PAC Waiver. eqhealth Solutions PAC Waiver Authorization Process

Transcription

1 PAC Waiver eqhealth Solutions PAC Waiver Authorization Process January

2 Purpose of Presentation Upon completion of the webinar, participants will be able to: 1. Prepare and submit PAC Waiver Requests for Exception to eqhealth Solutions 2. List the documents that are required to be submitted with PAC Waiver Requests for Exception 3. Interpret the message in the outcome letter that is sent in response to the Request for Exception to determine if the request was approved, denied or if additional documentation must be submitted 4. Identify resources that can be accessed if questions about PAC Waiver Requests arise 2

3 Introduction to eqhealth Solutions 3

4 Partnership: AHCA and eqhealth The Florida Agency for Health Care Administration awarded eqhealth Solutions the contract to provide comprehensive Medicaid Utilization Management Services (CMUMP) for services such as inpatient hospitalization, outpatient therapy services, DME, home health, and PAC Waiver. eqhealth Solutions is accredited by the Utilization Review Accreditation Commission (URAC) 4

5 How to Contact eqhealth Solutions Local office/operations address: 5802 Benjamin Center Drive, Suite 105 Tampa, FL Office Hours: Monday-Friday from 8 am 5 pm, EST 5

6 Preparing to Submit a Request for Exception for PAC Waiver Services 6

7 Preparing to Submit a Request Case managers must coordinate access to services through all available funding sources prior to accessing PAC waiver services. Services cannot be provided under the PAC waiver if they are available from another funding source. Other funding sources must be accessed in this order: 1. Third Party Payers including Medicaid Managed Care 2. Medicare 3. Other Medicaid Programs 4. PAC waiver Source: Page 3-2 of the Project AIDS Care Waiver Services Coverage and Limitations Handbook. 7

8 Preparing to Submit a Request Other funding sources may cover such services as: personal care services (through home health) restorative massage (through outpatient physical therapy) skilled nursing -RN or LPN (through home health) specialized medical equipment and supplies (through DME) management of substance of substance abuse (through behavioral health) 8

9 Required Documentation for Request for Exception for PAC Waiver Services 9

10 Required Documents Each time a Request for Exception is submitted, the following documents are required: 1. Request for Exception Form 2. Physician s prescription 3. Current level of care documentation (Notification of Level of Care, DOEA-CARES Form 607) 4. Most current social needs assessment Source: Page 2-14 of the Project AIDS Care Waiver Services Coverage and Limitations Handbook. 10

11 Required Documents, Continued Each time a Request for Exception is submitted, the following documents are required: 5. Plan of care for the month in which the request is submitted 6. Itemized cost list and work orders for environmental accessibility adaptation or specialized medical equipment and supplies 7. Narrative justification for the request 8. Length of time for which the exception is requested Source: Page 2-14 of the Project AIDS Care Waiver Services Coverage and Limitations Handbook. 11

12 Required Documents 1. Request for Exception Form 12

13 Required Documents 2. Physician s prescription: Amount (number of units) Frequency (how many times per week or month) Duration (number of weeks or months) The prescription must be signed and dated, and must be current. Expired prescriptions are not accepted. 13

14 Required Documents 3. Current level of care documentation (Notification of Level of Care, DOEA-CARES Form 607) Notification of Level of Care DOEA-CARES Form

15 Required Documents 4. Current Social Needs Assessment 15

16 Required Documents 5. Plan of care for the month in which the request is submitted 16

17 Required Documents 6. Itemized cost list and work orders for environmental accessibility adaptation or specialized medical equipment and supplies 17

18 Required Documents 7. Narrative justification for the request 18

19 Required Documents 8. Length of time for which the exception is requested 19

20 How to Submit a Request for Exception 20

21 How to Submit a Request 1. All required documents must be submitted in PDF format 2. Submit the request via encrypted to: pacwaiver@eqhs.org 3. Put PAC Request (Initials) (Last 4 Digits of the Medicaid Beneficiary ID number) (Date) in the Subject line 4. Submit only one request per 21

22 Interpreting the Outcome 22

23 Outcomes There are 4 possible outcomes for the Request for Exception: 1. Approved 2. Partially approved 3. Denied 4. Returned 23

24 Outcomes 1. Approved All required documentation was submitted The request matched the prescription 24

25 Outcomes 2. Partially Approved All required documentation was submitted There was a discrepancy in the documents. Examples: A prescription that expires prior to the Thru Date A request for services that exceeds 6 months 25

26 Outcomes 3. Denied All required documents were submitted The request did not meet the requirements of the PAC Waiver Handbook 26

27 Outcomes 4. Returned The request was not reviewed because of incomplete or insufficient documentation. Examples: Expired Notification of Level of Care Expired prescription Plan of Care was not submitted DOEA CARES Form 607 was not submitted Returned requests can be resubmitted when all required documentation is available. 27

28 How to Streamline the Request Process 28

29 Streamlining the Request Process 1. Submit all required documents with each request. 2. If a request is for continued services, submit all required documents with the continued service request, even if they were sent previously. 3. Place all required documents in a single PDF file per recipient. 4. Submit only one request per 29

30 Streamlining the Request Process 5. Submit all required documents in a single 6. Submit the request once; do not send duplicate requests. 7. Use the pacwaiver@eqhs.org only to submit requests. 30

31 How to Access Assistance with a Request 31

32 Assistance for Requests 1. Outcomes are typically ed to case managers within 5 business days. 2. If you need to obtain the status of a request for which you have not received an outcome after 5 business days, please contact eqhealth Solutions Customer Service at our toll free number: M-F (except state recognized holidays) 8 a.m. 5 p.m., Eastern Time 32

33 Questions and Answers 33

34 Questions and Answers Thank-you for attending. Your opinion is important to us. Please complete the survey which will appear on your computer when the webinar ends. 34