Automated process for providers to submit Prior Authorization (PA) requests to DDS and for DDS

to approve/modify/deny PA request and send automated reply back to the provider

• PAM pilot with two providers in NE Arkansas

• Pilot ran through December 31, 2008

• Pilot identified and resolved problems prior to statewide implementation

• Statewide implementation January 5, 2009

• First PA from Abilities Unlimited Jonesboro entered June 12, 2008 and received PA through PES June 18, 2008

• First PA from St. Francis Area Developmental Center entered June 19 and received PA through PES July 1, 2008

• Process sent to Providers and DDS staff December 1, 2008

• DDS staff trained by EDS/DDS December 9-10, 2008

• Providers are to contact EDS if they need training

• EDS Provider Electronic Solutions (PES)

• Software and Handbook available for download from DMS Website

• https://www.medicaid.state.ar.us/InternetSolution/Provider/software/pes/pesintall.aspx

• If provider is already billing electronically through PES, provider will not need any additional software or passwords to access electronic PA requests

• Problem/Question regarding PES, Contact EDS 501-374-6609

• On Forms menu, select 278 Prior Authorization Request or on the toolbar on the main screen, click on 278 Prior Authorization Request

• Available as batch only – not available interactively

• Five tabs – header 1, header 2, service 1, service 2, service 3

• Requesting Provider ID – click on or enter the correct provider number for the service you are requesting

• PA Reviewing Department – Click on DDS Waiver (N5010000)

• Recipient ID – enter Medicaid number

• Form list, select the recipients entry. If recipient’s information is already part of your list, the remaining recipient fields are filled automatically

• To add recipient to your list, double click on Recipient ID field. A data entry screen opens. Type the necessary data. Select Save. Then select “Select”

• Account # - number that can be assigned by provider as unique recipient ID

• Last Name – verify recipient’s last name

• First Name – verify recipient’s first name

• Type – N/A • Transmission Code – N/A • Control # - N/A • Comment –type in how,

who and when MAPS documents submitted to DDS– i.e. “Hand delivered MAPS forms to Jonesboro Office 7/1/08”

• Primary - Diagnosis Code

• Admit – Diagnosis Code• Other 1 through 6 –

select additional diagnosis codes related to visit, if applicable

• Related Causes – N/A• Incident Date – N/A• State – N/A

• Service Provider ID – from list select NPI or AR Medicaid Provider ID of provider who will render the services

• Request Category – from list click on HS for Health Services Review

• Request Type – from list select type of PA request (Initial or Revised)

• Place of Service – Enter correct code

• Service Type Code – N/A

• Trace # - filled automatically by PES

• Procedure Qualifier – from list click on BO for HCFA Common Procedural Coding System

• Procedure –enter appropriate procedure code and modifier for the service

• Units – N/A leave blank • Amount – total dollar amount

for service

• From DOS – beginning date for PA

• To DOS – ending date for PA

• Modifiers 1 through 4 – if service has modifier, enter appropriate modifiers

• Tooth Numbers – N/A

• Services 2 and 3 – N/A• Note: Cannot use SCD

codes – individual procedure codes must be used

• Example: Service 1 Supportive Living, Service 2 Community Experience, Service 3 Transportation

• When you have finished your PA entry, click on save then close

• If you are submitting PA requests for different provider numbers, you have to complete a separate PA Request for each

• When you submit your PA request, AR Medicaid returns a 278 Prior Authorization Response file

• The response confirms your PA request was accepted and provides the PA number to be used for submitting claims for the service

• If your PA request was rejected, the response guides you in correcting the problem so you can resubmit your request

• Open communication link in tool bar at top of screen

• In far left hand column, highlight 278 Prior Authorization Request

• Click on submission

• At this time, PES cannot accommodate electronic attachments such as MAPS documents

• MAPS documents can be emailed, regular mailed, hand delivered to Waiver Area Manager

• PA requests will be pended until such time as MAPS documents are received and worked by DDS

• DDS Process includes PAM Access, Assigning PA’s, Reports and Reviewing PA’s

• PAM Access – Manager emails Terrell Wade with name and AASIS number for new staff or when staff leave. Terrell will forward password information to the new staff

• Area Manager/designee will run PAM PA report, if needed, to identify the PA Requests for their area

• Area Manager/designee will assign PA Requests received each day to the appropriate Specialist for review

• See PAM Process for details on how to assign a PA Request

• Area Manager/designee will run daily report of PA Requests by county and then assign to the appropriate Specialist for Review

• Specialist will run daily report of new/pending PA’s assigned to them for review. Also will run PA report when PA worked

• See PAM Process for details on how to run reports

• PA Number – PAM pulls current PA number and inserts on PA

• Specialist must change PA number manually

• PAM automatically pends PA Requests after 48 hours

• First Number is last digit of current year

• Next 3 Numbers are the Julian calendar date

• Next 3 Numbers are assigned worker #

• Next 2 Numbers will be the latest number from the running total of PA’s you have approved for that day

• Last Number is 9 for ACS Waiver

• PES will validate key elements including provider number, Medicaid number, procedure codes and modifiers

• Once validated, PA request is routed from PES to PAM for DDS review

• DDS Specialist will access PA request and respond after MAPS review process is completed

• PAM system updates every 20 minutes

• Provider can access DDS PA Response on PES within 20 minutes of DDS entry in PAM system

• PA is posted to MMIS the next business day

• If DDS modifies the dollar amount, start date or stop date on a PA, provider will receive response through PES

• If DDS approves/modifies PA, the provider will receive PA number through PES

• If DDS denies or pends PA, provider will receive response through PES

• Certify in total (Approved)

• Not Certified (Denied)

• Modified (Changed dollar amount and/or PA start/stop date)

• Pend

• Duplicate – Duplicate (PA already exists for dates and procedure code)

• Exceeds Plan Maximums – Exceeds approved amount in MAPS Plan

• Level of Care Not Appropriate – Pervasive level not approved

• Non-Covered Service – service not approved

• Not Medically Necessary – Need Physician’s page/prescription

• Out of Network – used wrong provider number

• Request Forwarded to and Decision Response Forthcoming From an External Review Organization – Request forwarded to POC Review Committee for decision

• Requested Information not Received – additional information needed

• Requires Medical Review- Waiting for DDS Specialist review of MAPS documents

• Testing Not Included – ICF/MR Level of Care not current/expired

• Total dollar amount

• Beginning date of PA

• Ending date of PA

• Any other changes require PA to be denied and resubmitted by provider

• Once PA has been certified in total or denied, no further changes can be made

• If request has both community experience and supplemental support, will set as duplicate PA and one of the PA’s will have to be denied by DDS and entered manually into MMIS by DDS until program fixed to read modifiers

• Same for any other procedure code that is used with and without modifier

• PA will not accept if has overlapping start or stop date with an existing PA

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• Revisions to existing PA’s cannot be made through PAM

• Utilize current process through Specialist to request a revision to an existing PA

• If initial PA approved for 7/1/08 – 08/30/08 and then revision submitted to 9/1/08 – 6/30/09 it can be approved through PAM as would not be change to existing PA

• PA Unit Secretary runs PAM Error Report Daily

• If DDS PA erred off in transmission from PAM to MMIS, PA Secretary notifies Terrell Wade

• Terrell will work with appropriate Area Manager to resolve problem

• PA Unit runs PAM report daily of all processed PA’S

• PA Unit pulls up each PA on MMIS and enters type of service 9