Resources
What is the Review System found within JIVA to complete a review and can be utilized for both behavioral health and Medical
Interqual
What is the time frame required for urgent (initial request
24hr
We must Maintain our NCQA Accreditation Or Risk
Losing our contract and our job
A request for coverage of medical care or services that have been received (also referred to as a “post-service” review).
Retrospective Review
ASAM Levels 3.1* to 4.0 Is (type of Request)
Inpatient
What is the Review Source to complete for CMHRS
DMAS Provider Manuel
What is the NCQA time frame for Retrospective authorization requests
30 days
Name the Governing Entities of Virginia Premier
NCQA, DMAS, CMS
A request for coverage of medical care or services made while a member is in the process of receiving the requested medical care or services.
Concurrent
IN-NETWORK
No authorization is required for the member’s first 12 visits.
MD Psych Medication Management
What List Is Utilized before the authorization is submitted and can be found on the Virginia Premier Website
PAL (Patient Authorization List)
What is the TOT for Concurrent or Continued Stay Requests
72 Hrs
NCQA Has Clearly Defined Standards. Some of These standards are know as?
"Must Pass" Elements This means that these elements must be met 100% of the time.
In the opinion of a practitioner with knowledge of the member’s medical or behavioral condition, would subject the member to adverse health consequences without the care or treatment that is the subject of the request
Urgent Initial
Services that DO NOT require prior authorization:
◦Emergency Room Care
◦In and Out of network Observation auths
◦Participating Urgent Care Centers
◦Early Intervention (EI) Services- as long as criteria is met
What is the authorization resource for ARTS Only
DMAS Service Auth Guidelines
What are the expected TOT for Med 4 Authorizations
24-72hr 14 day -30 day
Name One Must Pass Element
TOT
A request for medical care or services for which application of the time periods for making a decision does not jeopardize the life or health of the member or the member’s ability to regain maximum function and would not subject member to severe pain.
Non-Urgent
Members with MLTSS and Medallion may be eligible for
Enhanced Care Coordination (ECC)
What list is reviewed initially by the IC and can provide the auth list for them to approve
IC Guide
What is NCQA Time frame for Pre-service Non -Urgent
15 days REMEMBER WE follow the most stringent guidelines of our 3 governing bodies and DMAS is 14 days so we must follow the most stringent and follow the 14 day TOT
Per:Which Governing Body must we as a company must follow the most stringent guidelines between these three governing bodies.
NCQA
•Could seriously jeopardize the life, health or safety of the member others due to the member’s psychological state, or
Urgent Initial
All OON (out of network) requests unless they fall within the KEPRO/COC guidelines or are explicitly defined as no auth required (Dialysis for medical, etc).
Single Case Agreement