names are: Western Region, Central Region, Northeast Region, and Southeast Region.

13 M License Number Enter the 2-digit county code where the AE’s office is located. If you are part of a

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BLOCK NUMBER

BLOCK CODE


county joinder, please enter the county code that comes first in alphabetical order. Page 6 contains a listing of the PA county codes.

14 M TELEPHONE NUMBER Enter the provider’s phone number, including area code. The phone number should be for the contact person at the provider’s organization who would be best to speak to regarding this prior authorization request.

15 M PRACTITIONER’S/PRESCRIBER’S STREET ADDRESS

Enter the address of the AE’s designated ODP Regional Office.

16 and 18 LB PRIMARY DIAGNOSIS SECONDARY DIAGNOSIS

This field is currently not a required field.

17 and 19 LB ICD-9CM/DSM-IV CODE These 2 blocks do not apply to ODP service programs. Do not enter any information in these blocks.

20A-25A M Description of Services/Supplies Requested

Enter a description of the service. Please note: each MA97 should contain no more than 2 procedure codes and service descriptions for SH or AIS services.

20B-25B M Procedure Code Enter the 5-digit procedure code. Must contain 5-digits or your request will be rejected and mailed back to the requestor. Eligible procedure codes are: W7070, W7084, W7085, or W7086. Please note: one prior authorization form should contain no more than 2 procedure codes and service descriptions for SH or AIS services.

20C-25C LB Modifier This block does not apply to ODP service programs. Do not enter any information in this block.

20D-25D M Quantity Enter the exact units of service requested. Both SH and AIS services are 15 minute units. For example, if the AE enters 5 units in this block that would equate to 5 x 15 minute units which would equal 1.25 hours. Do not enter hours or days. Enter only the

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BLOCK NUMBER

BLOCK CODE


number of 15 minute increments requested for the individual.

20E-25E LB AMOUNT PER UNIT This block does not apply to ODP service programs. Do not enter any information in this block.

20F-25F LB QUANTITY PER MONTH This block does not apply to ODP service programs. Do not enter any information in this block.

20G-25G LB NUMBER OF MONTHS This block does not apply to ODP service programs. Do not enter any information in this block.

26A M ESTIMATED LENGTH OF NEED Enter the estimated length of need in days. When estimating the length of need, please review the limitation associated with the requested service as defined in the approved Waiver.

26B M INITIAL DATE OF SERVICE

Enter the date that the individual first received the service requested even if the service period began prior to the date this prior authorization request was submitted because of an emergency situation. Enter the date in an 8-digit format using MMDDYYYY. Do not enter any lines or other symbols between the month, day, and year. If the individual never received the service prior to this request, leave space blank.

26C M BEGINNING DATE OF SERVICE FOR THIS REQUEST

Enter the date the individual will first receive the SH or AIS services. Enter the date in an 8- digit format using MMDDYYYY.

27 LB What Other Alternatives Have Been Tried or Used to Meet This Patient’s Needs?

This block does not need to be completed. This information is contained in the required attachment, DP 1031 form.

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BLOCK NUMBER

BLOCK CODE


28 M CHECK THE BOX WHICH APPLIES TO THIS PATIENT’S CURRENT RESIDENTIAL STATUS

Check the RESIDENTIAL box only.

29 LB Give a Narrative Description of the Specific Symptoms or Abnormalities the Service/Equipment/Supplies are Intended to Alleviate. Provide the Medical Justification Needed for the Evaluation of This Request.

This block does not need to be completed. This information is contained in the required DP 1031 Attachment.

30 M NUMBER OF ATTACHMENTS Enter the number of attachments. ODP requires one (1) attachment, the DP 1031 form, to be completed along with the MA 97. Visit odpconsulting.net > Resources > ODP Forms to access an electronic version of the DP 1031 attachment and instructions.

31 A INITIAL REQUEST If this is your first request for this provider to provide services to the individual, enter an “X” in box 31. If not, leave blank.

32 A Resubmission of Previously Denied Request

If this is a resubmission of a previously denied request, enter an “X” in Item 32 and the previously denied Prior Authorization Reference Number from the “Prior Authorization Notice”. If not, leave blank. This block does not apply to SH or AIS requests made before September 1, 2010.

33 M Signature of Patient/Authorized Representative

Enter in block 33 either “Signature Exception” or “Signature on File”. If this block is left blank, the MA 97 will be rejected and returned to the requestor.

34 M DATE (MMDDYYYY) Enter the date the MA 97 was completed in an 8-digit format using MMDDYYY. Do not enter any lines or other symbols between the month, day, and year.

35 M Practitioner/Prescriber Signature

Enter in block 35 either “Signature Exception” or “Signature on File”. If this block is left blank, the MA 97 will be rejected and returned to the requestor.

Page | 47


BLOCK NUMBER

BLOCK CODE


36 M Date (MMDDYYYY) Enter the date the MA 97 was completed in an 8-digit format using MMDDYYYY. Do not enter any lines or other symbols between the month, day, and year.

Page | 48

48 APPENDIX B: MA 97 FORM ***** FOR EXAMPLE ONLY ******

APPENDIX B: MA97 FORM (Hyperlink to MA 97 Form)

http://documents.odpconsulting.net/alfresco/d/d/workspace/SpacesStore/8b1634e0-712c-4fc8-8cdc-4eab37c7fe01/MA-97_Outpatient_Service_Auth_Request_Form_and_Instructions.pdf

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NOTE: If there is a line through the field below, that means the field should be left blank.

EXAMPLE ONE

MMDDYYY

Rm. 430 Willow Oak Bldg, P.O. Box 2675 17105

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EXAMPLE TWO

515184844

MMDDYYYY

MMDDYYYY MMDDYYYY

Piatt Place, Room 4900, 301 Fifth Avenue

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51 APPENDIX B: DP1031 FORM ***** FOR EXAMPLE ONLY ******

APPENDIX C: DP1031 Form

9/10

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52 APPENDIX D: Reason Codes on Notices

APPENDIX D: Reason Codes on Notices

NOTE: ODP reviewers and approvers may also use what is called an “E” code. If none of the reason codes listed above describe the determination sufficiently, the ODP approver will use an E-code and create a description associated with that code.

PROMISeTM

REASON CODE

PROMISeTM REASON CODE DESCRIPTION

5500 Individual’s ISP supports service for medical/physical health reasons

5510 Individual’s ISP supports service for behavioral reasons

5520 Individual’s ISP supports service for health and welfare reasons

5530 Individual’s ISP supports service for Other reasons

5531 Individual’s ISP supports service for retirement.

5540 Request for AIS denied because the individual’s needs are temporary; SH approved.

5550 Request denied because ISP does not support medical/physical health reasons.

5560 Request denied because ISP does not support behavioral reasons.

5570 Request denied because ISP does not support health and welfare reasons.

5571 Inappropriate use of this service.

5580 Request denied because there is no supporting ISP documentation.

5590 Request exceeds the criteria for timely filing

5591 Request denied because service was rendered without a prior authorization.

5592 Appeal Filed-Continuation of Service

5593 Service Approved Per Pre-Hearing Conference

5594 Continuance of Service - BHA Final Ruling

5595 BHA approved Reconsideration

5596 Commonwealth Court indefinite continuation of service

5597 Commonwealth Court Discontinuance of Service

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53 APPENDIX E: PRIOR AUTHORIZATION TIMELINE

STEP 1 DAY 1

STEP 2 DAYS

2-6

STEP 3 DAYS

7-9

STEP 4 DAYS 10-11

STEP 5 DAYS 12-13

STEP 6 DAYS 14-18

STEP 7 DAYS 19-21

APPENDIX E: PRIOR AUTHORIZATION TIMELINE FOR SH AND AIS

The SH or AIS prior authorization process should be completed no more than 21 calendar days after the need for the service or services is identified by the ISP Team.

The following pages detail each step in the prior authorization process for SH and AIS services and the maximum number of calendar days it should take to complete each step in the process.

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STEP 1 DAY 1

STEP 2 DAYS

2-6

STEP 3

DAYS 7-9

STEP 4 DAYS 10-11

STEP 5 DAYS 12-13

STEP 6 DAYS 14-18

STEP 7 DAYS 19-21

STEP 2 DAYS

2-6

STEP 1 DAY 1

STEP 3

DAYS 7-9

STEP 4 DAYS 10-11

STEP 5 DAYS 12-13

STEP 6 DAYS 14-18

STEP 7 DAYS 19-21

The Supports Coordinator convenes the ISP Team to discuss the need for SH or AIS services. The ISP Team determines the amount, frequency, and duration of the services.

The provider will communicate the need for SH or AIS services via e-mail to the SC, SC Director, and AE.

a. The provider will include the following information in the e-mail:

► Type of service; ► Level of service; ► Reason service is needed; ► The specific change to the individual’s circumstances that requires additional support; and ► Current staffing pattern for the residential habilitation service location where the individual

resides. b. If either SH or AIS services are needed effective the day of the request, the provider will indicate this

in the provider’s e-mail. ► As an example, additional staffing may be needed effective the day of the request when

there is less than 24 hours notice of a hospital discharge and a health and safety issue has been identified. If the provider has a question about what constitutes an immediate need for staffing, the provider should contact the AE.

► The AE will contact ODP at either (717)-783-4511 or (717) 525-5856 and e-mail

[email protected] no later than the next business day to confirm that SH or AIS services are needed immediately and the RO will determine whether the prior authorization will be made retroactive to the date of the request for SH or AIS services. The AE will send communication to [email protected] and use the following naming convention in the subject line of the e-mail: AE_MCI#_Immediate Need

► The provider, SCO, and AE have until the end of business day 6, from the day the AE e-mailed

ODP with the request, to convene the Team (see Step 2 of the timeline). Steps 3-5 of the timeline should be completed per the timeframes listed. If the decision is made by ODP to approve the request for immediate staffing, this approval will only be up to day 14 of the timeline until the ODP receives necessary documentation listed in the timeline.



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STEP 3 DAYS

7-9

STEP 1 DAY

1

STEP 2 DAYS

2-6

STEP 4 DAYS 10-11

STEP 5 DAYS 12-13

STEP 6 DAYS 14-18

STEP 7 DAYS 19-21

a. If the ISP Team determines that there is a need for SH or AIS services, the SC will update the ISP by documenting the need, number of units, timeframe service is needed, and attach the residential procedure code and the SH or AIS procedure codes to the individual’s ISP.

b. The SC should complete the “Recommended ISP Section” column of the ISP Review

Checklist which indicates where the information listed in the Checklist is recorded in the ISP. The SC should also ensure they document in the ISP all of the 11 topical areas that are located in Section D: Intensive Staffing of the ISP Review Checklist. Section D of the ISP Review Checklist has a column that specifies the ISP section that the information should be documented in.

c. Save Form -> (naming convention: MCI#_ISPChecklist). d. Forward checklist to the AE at the time of submission of the ISP.

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STEP 4 DAYS 10-11

STEP 1 DAY 1

STEP 2 DAYS

2-6

STEP 3 DAYS

7-9

STEP 5 DAYS 12-13

STEP 6 DAYS 14-18

STEP 7 DAYS 19-21

a. The AE will review the ISP that was submitted by the SC to ensure that it includes the required documentation listed in Section D: Intensive Staffing section of the ISP Review Checklist.

b. The AE will send an e-mail to [email protected] indicating their authorization recommendation for SH or AIS services. The following naming convention should be used in the subject line of the e-mail: AE_MCI#_Auth. Recommend The AE will include the following information in the e-mail:

i. Provider’s 13-digit MPI# and service location code

ii. Type of service; iii. Level of service; iv. Reason service is needed; v. The specific change to the individual’s circumstances that requires additional support;

vi. Current staffing pattern for the residential habilitation service location where the individual resides; and

vii. Authorization recommendation THE AE SHOULD NOT AUTHORIZE SH OR AIS SERVICES ON THE ISP UNTIL THE AE HAS BEEN NOTIFIED BY ODP THAT THE SERVICE HAS BEEN APPROVED. If the SH or AIS services are authorized on the individual’s ISP without prior authorization from ODP, the provider will not be paid for rendering this service.

c. Once ODP receives this e-mail from the AE, ODP will begin their prior authorization request review.


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STEP 5 DAYS 12-13

STEP 1 DAY 1

STEP 2 DAYS

2-6

STEP 3 DAYS

7-9

STEP 4 DAYS 10-11

STEP 6 DAYS 14-18

STEP 7 DAYS 19-21

STEP 6 DAYS 14-18

STEP 1 DAY 1

STEP 2 DAYS

2-6

STEP 3 DAYS

7-9

STEP 4 DAYS 10-11

STEP 5 DAYS 12-13

STEP 7 DAYS 19-21

1. The AE will complete the MA 97 form and the DP 1031 attachment and mail the originals to

the address below for loading into PROMISeTM.

DPW, Office of Developmental Programs PO Box 69027 Harrisburg, PA 17106-9027

2. The AE will send an e-mail to [email protected] indicating that the forms have been mailed. The following naming convention should be used in the subject line of the e-mail: AE_MCI#_Forms Mailed.

This e-mail should be sent the day the forms have been mailed and include the providers 13-digit MPI# and service location code in the body of the e-mail.

The Provider, AE, SCO, and the Individual will be notified of ODP’s prior authorization determination via the “Notice of Prior Authorization Decision” letter which is automatically generated and mailed by PROMISeTM. The PROMISeTM prior authorization decision letter will include the PROMISeTM prior authorization number if the service or services have been authorized.


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STEP 7 DAYS 19-21

STEP 1 DAY 1

STEP 2 DAYS

2-6

STEP 3 DAYS

7-9

STEP 4 DAYS 10-11

STEP 5 DAYS 12-13

STEP 6 DAYS 14-18

If the service is approved, the AE will authorize the service on the ISP and the provider will proceed with rendering the service per the service authorization notice in HCSIS. If the request to prior authorize SH or AIS services is denied, the AE will either:

Remove the service from the individuals ISP in HCSIS and notify the individual of the individual’s

right to a fair hearing, copying the provider and SCO. The AE will inform the SC to reconvene the ISP Team to discuss other service options.

Communicate with the SCO and instruct them to remove the service off of the individual’s ISP and request they reconvene the ISP Team to discuss other service options,

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59 APPENDIX F: DP1050 (ISP Review Checklist) – Sample [DO NOT USE]

APPENDIX F: DP1050, ISP Review Checklist www.odpconsulting.net > Resources > ODP Forms, DP 1050 (ISP Review Checklist)

SAMPLE


http://documents.odpconsulting.net/alfresco/d/d/workspace/SpacesStore/568a1b50-8958-4e48-a752-ba261f7d86ee/ISP_Review_Checklist_DP_1050_UF.pdf

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SAMPLE

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SAMPLE

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SAMPLE

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SAMPLE

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SAMPLE

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SAMPLE

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SAMPLE

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SAMPLE

SAMPLE

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