Provider Update: March 3, 2017

Changes in Service Authorization Processes

Effective Monday, March 6^th, the ADvantage Service Plan Authorization Department is implementing the following changes. These changes will provide a myriad of benefits to the Member, the Providers and the MSU. Benefits will include reductions in time and costs incurred by the Provider by assisting to eliminate billing errors and time spent on conditions. Ultimately, all changes will improve timely service delivery to the Member by enabling the Service Plan Authorization department to provide timely authorization decisions and support Providers in their service delivery efforts.

*Process Change Issue – Discrepancy between Personal Care (T1019) and/or AS/R (T1019-TF) units requested on Service Plan (SP) Cost Sheet and units documented in Service Plan (SP) Goals*
To prevent service delivery delays to Members and potential future billing errors, units will be authorized at the lower units of either the SP Cost Sheet or SP Goals.
Informational Condition will be included on ADv6g, advising: Unit discrepancy plan/goals. Lower units authorized; ensure goals match ADv6g.
Case Manager shall ensure the Member's SP Goals and the ADv6g match, by updating the incorrect document and placing corrected version in the Member's chart.
If authorized amount of units are incorrect, the Case Manager should submit corrections via SP addendum and/or revised SP goals, as appropriate, with a Provider Communication to support the request.

*Process Change Issue – Requests for ADvantage Personal Care (T1019) units for bathing or incontinence supplies for Members receiving either ADvantage Hospice or Medicare Hospice*
*Requests for ADvantage* Personal Care units for bathing will not be authorized.**
i. The total number of units requested for Personal Care (T1019) assistance will be reduced by the number of units requested specifically for bathing.
ii. Informational Condition will be included on ADv6g, advising: Bathing assist is Hospice covered service. Bathing hours not authorized.
iii. *If extenuating circumstances exist, the Case Manager should advise via Provider Communication when the ADvantage* Personal Care units are requested.**
Requests for incontinence products will not be authorized.
i. Informational Condition will be included on ADv6g, advising that this is a Hospice covered item/service.
ii. If extenuating circumstances exist, the Case Manager should advise via a Provider Communication when the incontinence supplies are requested.

*Process Change – Installation and/or Member instruction of DME items and/or PERS not included in Service Plan (SP) Goals*
Conditional authorizations will no longer be applied if installation and/or Member instruction are not included in the SP Goals.
The Case Manager will be advised of the need to include these Action Steps in the SP Goals via an informational Condition on the ADv6g, advising: Please update SP goals to address installation/instruction.
*NOTE:* *Payer source will continue to be a required Action Step for all services*

*Process Change – Requests for ADvantage Hospice (S9126)*
Currently, Hospice is authorized in increments similar to Medicare – 60 to 90 day authorizations.
Effective March 6, 2017, Hospice may be authorized for a six-month period if the physician documents a 6-month certification period on the Certification/Recertification of Terminal Illness form, which is required for all ADvantage Hospice requests.
In the event the Member is approaching the Service Plan Cost Cap, a shorter authorization will be applied and the Case Manager will be informed via Service Plan Review (SPR).

*Process Change – Requests for Nutritional Supplements (T1999)*
Currently, Nutritional Supplements are authorized at a maximum of 6-month intervals.
Effective Monday, March 6, 2017, Nutritional Supplements may be authorized for the duration of refills noted on the physician's prescription, up to the end of the Member's service plan year.

*Process Change – Requests for Environmental Modifications (S5165)*
Currently, requests are accepted with partial submission of required documents.
Effective March 6, 2017, Environmental Modification requests will not be accepted unless all required documents are included in the request packet. An Informational Condition will be included on ADv6g, advising: Incomplete Packet/Unable to process.
Required documents for Environmental Modification requests are:
i. Completed Environmental Modification Decision Tool (02CB031E)
ii. Level of Function and Environmental Assessment Tool (02CB033E), completed by Physical Therapist or Skilled Nurse
iii. Page 1 of the Environmental Modification Permission and Verification form (02CB032)
iv. Service Plan Cost Sheet or Addendum
v. Corresponding Service Plan Goals
vi. Bid – For items less than $2500
*Bid with schematic drawing from the selected ADvantage* Environmental Modification provider**
vii. Bids - For items equal to or greater than $2500
1. Three (3) bids with schematic drawings from each provider are required
2. If the Case Manager is unable to obtain three (3) bids for items equal to or greater than $2500, refusals to bid must be submitted from ALL remaining providers on referral in the Member's county
*Note:* *Be sure to use the most current referral information by checking the ADvantage Certified Agencies Report at* *http://advantage.ok.gov/bycnty.aspx*
3. If the lowest bid is not selected, supporting documentation via a Provider Communication must be submitted at the time of the request

Thank you.

If you have any questions regarding the information provided above, please feel free to contact us via email at: aauproviderquestion@aau.okdhs.org