Attention All Medicaid Providers
ATTENTION ALL MEDICAID PROVIDERS
To continue getting reimbursed for Medicaid and Health Choice services after October 1, 2011:
PLEASE BE SURE TO READ THIS INFORMATION AND COMPLY
Authorizations May Only Be Submitted Electronically –NO MORE FAXES
You must register with, and submit all authorizations electronically to the Medicaid UR vendors’ online web portals. Starting October 1, 2011, all authorizations must be done electronically – no more faxing.
NC Health Choice authorization requests are also be submitted electronically on ValueOptions’ ProviderConnect provider web portal.
It’s a good idea to get registered and familiar with the new process well before October 1st to avoid any delays caused by last minute registrations.
INSTRUCTIONS ON GETTING STARTED WITH VALUEOPTIONS
Go to the following website:
Scroll down and click on:
You will be brought to a page that will ask for your log in and user name. If you have not registered yet, scroll down to where it says New User, and click on the Register button.
(Picture shown below).
You will be brought to a page where you will type in your information and create a password to get registered. There is a phone number at the bottom of the webpage if you have any trouble or questions.
PROVIDER TRAINING AND USER GUIDES ON HOW TO SUBMIT AUTHORIZATIONS
• There is training available. From the main website above, scroll down towards the bottom to either CLICK on a previously recorded 1 hour webinar on the ITR or the ORF.
• There is information on how to register for an upcoming Webinar by clicking on a link for the date you/your staff would like to attend.
• There are also written instructions that walk you through step by step on authorizations:
Quick Reference Guide:
Provider Connect FAQs:
Instructions on how to submit online requests to Durham or Eastpointe LMEs may be found at their web sites.
MOST COMMON MISTAKES PROVIDERS MAKE REGARDING AUTHORIZATIONS
(Information from Value Options)
• Inadequate justification on the request
o Attach more information if needed. If you request psychological testing, write what question(s) you are trying to answer.
o Requested amount of testing exceeds guidelines. Providers must document their rationale for the need of additional time.
• Inadequate clinical information
• Requested service does not meet the Medical Necessity criteria
• Requested service is not consistent with Best Practice and there is a more appropriate service indicated. Information on Best Practice:
o American Psychiatric Association Website
o American Academy of Child and Adolescent Psychiatry
o American Society of Addiction Medicine (ASAM) Practice Guidelines
• Diagnosis and listed problems/treatments do not match
o (ex. Anxiety Disorder diagnosis with psychotic treatment)
• Safety issues: When a more intense and immediate intervention is needed than what is requested
o (ex. Report of SI/HI and engagement in risky behaviors –needs a psychiatric evaluation)
• Service definitions are copied onto the ORF but there is no clinical information to support the listed items
• Absent goals, or goals are not measurable
• For chronic conditions, there is no information to support the need for Disease Management
• Providers are unfamiliar with EPSDT for the under 21 population
• Lack of information (missing pages, missing or wrong CPT codes)
• Limited understanding about Due Process rules (which were updated May 27, 2011)
Section 2 bulleted item is the 14 page document to review
o May 2011 Medicaid Bulletin
http://www.ncdhhs.gov/dma/bulletin/0511bulletin.htm lists some of the major changes
A friendly reminder: Value Options cannot infer. They go by the information written by the provider to justify the services requested.