1. Service Authorization for Alzheimer's Assisted Living Waiver (Service Type 0980) Presented by: KePRO INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT 1

2. Methods of Submission Service Authorization Requests to KePRO Please note that for Alzheimer's Assisted Living Waiver, all requests must be submitted via KePRO’s Atrezzo Connect System To access Atrezzo Connect on KePRO’s website, go to http://dmas.kepro.com. http://dmas.kepro.com Provider registration is required to use Atrezzo Connect. The registration process for providers happens immediately on-line From http://dmas.kepro.com, providers not already registered with Atrezzo Connect may click on “Register” to be prompted through the registration process. Newly registering providers will need their 10- digit National Provider Identification (NPI) number and their most recent remittance advice date for YTD 1099 amount.http://dmas.kepro.com The Atrezzo Connect User Guide is available at http://dmas.kepro.com : Click on the Training tab, then the General tab. http://dmas.kepro.com 2

3. Service Authorization Requests: Contact Information for KePRO/ DMAS Provider Information Providers with questions about KePRO’s Atrezzo Connect Provider Portal may contact KePRO by email at atrezzoissues@kepro.com.atrezzoissues@kepro.com For service authorization questions, providers may contact KePRO at providerissues@kepro.com. providerissues@kepro.com KePRO may also be reached by phone at 1-888-827-2884, or via fax at 1- 877-OKBYFAX or 1-877-652-9329. 3

4. Medicaid Memoranda and Manuals DMAS publishes electronic and printable copies of its Provider Manuals and Medicaid Memoranda on the DMAS Web Portal at https://www.virginiamedicaid.dmas.virginia.gov/wps/portal. This link opens up a page that contains all of the various communications to providers, including Provider Manuals and Medicaid Memoranda. The Internet is the most efficient means to receive and review current provider information. If you do not have access to the Internet or would like a paper copy of a manual, you can order it by contacting: –Commonwealth-Martin at 1-804-780-0076. A fee will be charged for the printing and mailing of the manual updates that are requested. 4

5. Service Authorization Information Specific to Alzheimer's Assisted Living (AAL)Waiver Purpose: Allow individuals to remain in a home-like setting for a long as possible Remain in an environment that maximized their autonomy, privacy, and dignity even if they require a high level of services Provide relief for caregivers. This service is provided in an Assisted Living Facility (ALF) that is licensed by the Department of Social Services with a safe and secure unit. ALF providers must be approved by the Long Term Care Division of DMAS in order to become an enrolled Medicaid AAL Waiver Provider. Only DMAS approved ALF providers are able to admit individuals into Alzheimer's Waiver 5

6. Service Authorization Information Specific to Alzheimer's Assisted Living (AAL)Waiver Providers must submit documentation to KePRO within 10 business days of initiation of care or providers verification of Medicaid eligibility. If request is not submitted within 10 business days, the service must be authorized beginning with the date the information was received by KePRO. Requests for Alzheimer's Assisted Living Waiver must contain the following: –Completed AAL Waiver questionnaire via Atrezzo Connect for new admissions, readmissions, or continuation of care 6

7. Service Authorization Information Specific to Alzheimer's Assisted Living (AAL)Waiver AAL Waiver Procedure Code= T2031 Service Limit –The authorization is for a span of up to 365 days, 1 unit per day frequency 7

8. Member Eligibility for Alzheimer's Assisted Living Waiver Eligible Members include individuals who are: Enrolled in Medicaid Fee-For-Service (FFS) In the following Aid Categories:  012 Aged Auxiliary Grant Recipient (includes dually eligible QMB)  032 Blind Aged Auxiliary Grant Recipient (includes dually eligible QMB)  052 Disabled Auxiliary Grant Recipient (includes dually eligible QMB) 8

9. Criteria for Alzheimer's Assisted Living (AAL)Waiver The member must be:  Elderly as defined by § 1614 of the Social Security Act or  Disabled as defined by § 1614 of the Social Security Act Must meet criteria for admission to a nursing facility as determined by a preadmission screening team using the full UAI Must have a diagnosis of Alzheimer's or a related dementia as diagnosed by a licensed clinical psychologist or a licensed physician. The member may not have a diagnosis of mental retardation as defined by the American Association on Mental Retardation in Mental Retardation-Definition, Classifications, and Systems of Supports 10 th Edition, or a serious mental illness as defined in 42 CFR 483.102 (b). Must be receiving an auxiliary grant and residing in or seeking admission to a safe, secure unit of a DMAS approved ALF 9

10. Criteria for Alzheimer's Assisted Living (AAL)Waiver All admissions to the AAL Waiver are subject to preadmission screening prior to admission to the waiver. Under no circumstances are AAL Waiver admission to be approved without the necessary and required preadmission screening documentation in place (this includes DMAS 96 and UAI) The physician signature on the DMAS 96 must be on or prior to the enrollment date of the waiver. The Medicaid authorization code on the DMAS 96 must be either  16 Alzheimer's Assisted Living Waiver  01 Nursing Facility Placement  04 Elderly or Disabled with Consumer Direction If there is not DMAS 96 form present, the preadmission screening package is not valid. The DMAS-96 form is the actual authorization form for long term care services. 10

11. Alzheimer's Assisted Living (AAL)Waiver Questionnaire The questionnaire is used to submit all request to KePRO for srv auth. Requests are submitted by direct data entry only. The Alzheimer’s Assisted Living Waiver questionnaire must be completed in it’s entirety to request services for new admissions, readmissions or continuation of care. 11

12. AAL Waiver Questionnaire 12

13. AAL Waiver Questionnaire 13

14. AAL Waiver Questionnaire 14

15. AAL Waiver Questionnaire 15

16. AAL Waiver Questionnaire 16

17. AAL Waiver Questionnaire 17

18. General Information for All Service Authorization Submissions KePRO’s website has information related to the service authorization processes for all DMAS programs they review. Questionnaires and much more are on KePRO’s website. Providers may access this information by going to http://dmas.kepro.com.http://dmas.kepro.com KePRO will approve, deny, or pend requests. If there is insufficient medical necessity information to make a final determination, KePRO will pend the request back to the provider requesting additional information. Once the case has been received and reviewed, if additional information is needed from the provider, the case is pended for 5 business days to allow the provider time to submit additional documentation to KePRO for review Do not send responses to pends piecemeal since the information will be reviewed and processed upon initial receipt. If the information is not received within the time frame requested by KePRO, the request will automatically be sent to a physician for a final determination. In the absence of clinical information, the request will be submitted to the supervisor for an administrative review and final determination. Providers and members are issued appeal rights through the MMIS letter generation process for any adverse determination. Instruction on how to file an appeal is included in the MMIS generated letter. 18

19. General Information for All Service Authorization Submissions There are no automatic renewals of service authorizations. Providers must submit requests for continuation of care needs, with supporting documentation, prior to the expiration of the current authorization. Providers must verify member eligibility prior to submitting the request. Authorizations will not be granted for periods of member or provider ineligibility. Requests will be rejected if required demographic information is absent. Providers should take advantage of KePRO’s web based checklists/information sheets for the services(s) being requested. These sheets provide helpful information to enable providers to submit information relevant to the services being requested. Providers must submit a service authorization request under the appropriate service type. Service authorization requests cannot be bundled under one service type if the service types are different. 19

20. VIRGINIA MEDICAID WEB PORTAL DMAS offers a web-based Internet option to access information regarding Medicaid or FAMIS member eligibility, claims status, check status, service limits, service authorizations, and electronic copies of remittance advices. Providers must register through the Virginia Medicaid Web Portal in order to access this information. The Virginia Medicaid Web Portal can be accessed by going to: www.virginiamedicaid.dmas.virginia.gov. www.virginiamedicaid.dmas.virginia.gov If you have any questions regarding the Virginia Medicaid Web Portal, please contact the Xerox State Healthcare Web Portal Support Helpdesk, toll free, at 1-866-352-0496 from 8:00 a.m. to 5:00 p.m. Monday through Friday, except holidays. The MediCall audio response system provides similar information and can be accessed by calling 1-800-884-9730 or 1-800-772-9996. Both options are available at no cost to the provider. Providers may also access service authorization information including status via KePRO’s Provider Portal at http://dmas.kepro.com.http://dmas.kepro.com 20

21. ELIGIBILITY VENDORS: How to check for Member Eligibility DMAS has contracts with the following eligibility verification vendors offering internet real-time, batch and/or integrated platforms. Eligibility details such as eligibility status, third party liability, and service limits for many service types and procedures are available. Contact information for each of the vendors is listed below: –Passport Health Communications, Inc. www.passporthealth.com, sales@passporthealth.comwww.passporthealth.comsales@passporthealth.com Telephone: 1 (888) 661-5657 –SIEMENS Medical Solutions – Health Services Foundation Enterprise Systems/HDX www.hdx.com Telephone: 1 (610) 219-2322 –Emdeon www.emdeon.com Telephone: 1 (877) 363-3666 21

22. DMAS Helpline Information The “HELPLINE” is available to answer questions Monday through Friday from 8:00 a.m. to 5:00 p.m., except on holidays. The “HELPLINE” numbers are: –1-804-786-6273 Richmond area and out-of-state long distance –1-800-552-8627 All other areas (in-state, toll-free long distance) Please remember that the “HELPLINE” is for provider use only. Please have your Medicaid Provider Identification Number available when you call. 22

23. Questions??? INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT 23