1. INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT
Service Authorization Process for EPSDT Personal/Attendant Care (Service Type 0091) and
Private Duty Nursing (Service Types 0098 & 0090)
Presented by: KePRO

2. Methods of Submission Service Authorization Requests to KePRO
All requests for service authorization must be submitted to KEPRO via Atrezzo Provider Portal Connect effective 9/1/2015
Reference DMAS Medicaid Memo dated 6/15/2015
Notification that KEPRO is Converting to Electronic Process for Submitting Service Authorization Requests – Effective September 1, 2015 2

3. Resources for Submitting Service Authorization Requests to KEPRO
KEPRO Website
DMAS Website portal: wps/portal.
For any questions regarding the submission of Srv Auth requests please contact KePRO at or 3

4. Provider Manual/Medicaid Memorandums
DMAS publishes electronic and printable copies of its Provider Manuals and Medicaid Memoranda on the DMAS Web Portal at
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 A fee will be charged for the printing and mailing of the manual updates that are requested.

5. Covered Services under EPSDT:
Service Authorization Information Specific to Personal Care/Attendant Care, Private Duty Nursing (PDN)
Covered Services under EPSDT:
EPSDT Personal/Attendant Care-0091
EPSDT Private Duty Nursing-0090
EPSDT Private Duty Nursing in School (MCO)-0098

6. EPSDT Personal Care/Attendant Care
Service Authorization Information Specific to Personal Care/Attendant Care
EPSDT Personal Care/Attendant Care

7. Service Authorization Information Specific to Personal Care/Attendant Care
Providers must submit request to the designated preauthorization contractor within 10 business days of initiating care or within 10 business days of receiving verification of Medicaid eligibility from the local DSS, unless otherwise specified in the DMAS Provider Manual.
Please note that some services can not be retro authorized and must be submitted by the SOC date requested. Refer to the specific Provider Waiver Manual for the submission requirements for each service/procedure code.

8. EPSDT Personal/Attendant Care: 0091
Service Authorization Information Specific to Personal Care/Attendant Care
EPSDT Personal/Attendant Care: 0091
EPSDT services are available to Medicaid members under 21 years of age. Personal care may be provided exclusively through EPSDT to eligible persons who have demonstrated a medical need for personal care that is not covered under an existing Medicaid program for which the individual is enrolled.

9. Procedure/Service Codes that Require Service Authorization:
Service Authorization Information Specific to Personal Care/Attendant Care
Procedure/Service Codes that Require Service Authorization:
T1019 (Agency Directed Personal Care)‏
S5126 (Consumer Directed Personal Care)‏

10. Eligible Members include individuals who are:
Service Authorization Information Specific to Personal Care/Attendant Care
Eligible Members include individuals who are:
Under 21 yrs old and enrolled in Medicaid FFS, Medicaid MCO, or FAMIS Plus on dates of services requested.
Under the age 19 yrs old and enrolled in FAMIS FFS on the dates of services requested.
Personal Care is not a covered services by FAMIS MCOs

11. Timeliness Requirements for Submission:
Service Authorization Information Specific to Personal Care/Attendant Care
Timeliness Requirements for Submission:
Providers must submit documentation to KePRO within 10 business days of start of care.
Continuation of service reviews are required to be submitted prior to the end of the current authorization period.
If request is not submitted within the required timeframe, the service must be authorized beginning with the date the information was received by KePRO.

12. Service Authorization Information Specific to EPSDT Personal Care/Attendant Care
Provider will be required to complete the questionnaire utilizing the information found on the following forms:
DMAS 7 (signed and dated by physician, physician’s assistant, or nurse practitioner)
DMAS 7-A from provider
DMAS 99 Community Based Care Recipient Assessment Report
Back-up plan documented
Detailed Schedule of current services available to individual
NOTE***If additional information is needed from the provider, the case is pended for 5 business days to allow provider time to submit additional documentation to KePRO for review.

13. Service Authorization Information Specific to Personal Care/Attendant Care
In addition to medical necessity, the following criteria must be met in order for personal care services to be determined as appropriate:
The member must have a plan of care developed by a currently enrolled personal care provider or service facilitator
The plan of care (DMAS- 7A) should be consistent with the findings on the EPSDT functional assessment (DMAS -7) and demonstrate the need for personal care.
The member must have a viable back-up plan, such as a family member, neighbour, or friend who is willing and able to assist the individual on very short notice in case the personal care aide does report for work as expected.
Individuals who do not have a viable back-up plan are not eligible for services until a backup plan as has been established.
Individuals receiving EPSDT personal care must have a physician referral due to health conditions documented during an EPSDT medical exam

14. Service Authorization Information Specific to EPSDT Personal Care/Attendant Care
Medical Necessity
Health conditions must cause the individual to be functionally limited in performing three or more activities of daily living (ADL)
These categories are bathing, dressing, transfers, ambulation, eating/feeding, toileting, and continence
The individual’s inability to perform an ADL cannot be exclusively due to typical limitations associated with typical attainment of developmental milestones

15. Service Authorization Information Specific to EPSDT Personal Care/Attendant Care
EPSDT Personal Care Services may be provided in a school setting if the service is not included in the member’s Individualized Education Program (IEP) and the services are deemed medically necessary
Providers must document the medical need for coverage in the school setting and document that the services is not included in the member’s IEP
EPSDT allows supervision hours when it is medically necessary for the member to receive supervision due to a health condition.
Disruptive behaviours such as aggression, self-injury, elopement/wandering, impulsivity, property destruction, etc. may require constant supervision from a personal or attendant care aide to maintain the child’s safety in addition to the hours required for ADL/IADL supports.

16. The Following Services are Covered:
Service Authorization Information Specific to EPSDT Personal Care/Attendant Care
The Following Services are Covered:
Assistance with activities of daily living (ADLs): bathing, dressing, toileting, transferring, eating/feeding, ambulation, and bowel and bladder continence
Assistance with meal preparation for the individual
Medically Necessary Supervision related to a health condition
The Following Services are not Covered:
General Supervision
Respite
Performance of tasks for the sole purpose of assisting with the completion of job requirements
Assistance provided in hospitals, other institutions, assisted living facilities, and licensed group homes
Services included in the member’s Individualized Education Program (IEP)

17. EPSDT Private Duty Nursing (PDN)
Service Authorization Information Specific to EPSDT Private Duty Nursing
EPSDT Private Duty Nursing (PDN)

18. Private Duty Nursing: Must be provided by: RN LPN
Service Authorization Information Specific to EPSDT Private Duty Nursing (PDN)
Private Duty Nursing:
A continuous medically necessary nursing service provided for an individual in a home or community based setting.
Must be provided by: RN
LPN
Employed by a DMAS/MCO enrolled private duty nursing provider

19. Procedure/Service Codes that Require Service Authorization:
Service Authorization Information Specific to EPSDT Private Duty Nursing (PDN)
Service Type:
0090-FFS Members
0098 MCO/Carve Out school based PDN
Procedure/Service Codes that Require Service Authorization:
S9123-RN Nursing Services and Assessment
S9124-LPN Nursing Services
G0162-RN Congregate Nursing Services
G0163-LPN Congregate Nursing Services

20. Eligible Members for 0090 include individuals who are:
Service Authorization Information Specific to Private Duty Nursing (PDN)
Eligible Members for 0090 include individuals who are:
Under 21 yrs old and enrolled in Medicaid FFS, FAMIS, or FAMIS Plus on dates of services requested
Under the age of 19 yrs old and enrolled in FAMIS FFS on the dates of services requested

21. Timeliness Requirements for Submission:
Service Authorization Information Specific to Private Duty Nursing (PDN)
Timeliness Requirements for Submission:
Providers must submit documentation to the service authorization contractor within 10 business days of the initial start of care.
Continuation of service reviews are required to be submitted prior to the end of the current authorization period.
If request is not submitted within the required timeframe, the service must be authorized beginning with the date the information was received by the service authorization contractor
NOTE**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 for review.

22. Congregate Private Duty Nursing
Service Authorization Information Specific to Private Duty Nursing (PDN)
Private Duty Nursing
May be used while a child is enrolled in a waiver, if that waiver does not provide PDN or does not provide congregate PDN
PDN services are limited to the hours of skilled medical care and skilled supervision as specified in the Plan of Care (POC) and limited to the number of hours approved.
Congregate Private Duty Nursing
Provided when more than 1 individual who requires private duty nursing resides in the same home
Limited to a maximum ratio of one PDN to two individuals who receive nursing via the Tech Waiver or EPSDT
When 3 or more Waiver/EPSDT individuals share a home, service staff ratios are determined by assessing the combined needs of the individuals

23. Service Authorization Information Specific to EPSDT Private Duty Nursing (PDN)
Provider will be required to complete the questionnaire utilizing the information found on the following forms for 0090
DMAS 62-signed by Physician
Home Health Certification and Plan of Care (may use DMAS or equivalent to meet documentation requirements)

24. Service Authorization Information Specific to EPSDT Private Duty Nursing (PDN)
Documentation is required utilizing the following forms for MCO Referral Requests:
Signed DMAS 62-signed by Physician (a new DMAS 62 is required every 6 months)
Home Health Certification and Plan of Care (may use DMAS 485 or equivalent to meet documentation requirements)

25. Service Authorization Information Specific to Private Duty Nursing (PDN)
Dual Use of EPSDT PDN:
If a child is enrolled in a Medicaid Waiver Program, the provider must document that the waiver does not offer PDN coverage or does not offer congregate Private Duty Nursing coverage.
If the member’s waiver offers PDN, then the EPSDT benefit is not available.
Members may be authorized for EPSDT PDN if enrolled in the EDCD Waiver.
Members may use any of the EDCD waiver services while receiving EPSDT PDN. EPSDT is not used to authorize respite care.
Services may be approved for school based nursing supports. The hours used during the school day will count toward the number of hours allowed based on the individual’s medical need for care.

26. General Information for All Service Authorization Submissions.
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
All responses to pended information must be submitted at one time only. 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.

27. 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.
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.

28. Out of State Providers Out of State Providers:
Out of state providers must be enrolled with Virginia Medicaid in order to submit a request for out of state services to the Contractor. If the provider is not enrolled as a participating provider with Virginia Medicaid, the provider is still encouraged to submit the request to the Contractor, as timeliness of the request will be considered in the review process starting November 1, These providers will not have a NPI number but may submit a request to the Contractor.
The Contractor will advise out of state providers that they may enroll with Virginia Medicaid by going to:
(At the toolbar at the top of the page, click on Provider Services and then Provider Enrollment in the drop down box.  It may take up to 10 business days to become a Virginia participating provider.)

29. 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:
If you have any questions regarding the Virginia Medicaid Web Portal, please contact the Xerox State Healthcare Web Portal Support Helpdesk, toll free, at 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 or Both options are available at no cost to the provider.
Providers may also access service authorization information including status via KePRO’s Atrezzo Provider Portal Connect at

30. 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:
Richmond area and out-of-state long distance
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.

31. INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT
Thank you