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2. This presentation is to facilitate training of the subject matter in portions of the Virginia Medicaid manuals (and updates) Training material contains only highlights of manuals and is not meant to substitute for or take the place of the Community Mental He
Department of Medical Assistance Services

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1. 1 Department of Medical Assistance Services Virginia, like many other states, seeks ways to control health care spending. The Department of Medical Assistance Services (DMAS) is dedicated to providing all medically necessary care for enrollees while balancing the fiscal needs of Virginia taxpayers. In an effort to address some of the budgetary issues of the Commonwealth, DMAS is looking at our core business efficiencies. Beginning July 1, 2009, DMAS will implement the following provisions to specific community mental health services: Prior Authorizations iEXCHANGE Web Based Prior Authorizations Service Limit Edits in the MMIS Community Mental Health Auditing ContractorVirginia, like many other states, seeks ways to control health care spending. The Department of Medical Assistance Services (DMAS) is dedicated to providing all medically necessary care for enrollees while balancing the fiscal needs of Virginia taxpayers. In an effort to address some of the budgetary issues of the Commonwealth, DMAS is looking at our core business efficiencies. Beginning July 1, 2009, DMAS will implement the following provisions to specific community mental health services: Prior Authorizations iEXCHANGE Web Based Prior Authorizations Service Limit Edits in the MMIS Community Mental Health Auditing Contractor

2. 2 This presentation is to facilitate training of the subject matter in portions of the Virginia Medicaid manuals (and updates) Training material contains only highlights of manuals and is not meant to substitute for or take the place of the Community Mental Health Rehabilitative Services Manual. For a complete copy of manual:

3. 3 Objectives of Today?s Training

4. 4 All OF THE COMMUNITY MENTAL HEALTH SERVICES?.. have four specific components: These we are discussing will be requiring PAThese we are discussing will be requiring PA

5. 5 Intensive Community Treatment (H0039)

6. 6 Intensive Community Treatment (ICT) is?. an array of mental health services?. for adults with a serious emotional illness who need intensive levels of support & service in their natural environment to permit or enhance functioning in the community. SERVICE DEFINITION:

7. 7 Intensive Community Treatment (ICT) has been designed to be provided through a designated multi-disciplinary team of mental health professionals It is available either directly or on call 24 hours per day, seven days per week, 365 days per year. SERVICE DEFINITION cont?d.

8. 8 Eligibility Criteria: The individuals must meet one or more of the following criteria: Is at high-risk for psychiatric hospitalization or for becoming/remaining homeless or requires intervention by the mental health or criminal justice system due to inappropriate social behavior. Has a history (3 months or more) of a need for intensive mental health treatment or treatment for serious mental illness & chemical addiction and demonstrates a resistance to seek out and utilize appropriate treatment options.

9. 9 Co-occurring Mental Health and Substance Abuse Disorders If an individual has co-occurring mental health and substance abuse disorders, integrated treatment for both disorders is allowed within ICT services as long as the treatment for the substance abuse condition is intended to positively impact the mental health condition.

10. 10

11. 11 Assessment Code for ICT The Assessment billing code is H0032, Modifier U9 (available August 1, 2009) Assessment codes never require PA Limit is 2 per provider per fiscal year Used for new and existing recipients (initial and reassessment) Provider bills assessment code with modifier for 1 unit. Rate is the current unit rate for the service $139/unit (rural) $153/unit (urban) $139/unit (rural) $153/unit (urban) 1 unit $139/unit (rural) $153/unit (urban) 1 unit

12. 12 For New Admissions: Individuals that have not had treatment between January 1, 2009 and July 31, 2009 are considered new admission cases. Must bill the appropriate assessment code (with modifier) to determine needs (start Aug 1, 2009 The provider gets the 5 units without PA only first time in treatment as of 8/1/09 (New admits) In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit

13. 13 New Admissions, cont?d. If services are to continue (beyond the allowable units without PA), provider must contact KePRO to obtain PA. PA will be allowed for up to 6 month increments Provider bills service using the treatment code after assessment is completed (after the allowable service limits are used, if no PA the claim will deny)

14. 14 For Existing Recipients: Individuals currently receiving services are defined as those that have been receiving service on or after January 1, 2009. System edit will look to see if previous service claims are found, classify as existing recipient and PA will be required for services - there is no 5 unit service limit for ?existing individuals? May bill for ?reassessment? to determine continued need for services (maximum of 2 per provider per fiscal year for each service and does not require PA) In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit When re-assessment code is billed? PA will be required from that date forward. All existing client will need PA by 1/1/10. The 2 assessment paid per FY include a reassessment. In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit When re-assessment code is billed? PA will be required from that date forward. All existing client will need PA by 1/1/10. The 2 assessment paid per FY include a reassessment.

15. 15 Prior Authorization Process for ICT Changes to the Program Effective August 1, 2009, Prior Authorization will be required for Intensive Community Treatment for individuals currently receiving treatment, as well as new cases. This will change from a self-approval / authorization process, currently performed by the LMHP provider, to a prior authorization process conducted by KePRO using DMAS criteria. KePRO will be describing the specific details regarding the PA request process.

16. 16 Service Units & Maximum Service Limitations A unit equals one hour. There is a limit of 130 units annually. Starting August 1, 2009 and each July 1st thereafter, all service limits will be set to zero. The fiscal year period for the start up of this process will be August 1, 2009 through June 30, 2010. All subsequent fiscal years will be July 1 through June 30. As of August 1 there will be a payment edit that cuts back or denies payment for any service billed beyond 130 units. The 130 units allowed per FY includes the 5 that are allowed without PA. The 130 units allowed per FY includes the 5 that are allowed without PA.

17. 17 Prior Authorization Requirements: For new clients admitted on or after August 1, 2009 ? (after initial assessment) providers have five units to begin providing service. For any services to be paid beyond five units a PA is required. For clients currently receiving services, the provider should request PA after their next 6 month ?re-assessment review? for continued service. For continued payment all current clients must have a PA by January 1, 2010. The 5 units for new clients is not renewable annuallyThe 5 units for new clients is not renewable annually

18. 18 Prior Authorization Requirements: The provider will need to submit recipient?s demographic information & also include the following: Procedure Code ? H0039 PA Service Type - 0650 Number of units requested From & Through dates (span 6 months)

19. 19 Initial Review (New Recipient to Provider): For ICT services, individuals must meet the Diagnostic Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnostic criteria for an Axis I or Axis II Mental Health Disorder. (DMAS requirement) If this is a dual diagnosis of Mental Health (MH) and SA, services must be integrated.

20. 20 ? The individual must meet one or more of the following criteria (describe symptoms that interfere with primary activities of daily living [ADLs] that prevent independent functioning and intensive treatment and support): o Is at high risk for psychiatric hospitalization or for becoming or remaining homeless, or require intervention by the mental health or criminal justice system due to inappropriate social behavior; ? Describe risk ? Describe problems in ability to form relationships ? Describe role performance at work, school and in caring for dependents ? Describe support system or lack thereof; and/or Initial Review (New Recipient to Provider):

21. 21 o Has a history (three months or more) of a need for intensive mental health treatment or treatment for serious mental illness and substance abuse and demonstrates a resistance to seek out and utilize traditional treatment options. ? Describe need ? Describe resistance to treatment Initial PA Request cont?d.

22. 22 Initial PA Request cont?d. KePRO will prior authorize services in 6 month increments Initial requests will be approved (based on the medical necessity) for up to 6-months for up to one half the service units available. Denials of services for medical necessity may be resubmitted at a later date when the individual meets criteria

23. 23 PA For Continued Treatment: Continued PA is required within 30 days prior to end of previous authorization DSM- IV-TR, Axis I Mental Health Disorder is required. V codes are not acceptable as a stand alone diagnoses. Within past month: Describe symptoms and behaviors Describe recipient?s functioning to include: Social/interpersonal behavior Ability to manage IADLs Medication compliance (or lack) Program Compliance

24. 24 PA For Continued Treatment: Continued service requests will be approved for up to 6-month increments for the remaining annual service limit. PA requests after denials of services for medical necessity may be resubmitted at a later date when the individual meets criteria Providers will begin receiving their official authorization determinations (denials or approvals) via the First Health automated letter generation process. The letter generated from First Health will include a PA number. This number must be used when submitting claims. Claims submitted for services that exceed the units authorized will be denied. Providers will begin receiving their official authorization determinations (denials or approvals) via the First Health automated letter generation process. The letter generated from First Health will include a PA number. This number must be used when submitting claims. Claims submitted for services that exceed the units authorized will be denied.

25. 25

26. 26

27. 27 Psychosocial Rehabilitation (H2017) SERVICE DEFINITION: Psychosocial Rehabilitation Services are provided to groups of adult individuals in a nonresidential setting. These services include assessment, education to teach the patient about the diagnosed mental illness and appropriate medications to avoid complication and relapse, opportunities to learn and use independent living skills and to enhance social and interpersonal skills within a supportive and normalizing program structure and environment. Programs must be 2 or more hours per day

28. 28 Eligibility Criteria: The individual must demonstrate: clinical necessity for the service arising from a condition due to mental behavioral emotional illness That results in significant functional impairments in major life activities.

29. 29 Eligibility Criteria cont?d. Individuals must meet at least two of the following on a continuing or intermittent basis?.. Have difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or homelessness because of conflicts with family or community.

30. 30 Eligibility Criteria cont?d. Require help in basic living skills such as?. maintaining personal hygiene preparing food & maintaining adequate nutrition managing finances to such a degree that health or safety is jeopardized.

31. 31 Eligibility Criteria cont?d. Exhibit such inappropriate behavior that repeated interventions by the mental health, social services or judicial system are necessary. Exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior.

32. 32 Eligibility Criteria cont?d. Individuals must meet one of the following?.. Have had long-term or repeated psychiatric hospitalization; or Lack daily living skills & interpersonal skills; or

33. 33 Eligibility Criteria cont?d. Have a limited or nonexistent support system or Be unable to function in the community without intensive intervention or Require long-term services to be maintained in the community

34. 34 Co-occurring Mental Health and Substance Abuse Disorders If an individual has co-occurring mental health and substance abuse disorders, integrated treatment for both disorders is allowed within psychosocial rehabilitation services as long as the treatment for the substance abuse condition is intended to positively impact the mental health condition.

35. 35 Required Activities:

36. 36 Assessment Code for PSR The Assessment billing code is H0032, U6 Assessment codes never require PA Limit is 2 per provider per fiscal year Used for new and existing recipients (initial and reassessment) Will be available 8/1/2009 Provider bills assessment code with modifier for 1 unit. Rate is the current unit rate for the service $24.23/unit

37. 37 For New Admissions: Individuals that have not had treatment between January 1, 2009 and July 31, 2009 are considered new admission cases. Must bill the appropriate assessment code (with modifier) to determine needs The provider gets the 10 units without PA only first time in treatment as of 8/1/09 (New admits) Provider bills using treatment code-- after assessment is completed (after allowable service limits used, if no PA the claim will deny) In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit

38. 38 For Existing Recipients: Individuals currently receiving services are defined as those that have been receiving service on or after January 1, 2009. System edit will look to see if previous service claims are found, classify as existing recipient and PA will be required for services - there is no 10 unit service limit for ?existing individuals? May bill for ?reassessment? to determine continued need for services (2 per provider per fiscal year for each service and does not require PA) In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit When re-assessment code is billed? PA will be required from that date forward. All existing client will need PA by 1/1/10. The 2 assessment paid per FY include a reassessment. In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit When re-assessment code is billed? PA will be required from that date forward. All existing client will need PA by 1/1/10. The 2 assessment paid per FY include a reassessment.

39. 39 Prior Authorization Process for PSR Changes to the Program Effective August 1, 2009, Prior Authorization will be required for PSR for individuals currently receiving treatment, as well as new cases. This will change from a self-approval / authorization process, currently performed by the LMHP provider, to a prior authorization process conducted by KePRO. KePRO will be describing the specific details regarding the PA request process.

40. 40 Service Units & Maximum Service Limitations:

41. 41 Prior Authorization Requirements: For new clients? after initial assessment providers have ten units to begin providing service. For any services to be paid beyond ten units a PA is required. For clients currently receiving services, the provider should request PA at their next 6 month ?re-assessment review? for continued service. For continued payment all current clients must have a PA by January 1, 2010. The 10 units is not renewable annuallyThe 10 units is not renewable annually

42. 42 Prior Authorization Requirements: The provider will need to submit recipients demographic information & also include the following: Procedure Code ? H2017 PA Service Type - 0650 Number of units requested From & Through dates (span 6 months) (*Must be registered with i-EXCHANGE to submit requests)

43. 43 Initial Review (New Recipient to Provider):

44. 44 Initial PA Request cont?d. Describe symptoms/severity of illness: Individual must exhibit significant functional impairments in major life activities due to a mental, behavioral, or emotional illness. Describe how individual meets two of the following: Have difficulty establishing or maintaining normal interpersonal relationships to the degree they are at risk of hospitalization, homelessness because of conflicts with family or community, or;

45. 45 Initial PA Request cont?d. Have behaviors that require repeated interventions by the mental health, social services or judicial system; or Be unable to recognize personal danger or significantly inappropriate social behavior; or Require help in basic living skills to such a degree that health or safety is jeopardized.

46. 46 Initial PA Request cont?d. Describe how individual meets one of the following: Have experienced long-term or repeated psychiatric hospitalizations; or Lack daily living skills and interpersonal skills; or Have limited or non-existent support system; or Be unable to function in community without intensive intervention; or Require long-term services to be maintained in the community.

47. 47 Initial PA Request cont?d. KePRO will prior authorize services in 6 month increments Initial requests will be approved (based on the medical necessity) for up to 6-months for up to one half the service units available. Denials of services for medical necessity may be resubmitted at a later date when the individual meets criteria

48. 48 PA For Continued Treatment: Continued PA is required prior to end of previous authorization ? For PR, individuals must meet DSM-IV diagnostic criteria for an Axis I or Axis II Mental Health Disorder. V codes are not acceptable as stand alone diagnoses

49. 49 PA For Continued Treatment: MUST describe how continues to meet two of the following: Have difficulty establishing or maintaining normal interpersonal relationships to the degree they are at risk of hospitalization, homelessness, or Have behaviors that require repeated interventions by the mental health, social services or judicial system; or

50. 50 Be unable to recognize personal danger or significantly inappropriate social behavior; or Require help in basic living skills to such a degree that health or safety is jeopardized. PA For Continued Treatment:

51. 51 PA For Continued Treatment: Individual must continue to meet one of the following: Have experienced long-term or repeated psychiatric hospitalizations; or Lack daily living skills and interpersonal skills; or Have limited or non-existent support system; or Be unable to function in the community without intensive intervention; or Require long-term services to be maintained in the community.

52. 52 PA For Continued Treatment: KePRO will approve continued service requests (based on PA criteria) for up to 6-month increments for the remaining annual service limit. PA requests after denials of services for medical necessity may be resubmitted at a later date when the individual meets criteria Providers will begin receiving their official authorization determinations (denials or approvals) via the First Health automated letter generation process. The letter generated from First Health will include a PA number. This number must be used when submitting claims. Claims submitted for services that exceed the units authorized will be denied. Providers will begin receiving their official authorization determinations (denials or approvals) via the First Health automated letter generation process. The letter generated from First Health will include a PA number. This number must be used when submitting claims. Claims submitted for services that exceed the units authorized will be denied.

53. 53

54. 54 Mental Health Support Services (H0046)

55. 55 Service Definition: Training and supports to enable individuals to achieve and maintain community stability & independence in the most appropriate, least restrictive environment. Services may be authorized for six consecutive months.

56. 56 A Minimum age for MHSS The treatment focus is on assisting the client with independent living skills training and is therefore appropriate for recipients that are a minimum of 16 years or older.

57. 57 Eligibility Criteria: Individuals must demonstrate a clinical need for this service arising from a condition due to mental, behavioral, or emotional illness which results in significant functional impairments in major life activities.

58. 58 Eligibility Criteria cont?d. The individual must meet at least two of the following on a continuing or intermittent basis: Experiencing difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization, homelessness, because of conflicts with family or community, or

59. 59 Eligibility Criteria cont?d. Exhibit such inappropriate behavior that repeated interventions by the mental health, social services, or judicial system are necessary. Exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior.

60. 60 Eligibility Criteria cont?d. Require help in basic living skills, such as?. maintaining personal hygiene preparing food & maintaining adequate nutrition or managing finances to such a degree that health or safety is jeopardized.

61. 61 Eligibility Criteria cont?d. Co-Occurring Mental Health and Substance Abuse Disorders: Integrated treatment for both disorders is allowed as long as the treatment for the substance abuse condition is intended to positively impact the mental health condition. The impact of the substance abuse condition on the mental health condition must be documented in the assessment, the ISP, and the progress notes.

62. 62 Required Activities:

63. 63 Assessment Code for MHSS The Assessment billing code is H0032, U8 Assessment codes never require PA Limit is 2 per provider per fiscal year Used for new and existing recipients (initial and reassessment) Will be available 8/1/2009 Provider bills assessment code with modifier for 1 unit. Rate is the current unit rate for the service $83/ 1 unit (rural) $91/1 unit (urban) $139/unit (rural) $153/unit (urban) 1 unit $139/unit (rural) $153/unit (urban) 1 unit

64. 64 For New Admissions: Individuals that have not had treatment between January 1, 2009 and July 31, 2009 are considered new admission cases. Must bill the appropriate assessment code (with modifier) to determine needs The provider gets the 5 units without PA only first time in treatment as of 8/1/09 (New admits) In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit

65. 65 For New Admissions, cont?d. If services are to continue (beyond the allowable units without PA), provider must contact KePRO to obtain PA. PA will be allowed for up to 6 month increments Provider bills using treatment code-- after assessment is completed (after allowable service limits used, if no PA the claim will deny)

66. 66 For Existing Recipients: Individuals currently receiving services are defined as those that have been receiving service on or after January 1, 2009. System edit will look to see if previous service claims are found, classify as existing recipient and PA will be required for services - there is no 5 unit service limit for ?existing individuals? May bill for ?reassessment? to determine continued need for services (a maximum of 2 per provider per fiscal year for each service and does not require PA) In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit When re-assessment code is billed? PA will be required from that date forward. All existing client will need PA by 1/1/10. The 2 assessment paid per FY include a reassessment. In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit When re-assessment code is billed? PA will be required from that date forward. All existing client will need PA by 1/1/10. The 2 assessment paid per FY include a reassessment.

67. 67 Prior Authorization Process for MHSS Changes to the Program Effective August 1, 2009, Prior Authorization will be required for MHSS for individuals currently receiving treatment, as well as new cases. This will change from a self-approval / authorization process, currently performed by the LMHP provider, to a prior authorization process conducted by KePRO. KePRO will be describing the specific details regarding the PA request process.

68. 68 Service Units & Limitations: Services are limited annually to 372 units per year. Starting August 1, 2009 and each July 1st thereafter, all service limits will be set to zero. The fiscal year period for the start up of this process will be August 1, 2009 through June 30, 2010. All subsequent fiscal years will be July 1 through June 30. One unit is 1 - 2.99 hours Two units= 3 - 4.99 hours Three units= 5 - 6.99 hours Four units= 7+ hours (Time may be accumulated to a billable unit)

69. 69 Prior Authorization Requirements: For new clients? after assessment --providers have five units to begin providing service. For any services to be paid beyond five units a PA is required. For clients currently receiving services, the provider should request PA at their next 6 month ?re-assessment review? for continued service. For continued payment all current clients must have a PA by January 1, 2010. The 5 units is not renewable annuallyThe 5 units is not renewable annually

70. 70 Prior Authorization Requirements: The provider will need to submit recipients demographic information & also include the following: Procedure Code ? H0046 PA Service Type - 0650 Number of units requested From & Through dates (span 6 months)

71. 71 Initial Review (New Recipient to Provider):

72. 72 Initial PA Request cont?d. Describe symptoms/severity of illness: Individual must exhibit significant functional impairments in major life activities due to a mental, behavioral, or emotional illness. Describe how meets two of the following: Have difficulty establishing or maintaining normal interpersonal relationships to the degree they are at risk of hospitalization, homelessness, or isolation from social supports Have behaviors that require repeated interventions by the mental health, social services or judicial system; or

73. 73 Initial PA Request cont?d. Be unable to recognize personal danger or significantly inappropriate social behavior; or Require help in basic living skills to such a degree that health or safety is jeopardized. KePRO will prior authorize services in 6 month increments Initial requests will be approved (based on the medical necessity) for up to 6-months for up to one half the service units available. PA requests after denials of services for medical necessity may be resubmitted at a later date when the individual meets criteria

74. 74 PA For Continued Treatment (Same Provider): Continued PA is required prior to end of previous authorization ? For MHSS, individuals must meet DSM-IV diagnostic criteria for an Axis I or Axis II Mental Health Disorder. V codes are not acceptable as stand alone diagnoses

75. 75 PA For Continued Treatment: MUST continue to meet two of the following: Have difficulty establishing or maintaining normal interpersonal relationships to the degree they are at risk of hospitalization, homelessness, or isolation from social supports; Have behaviors that require repeated interventions by the mental health, social services or judicial system; or Be unable to recognize personal danger or significantly inappropriate social behavior; or Require help in basic living skills to such a degree that health or safety is jeopardized.

76. 76 PA For Continued Treatment: Continued service requests will be approved for up to 6-month increments for the remaining annual service limit. PA requests after denials of services for medical necessity may be resubmitted at a later date when the individual meets criteria

77. 77

78. 78 DMAS RESOURCES TO CHECK SERVICE LIMITS MediCall Automated Voice Response System A telephone voice response system to: Confirm recipient eligibility status; Obtain up-to-date status on a claim; and Check on the status of recent claim remittances. Not for use by recipients.

79. 79 Resources to Check Service Limits Accessing the system: Have a currently active Medicaid provider number Limited number of inquires per session Call either a toll-free or local Richmond number 1-800-772-9996 - Toll-free 1-800-884-9730 - Toll-free 804- 965-9732 ? Richmond Area

80. 80 2. Automated Response System (ARS) An Internet Web-enabled tool to: Access current enrollee eligibility information, service limits, claim status, prior authorizations, provider check status Inquires submitted in real-time quickly and conveniently

81. 81 Resources to Check Service Limits Accessing the System: For current Medicaid and FAMIS providers No limit on the number of inquiries per session Need internet connect, PC, and a web browser https://uac.fhsc.com/uac/pages/unsecured/common/home.jsf

82. 82 3. HELPLINE A telephonic (live response) tool to assist Providers in: Interpreting Medicaid policy and procedures; and in Resolving problems with individual claims Do not use the HELPLINE for recipient eligibility verification and eligibility questions Resources to Check Service Limits

83. 83 3. HELPLINE Accessing the System: Available Monday through Friday from 8:30 a.m. to 4:30 p.m., except on State holidays Medicaid Provider number must accompany all inquiries For providers only - do not give the HELPLINE numbers to recipients. Local and Toll-free numbers: 804-786-6273 - Richmond Area and out-of-state long distance 1-800-552-8627 - In-state long distance (toll free) Resources to Check Service Limits

84. 84 Therapeutic Day Treatment for Children & Adolescents (H0035) SERVICE DEFINITION Psychotherapeutic interventions combined with medication education and mental health treatment Offered in programs of 2 or more hours per day with groups of children/adolescents

85. 85 TDT Eligibility Criteria: Individual demonstrates a: Mental, behavioral or emotional illness resulting in significant functional impairments in major life activities Impairment has become more disabling over time Require significant intervention services offered over a period of time that are: Supportive & Intensive Determination of significant disability should be based upon consideration of the social functioning of most children who are the same age. The disability must have become more disabling over time and must require significant intervention through services that are supportive, intensive, and offered over a protracted period of time in order to provide therapeutic intervention. Determination of significant disability should be based upon consideration of the social functioning of most children who are the same age. The disability must have become more disabling over time and must require significant intervention through services that are supportive, intensive, and offered over a protracted period of time in order to provide therapeutic intervention.

86. 86 Individuals must meet at least two: 1. Difficulty in establishing or maintaining normal interpersonal relationships, at risk of hospitalization or out-of-home placement because of conflicts with family/community 2. Exhibit inappropriate behavior: Repeated interventions in the community- by mental health agencies by social service agencies by judicial system TDT Eligibility Criteria:

87. 87 3. Exhibit difficulty in cognitive ability: Unable to recognize??... personal danger OR significantly inappropriate social behavior This service is designed for youth who meet one of the following: Require year-round treatment in order to sustain behavioral or emotional gains, or TDT Eligibility Criteria cont?d.

88. 88 Have behavior/emotional problems so severe they cannot be handled in self-contained or special classrooms (ED) without this programming during the school day or as a supplement to the school day/year, or Would otherwise be placed on homebound instruction because of behavior, or TDT Eligibility Criteria:

89. 89 or Have deficits in: social skills peer relations dealing with authority are hyperactive have poor impulse control are extremely depressed marginally connected with reality or TDT Eligibility Criteria cont?d.

90. 90 or Preschool child in an enrichment & early intervention program & cannot function in this program (due to the severity of their emotional/behavioral problems) without these additional services. TDT Eligibility Criteria cont?d.

91. 91

92. 92 Assessment Code for TDT The Assessment billing code is H0032 Modifier U7 Assessment codes never require PA Limit is 2 per provider per fiscal year Used for new and existing recipients (initial and reassessment) Will be available 8/1/2009 Provider bills assessment code with modifier for 1 unit. Rate is the current unit rate for the service $38.05/unit $139/unit (rural) $153/unit (urban) 1 unit $139/unit (rural) $153/unit (urban) 1 unit

93. 93 For New Admissions: Individuals that have not had treatment between January 1, 2009 and July 31, 2009 are considered new admission cases. Must bill the appropriate assessment code (with modifier) to determine needs The provider gets the 5 units without PA only first time in treatment as of 8/1/09 (New admits) In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit

94. 94 If services are to continue (beyond the allowable units without PA), provider must contact KePRO to obtain PA. PA will be allowed for up to 6 month increments Provider bills using treatment code-- after assessment is completed (after allowable service limits used, if no PA the claim will deny) For New Admissions:

95. 95 For Existing Recipients: Individuals currently receiving services are defined as those that have been receiving service on or after January 1, 2009. System edit will look to see if previous service claims are found, classify as existing recipient and PA will be required for services - there is no 5 unit service limit for ?existing individuals? May bill for ?reassessment? to determine continued need for services (2 per provider per fiscal year for each service and does not require PA) In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit When re-assessment code is billed? PA will be required from that date forward. All existing client will need PA by 1/1/10. The 2 assessment paid per FY include a reassessment. In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit When re-assessment code is billed? PA will be required from that date forward. All existing client will need PA by 1/1/10. The 2 assessment paid per FY include a reassessment.

96. 96 Prior Authorization Process for TDT Changes to the Program Effective August 1, 2009, Prior Authorization will be required for TDT for individuals currently receiving treatment, as well as new cases. This will change from a self-approval / authorization process, currently performed by the LMHP provider, to a prior authorization process conducted by KePRO. KePRO will be describing the specific details regarding the PA request process.

97. 97 Service Units & Limitations: Services are limited annually to 780 units per year. Starting August 1, 2009 and each July 1st thereafter, all service limits will be set to zero. The fiscal year period for the start up of this process will be August 1, 2009 through June 30, 2010. All subsequent fiscal years will be July 1 through June 30. One Unit of service is defined as a minimum of two hours on a given day.

98. 98 Prior Authorization Requirements: For new clients? after assessment --providers have five units to begin providing service. For any services to be paid beyond five units a PA is required. For clients currently receiving services, the provider should request PA at their next review for continued service. For continued payment all current clients must have a PA by January 1, 2010. The 5 units is not renewable annuallyThe 5 units is not renewable annually

99. 99 Prior Authorization Requirements: The provider will need to submit recipients demographic information & also include the following: Procedure Code ? H0035 PA Service Type - 0650 Number of units requested From & Through dates (span 6 months)

100. 100 Initial Review (New Recipient to Provider): ? For TDT, individuals must DSM IV Axis I Mental Health Disorder. V codes are not acceptable as stand alone diagnoses. ? If there is a dual diagnosis of Mental Health (MH) and SA, services must be integrated. ? Confirmation of face-to-face diagnostic assessment by a QMHP, with approval by a LMHP prior to start of service. ? Confirm plan for a minimum of two hours per day programming with a minimum of two therapeutic activities daily.

101. 101 Initial PA Request cont?d. Describe symptoms/severity of illness: Children must exhibit significant functional impairments in major life activities due to a mental, behavioral, or emotional illness, which has become more disabling over time. Must describe how meets two of the following: Have difficulty establishing or maintaining normal interpersonal relationships to the degree they are at risk of hospitalization or out of home placement; or Have behaviors that require repeated interventions by the mental health, social services or judicial system; or Be unable to recognize personal danger or significantly inappropriate social behavior.

102. 102 Must describe how meets one of the following: Requires year-round treatment to sustain behavioral or emotional gains; or Have problems so severe cannot be maintained in self-contained or resource (ED) classrooms without programming during the school day or as supplement to school day; or Would otherwise be placed on homebound instruction due to severe emotional or behavioral problems that interfere with learning; or Have emotional or behavioral problems so severe the child cannot function in preschool enrichment or early intervention programs without additional services. Initial PA Request cont?d.

103. 103 Initial PA Request cont?d. KePRO will prior authorize services in 6 month increments Initial requests will be approved (based on the medical necessity) for up to 6-months for up to one half the service units available. PA requests after denials of services for medical necessity may be resubmitted at a later date when the individual meets criteria

104. 104 PA For Continued Treatment: ? ?

105. 105 PA For Continued Treatment:

106. 106 PA For Continued Treatment:

107. 107 PA For Continued Treatment:

108. 108 PA For Continued Treatment: Continued service requests will be approved for up to 6-month increments for the remaining annual service limit. PA requests after denials of services for medical necessity may be resubmitted at a later date when the individual meets criteria Providers will begin receiving their official authorization determinations (denials or approvals) via the First Health automated letter generation process. The letter generated from First Health will include a PA number. This number must be used when submitting claims. Claims submitted for services that exceed the units authorized will be denied. Providers will begin receiving their official authorization determinations (denials or approvals) via the First Health automated letter generation process. The letter generated from First Health will include a PA number. This number must be used when submitting claims. Claims submitted for services that exceed the units authorized will be denied.

109. 109

110. 110 Day Treatment / Partial Hospitalization (H0035)

111. 111 DT/PH is a combination of diagnostic, medical, psychiatric, psychosocial and psycho-educational treatment modalities for individuals age 21 & older with serious mental disorders who require coordinated, intensive, comprehensive, and multidisciplinary treatment who do not require inpatient treatment. Services are offered in programs of two or more hours per day provided to groups of individuals in a non-residential setting. SERVICE DEFINITION

112. 112 Eligibility Criteria: The individual must demonstrate: clinical necessity for the service arising from a condition due to mental behavioral emotional illness That results in significant functional impairments in major life activities.

113. 113 Eligibility Criteria cont?d. Individuals must meet at least two of the following on a continuing or intermittent basis?.. Have difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or homelessness or conflicts with family or community.

114. 114 Eligibility Criteria cont?d. Require help in basic living skills such as?. maintaining personal hygiene preparing food & maintaining adequate nutrition managing finances to such a degree that health or safety is jeopardized.

115. 115 Eligibility Criteria cont?d. Exhibit such inappropriate behavior that repeated interventions by the mental health, social services or judicial system are necessary. Exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior.

116. 116 Co-occurring Mental Health and Substance Abuse Disorders If an individual has co-occurring mental health and substance abuse disorders, integrated treatment for both disorders is allowed within psychosocial rehabilitation services as long as the treatment for the substance abuse condition is intended to positively impact the mental health condition.

117. 117 Required Activities:

118. 118 Assessment Code for DT/PH The Assessment billing code is H0032, Modifier U7 Assessment codes never require PA Limit is 2 per provider per fiscal year Used for new and existing recipients (initial and reassessment) Will be available 8/1/2009 Provider bills assessment code with modifier for 1 unit. Rate is the current unit rate for the service $38.05/unit $139/unit (rural) $153/unit (urban) 1 unit $139/unit (rural) $153/unit (urban) 1 unit

119. 119 For New Admissions: Individuals that have not had treatment between January 1, 2009 and July 31, 2009 are considered new admission cases. Must bill the appropriate assessment code (with modifier) to determine needs The provider gets the 5 units without PA only first time in treatment as of 8/1/09 (New admits) In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit

120. 120 If services are to continue (beyond the allowable units without PA), provider must contact KePRO to obtain PA. PA will be allowed for up to 6 month increments Provider bills using treatment code-- after assessment is completed (after allowable service limits used, if no PA the claim will deny) For New Admissions:

121. 121 For Existing Recipients: Individuals currently receiving services are defined as those that have been receiving service on or after January 1, 2009. System edit will look to see if previous service claims are found, classify as existing recipient and PA will be required for services - there is no 5 unit service limit for ?existing individuals? May bill for ?reassessment? to determine continued need for services (2 per provider per fiscal year for each service and does not require PA) In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit When re-assessment code is billed? PA will be required from that date forward. All existing client will need PA by 1/1/10. The 2 assessment paid per FY include a reassessment. In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit When re-assessment code is billed? PA will be required from that date forward. All existing client will need PA by 1/1/10. The 2 assessment paid per FY include a reassessment.

122. 122 Prior Authorization Process for DT/PH Changes to the Program Effective August 1, 2009, Prior Authorization will be required for DT/PHP for individuals currently receiving treatment, as well as new cases. This will change from a self-approval / authorization process, currently performed by the LMHP provider, to a prior authorization process conducted by KePRO. KePRO will be describing the specific details regarding the PA request process.

123. 123 Service Units & Service Limitations:

124. 124 Prior Authorization Requirements: For new clients? after assessment --providers have five units to begin providing service. For any services to be paid beyond five units a PA is required. For clients currently receiving services, the provider should request PA at their next 6 month ?re-assessment review? for continued service. For continued payment all current clients must have a PA by January 1, 2010. The 5 units are not renewable annuallyThe 5 units are not renewable annually

125. 125 Prior Authorization Requirements: The provider will need to submit recipients demographic information & also include the following: Procedure Code ? H0035 PA Service Type - 0650 Number of units requested From & Through dates (span 6 months)

126. 126 Initial Review (New Recipient to Provider):

127. 127 Initial PA Request cont?d. Describe symptoms/severity of illness: Individual must exhibit significant functional impairments in major life activities due to a mental, behavioral, or emotional illness. Describe how meets two of the following: Have difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or homelessness because of conflicts with family or community; or

128. 128 Initial PA Request cont?d. Require help in basic living skills such as maintaining personal hygiene, preparing food and maintaining adequate nutrition, or managing finances to such a degree that health or safety is jeopardized. Have behaviors that require repeated interventions by mental health, social services, or judicial system are necessary. Be unable to recognize personal danger or recognize significantly inappropriate social behavior.

129. 129 Initial PA Request cont?d. KePRO will prior authorize services in 6 month increments Initial requests will be approved (based on the medical necessity) for up to 6-months for up to one half the service units available. PA requests after denials of services for medical necessity may be resubmitted at a later date when the individual meets criteria

130. 130 PA For Continued Treatment: Continued PA is required within 30 days prior to end of previous authorization ? For DT/ PH, individuals must DSM IV Axis I or Axis II Mental Health Disorder. V codes are not acceptable as stand alone diagnoses ?

131. 131 PA For Continued Treatment: MUST continue to describe how the individual meets two of the following: Have difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or homelessness because of conflicts with family or community; or Require help in basic living skills such as maintaining personal hygiene, preparing food and maintaining adequate nutrition, or managing finances to such a degree that health or safety is jeopardized.

132. 132 PA For Continued Treatment cont?d. ? Have behaviors that require repeated interventions by mental health, social services, or judicial system are necessary. ? Be unable to recognize personal danger or recognize significantly inappropriate social behavior.

133. 133 PA For Continued Treatment: KePRO will approve continued service requests (based on PA criteria) for up to 6-month increments for the remaining annual service limit. PA requests after denials of services for medical necessity may be resubmitted at a later date when the individual meets criteria Providers will begin receiving their official authorization determinations (denials or approvals) via the First Health automated letter generation process. The letter generated from First Health will include a PA number. This number must be used when submitting claims. Claims submitted for services that exceed the units authorized will be denied. Providers will begin receiving their official authorization determinations (denials or approvals) via the First Health automated letter generation process. The letter generated from First Health will include a PA number. This number must be used when submitting claims. Claims submitted for services that exceed the units authorized will be denied.

134. 134

135. 135 Mental Health Case Management (H0023)

136. 136 Service Definition Mental health case management services assist individual children and adults in accessing needed medical, psychiatric, social, educational, vocational, and other supports essential to meeting basic needs. This comes directly from the service definition of Mental Health Case Management. Although this service has a wealth of information, today we are going to concentrate on assessment, ISP, duties and quarterly reports. Hand outs are included to provide further detail on areas briefly covered or omitted entirely from today?s power point presentation.This comes directly from the service definition of Mental Health Case Management. Although this service has a wealth of information, today we are going to concentrate on assessment, ISP, duties and quarterly reports. Hand outs are included to provide further detail on areas briefly covered or omitted entirely from today?s power point presentation.

137. 137 Eligibility Criteria: ?There must be documentation of the presence of serious mental illness for an adult individual or of serious emotional disturbance or a risk of serious emotional disturbance for a child or adolescent. ?The individual must require case management as documented on the ISP, which is developed by a qualified mental health case manager and based on an appropriate assessment and supporting documentation. ?To receive case management services, the individual must be an ?active client,? which means that the individual has a ISP in effect which requires regular direct or client-related contacts and communication or activity with the client, family, service providers, significant others, and others, including a minimum of one face-to-face contact every 90 days.

138. 138 Co-occurring Mental Health and Substance Abuse Disorders If an individual has co-occurring mental health and substance abuse disorders, integrated treatment for both disorders is allowed within psychosocial rehabilitation services as long as the treatment for the substance abuse condition is intended to positively impact the mental health condition.

139. 139 Required Activities: An assessment must be completed by minimally by a qualified mental health case manager to determine eligibility and the need for services.

140. 140 PA Requirement: PA is required effective 01/01/10 for new and existing recipients. If admitted on/after 01/01/10 there is a 1 unit (or 1 month) that does not require PA. Payment Rate is the current unit rate for the service ($326.50) In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit

141. 141 PA for All Client?s cont?d. If services are to continue (beyond the allowable unit without PA), provider must contact KePRO to obtain PA. PA will be allowed for 11 months in the 1st year Provider bills using H0023 code? (if no PA claim will deny) KePRO will be describing the specific details regarding the PA request process. In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit In order for the system to determine if recipient is ?New Admission? system will be set to look for previous services for the period 1/1/09 - 6/30/09. If no services billed, recipient is considered new admit

142. 142 Service Units & Maximum Service Limitations:

143. 143 Prior Authorization Requirements: For new clients & existing clients ? providers have 1 unit (calendar month) to assess the client and begin providing service. For any services to be paid beyond 1 unit a PA is required. The 1 unit is renewable annuallyThe 1 unit is renewable annually

144. 144 Prior Authorization Requirements: The provider will need to submit recipients demographic information & also include the following: Procedure Code ? H0023 PA Service Type - 0650 Number of units requested From & Through dates (span 12 months)

145. 145 Initial Review (New Recipient to Provider): ? For MHCM, DSM-IV- Axis I or Axis II Diagnosis (Adjustment Disorder or V codes are not acceptable as stand alone diagnoses for SED & Adults). ? If there is a dual diagnosis of Mental Health (MH) and SA, services must be integrated.

146. 146 Initial PA Request cont?d. Describe symptoms/severity of illness: Birth through age 7 Must exhibit being at risk of serious emotional disturbance and meet at least one of the following criteria: - The child exhibits behavior or maturity that is significantly different from most children of the child?s age and that is not primarily the result of developmental disabilities or mental retardation; or - Parents or persons responsible for the child?s care have predisposing factors themselves, such as inadequate parenting skills, substance use disorder, mental illness, or other emotional difficulties, that could result in the child developing serious emotional or behavioral problems; or

147. 147 Initial PA Request cont?d. Describe symptoms/severity of illness: Birth through age 7 (AT RISK) - The child has experienced physical or psychological stressors, such as living in poverty, parental neglect, or physical or emotional abuse, that have put him or her at risk for serious emotional or behavioral problems; and - An Axis I diagnosis is required for claims payment. This may be a rule-out or an adjustment disorder diagnosis.

148. 148 Initial PA Request cont?d. Describe symptoms/severity of illness: Birth through age 17 -Must exhibit serious emotional disturbance. (SED) Child must exhibit all of the following: ? Problems in personality development and social functioning that have been evident over the past year; and ? Problems that are significantly disabling based on social functioning of peers; and ? Problems that have become more disabling over time; and ? Service needs that require significant intervention by more than one agency.

149. 149 Initial PA Request cont?d. Adults, age 18+- Must exhibit severe and recurrent disability from mental illness and meet 2 of the following: Is unemployed; is employed in a sheltered setting or supportive work situation; has markedly limited or reduced employment skills; or has a poor employment history. Requires public financial assistance to remain in the community and may be unable to procure such assistance without help. Has difficulty establishing or maintaining a personal social support system. Requires assistance in basic living skills. Exhibits inappropriate behavior that often results in intervention by mental health or judicial system.

150. 150 Initial PA Request cont?d. KePRO will prior authorize services in 11 month increments Initial requests will be approved (based on the medical necessity) for 11 months PA requests after denials of services for medical necessity may be resubmitted at a later date when the individual meets criteria

151. 151 PA For Continued Treatment: ? For MHCM, individuals must Axis I Mental Health Disorder. (Adjustment Disorder or V codes are not acceptable as stand alone diagnoses for SED & adults)

152. 152 PA For Continued Treatment: Describe symptoms/severity of illness: Birth through age 7 (At Risk) Must continue to exhibit being at risk of serious emotional disturbance and meet at least one of the following criteria: - The child exhibits behavior or maturity that is significantly different from most children of the child?s age and that is not primarily the result of developmental disabilities or mental retardation; or - Parents or persons responsible for the child?s care have predisposing factors themselves, such as inadequate parenting skills, substance use disorder, mental illness, or other emotional difficulties, that could result in the child developing serious emotional or behavioral problems; or

153. 153 PA For Continued Treatment: Describe symptoms/severity of illness: Birth through age 7 - The child has experienced physical or psychological stressors, such as living in poverty, parental neglect, or physical or emotional abuse, that have put him or her at risk for serious emotional or behavioral problems; and - An Axis I diagnosis is required for claims payment. This may be a rule-out or an adjustment disorder diagnosis.

154. 154 PA For Continued Treatment: Attestation of continued need for MHCM, within past month, continued symptoms and behaviors, as follows: Birth through age 17 -Must exhibit serious emotional disturbance (SED). Child must continue to exhibit all of the following: Problems in personality development and social functioning that have been evident over the past year; and Problems that are significantly disabling based on social functioning of peers; and

155. 155 PA For Continued Treatment: Birth through age 17 cont?d. Attestation of continued need for MHCM: Problems that have become more disabling over time; and Service needs that require significant intervention by more than one agency.

156. 156 PA For Continued Treatment: Adults, age 18+- Must continue to exhibit severe and recurrent disability from mental illness and meet 2 of the following: ? Is unemployed; is employed in a sheltered setting or supportive work situation; has markedly limited or reduced employment skills; or has a poor employment history. ? Requires public financial assistance to remain in the community unable to procure such assistance without help. ? Has difficulty establishing or maintaining a personal social support system. ? Requires assistance in basic living skills. ? Exhibits inappropriate behavior that often results in intervention by mental health or judicial system.

157. 157 Continued PA Request: If individual continues to require MHCM beyond the initial auth period, a request must be submitted to KePRO at least 30 days prior to the PA end date and no later than the last day of the current PA. KePRO will continue to prior authorize services in 12 month increments Continued requests will be approved (based on the medical necessity) for 12 months PA requests after denials of services for medical necessity may be resubmitted at a later date when the individual meets criteria Providers will begin receiving their official authorization determinations (denials or approvals) via the First Health automated letter generation process. The letter generated from First Health will include a PA number. This number must be used when submitting claims. Claims submitted for services that exceed the units authorized will be denied. Providers will begin receiving their official authorization determinations (denials or approvals) via the First Health automated letter generation process. The letter generated from First Health will include a PA number. This number must be used when submitting claims. Claims submitted for services that exceed the units authorized will be denied.

158. 158

159. 159 DMAS RESOURCES TO CHECK SERVICE LIMITS MediCall Automated Voice Response System A telephone voice response system to: Confirm recipient eligibility status; Obtain up-to-date status on a claim; and Check on the status of recent claim remittances. Not for use by recipients.

160. 160 Resources to Check Service Limits Accessing the system: Have a currently active Medicaid provider number Limited number of inquires per session Call either a toll-free or local Richmond number 1-800-772-9996 - Toll-free 1-800-884-9730 - Toll-free 804- 965-9732 ? Richmond Area

161. 161 2. Automated Response System (ARS) An Internet Web-enabled tool to: Access current enrollee eligibility information, service limits, claim status, prior authorizations, provider check status Inquires submitted in real-time quickly and conveniently

162. 162 Resources to Check Service Limits Accessing the System: For current Medicaid and FAMIS providers No limit on the number of inquiries per session Need internet connect, PC, and a web browser https://uac.fhsc.com/uac/pages/unsecured/common/home.jsf

163. 163 3. HELPLINE A telephonic (live response) tool to assist Providers in: Interpreting Medicaid policy and procedures; and in Resolving problems with individual claims Do not use the HELPLINE for recipient eligibility verification and eligibility questions Resources to Check Service Limits

164. 164 3. HELPLINE Accessing the System: Available Monday through Friday from 8:30 a.m. to 4:30 p.m., except on State holidays Medicaid Provider number must accompany all inquiries For providers only - do not give the HELPLINE numbers to recipients. Local and Toll-free numbers: 804-786-6273 - Richmond Area and out-of-state long distance 1-800-552-8627 - In-state long distance (toll free) Resources to Check Service Limits

165. 165 You may email any specific questions to the following email address: cmhrs@dmas.virginia.gov

166. 166


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