1. INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT DMAS/ KEPRO Service Authorization Process for Individual and Family Developmental Disabilities Support (DD) Waiver Revised Sept 20151

2. Provider Manual/Medicaid Memorandums 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. Revised Sept 20152

3. Resources for Submitting Service Authorization Requests to KEPRO KEPRO Website https://dmas.KEPRO.comhttps://dmas.KEPRO.com DMAS Website portal: https://www.virginiamedicaid.dmas.virginia.gov/w ps/portal. https://www.virginiamedicaid.dmas.virginia.gov/w ps/portal For any questions regarding the submission of Srv Auth requests please contact KEPRO at 888-827-2884 or 804-622-8900. Revised Sept 20153

4. 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. The link is: https://atrezzo.KEPRO.com/Account/Login.aspx https://atrezzo.KEPRO.com/Account/Login.aspx Please reference the DMAS Medicaid Memo dated 6/15/2015, Notification that KEPRO is Converting to Electronic Process for Submitting Service Authorization Requests – Effective September 1, 2015. Revised Sept 20154

5. Srv Auth Requests Covered Services under: Individual and Family Developmental Disabilities Support Waiver (DD)-0902 Revised Sept 20155

6. DD Waiver Requests DD Waiver Service Authorization (Srv Auth) Service Type: 0902 DBHDS performs enrollments for DD Waiver. Requests for DD Waiver services that require authorization are to be submitted to KEPRO via via Atrezzo Provider Portal Connect. Revised Sept 20156

7. DD Waiver Requests DD Waiver Srv Auth Service Type: 0902 The following are the services available under the DD Waiver by procedure code : T1019(Agency Directed Personal Care)‏ S5126(Consumer Directed Personal Care)‏ T1005(Agency Directed Respite)‏ S5150( Consumer Directed Respite)‏ T1002(Skilled Nursing Services-RN)‏ T1003(Skilled Nursing Services-LPN)‏ Revised Sept 20157

8. DD Waiver Requests S5165 (Environmental Modifications) 99199 (U4 EM Maintenance)‏ T1999 (Assistive Technology) T1999 (U5 AT Maintenance)‏ H2011 (Crisis Stabilization)‏ H0040 (Crisis Stabilization - Supervision)‏ S5111 (Family Caregiver Training)‏ H2025 (Pre-Vocational Services-Regular Intensity) H2025 U1 (Pre-Vocational Services High Intensity) Revised Sept 20158

9. DD Waiver Requests S5135 (Companion Care)‏ S5136 (Companion Care: Consumer Directed)‏ H2014 (In-Home Residential Services) H2023 (Supported Employment- Individual)‏ H2024 (Supported Employment- Enclave)‏ 97537 (Day Support – Regular) 97537 U1 (Day Support - High Intensity) 97139 (Therapeutic Consultation)‏ Revised Sept 20159

10. DD Waiver Requests S5160 Personal Emergency Response System (PERS) Installation S5160 U1 Personal Emergency Response System (PERS)‏ Medication Monitoring Installation S5161 Personal Emergency Response System (PERS) Revised Sept 201510

11. DD Waiver Requests  S5185 Personal Emergency Response System (PERS) Medication Monitoring  H2021 TD Personal Emergency Response System(PERS) Nursing - RN  H2021 TE Personal Emergency Response System (PERS) LPN‏ Revised Sept 201511

12. DD Waiver Requests The following procedure codes only require submission of the request via the Atrezzo Provider Portal Connect: 97537 & 97537 U1 (Day Support- Regular and High Intensity)‏ H2011(Crisis Stabilization)‏ H0040 (Crisis Supervision)‏ H2023 (Supported Employment- Individual)‏ H2024 (Supported Employment- Group)‏ S5135 (Companion Care- Agency)‏ S5136 (Companion Care- Consumer Directed)‏ T1002 and T1003 (Skilled Nursing- RN or LPN)‏ 97139 (Therapeutic Consultation)‏ S5160/S6160 U1; S5161/S5185 (PERS Installation & Monitoring)‏ H2021 TD & H2021 TE (PERS Nursing) Revised Sept 201512

13. DD Waiver Requests DD Waiver Procedure Codes that requires additional Clinical Review with the Srv Auth Requests T1019/S5126 (Agency & Consumer Directed Personal Care)‏ T1005/S5150 (Agency & Consumer Directed Respite Care)‏ S5111 (Family Caregiver Training)‏ H2025 and H2025 U1 (Pre-Vocational Services-Regular and High Intensity)‏ S5165 & 99199 U4 (Environmental Modifications and EM Maintenance)‏ T1999/T1999 U5 (Assistive Technology & AT Maintenance)‏ H2014 (In-Home Residential)‏ Revised Sept 201513

14. General DD Waiver Rules Enrollment into the DD Waiver is performed by DBHDS. The DMAS POC must be approved & received by KEPRO prior to the Srv Auth request being submitted. Total hours/units authorized cannot exceed the total hours approved on the DMAS POC. Any request for a change in hours/units, services, etc. require a revision to the DMAS POC prior to services being authorized. Revised Sept 201514

15. General DD Waiver Rules All Requests received prior to KEPRO's receipt of the DMAS approved POC will be pended for 5 business days. If the approved POC is not received during this timeframe, the request will be rejected and resubmission will be required upon verification that KEPRO has received the DMAS POC. Revised Sept 201515

16. T1019 (Agency Directed) & S5126 (Consumer Directed) Personal Care When an individual is re-admitted after discharge or transferred to a new provider, documentation of a new assessment (DMAS 99) must be uploaded with Srv Auth request. New assessment must be signed/dated on or before the new SOC date. Services cannot be authorized prior to date DMAS 99 is signed. If there is an increase or decrease in the amount of hours from the prior agency, a new provider Plan of Care (POC; DMAS 97A/B) and justification to support the change in hours must be uploaded for review. The DMAS POC must be revised prior to Srv Auth requests for readmissions, but is only required for transfer requests when there is a change in services/hours (i.e. More or less hours then previously authorized). Revised Sept 201516

17. T1019 (Agency Directed) & S5126 (Consumer Directed) Personal Care For Transfer Requests: Hours above the cap and services previously authorized may not be automatically re-authorized. Justification for these hours must be included with the Srv Auth request. Timely submission guidelines still apply for re- admissions and transfers just as a new request for both Agency and CD Personal Care. Please refer to the DD Waiver Provider Manual for Srv Auth submission criteria. Revised Sept 201517

18. T1019 (Agency Directed) & S5126 (Consumer Directed) Personal Care Attendants may not be the parents of minor children, the spouse of the individuals who are receiving waiver services or the family/caregivers that are directing the individual's care. Documentation must include the name of the attendant/aide and the relationship to the Waiver Individual. Revised Sept 201518

19. T1019 (Agency Directed) & S5126 (Consumer Directed) Personal Care For CD Respite - Attendants must not be the family/caregivers that are directing the individual's care. Respite Care cannot be authorized when services are rendered by the other family members who live under the same roof as the individual, UNLESS there is objective written documentation as to why there are no other providers available to provide care. Revised Sept 201519

20. T1019 (Agency Directed) & S5126 (Consumer Directed) Respite Care Respite services can be authorized past the DMAS POC plan year for 24 months. If submitting a respite transfer request, the new provider should only request the balance of hours remaining for the Waiver individual for that fiscal year. If there is no coordination of services with the previous Respite Care provider, the previous provider's Srv Auth must be discharged prior to the new provider obtaining a new Respite Care authorization. Revised Sept 201520

21. S5111 (Family Caregiver Training) Individuals can receive up to 80 hours of Family Caregiver Training (FCT) per POC year. Individuals must be receiving one other DD Waiver service; in addition to Case Management Services. Documentation must include name of the person who will receive the training and their relationship to the individual, as well as the name and title of the professional providing the training. Revised Sept 201521

22. S5111 (Family Caregiver Training) Training does not include school/college educational courses. Family is defined as unpaid people who live with or provide care to an individual on the Waiver. “Family” does not include people who are employed to care for the individual. FCT must be one of the following licensed professionals: Occupational Therapist, Physical Therapist, Speech Language Pathologist, Physicians, Psychologists, LCSW, LPC, RNs, and Special Education Teachers. Revised Sept 201522

23. H2025 (Pre-Vocational Services-Regular Intensity) and H2025 U1 (High Intensity)‏ Documentation must include specific information as to the type of services to be rendered. Revised Sept 201523

24. S5165 (Environmental Modifications), 99199 U4 (EM Maintenance) & T1999 (Assistive Technology) & T1999 U5 (AT Maintenance)‏ Any request for a change in cost (increase or decrease) requires a revision to the DMAS approved POC prior to Srv Auth. Description of item/modification submitted must match the name of the item/service and the total cost of the item as listed on the DMAS approved POC. Individual must be receiving one other DD Waiver service, in addition to Case Management Services. Revised Sept 201524

25. S5165 (Environmental Modifications), 99199 U4 (EM Maintenance) & T1999 (Assistive Technology) & T1999 U5 (AT Maintenance)‏ Maximum Medicaid funded expenditure is $5,000.00 per DMAS POC year for all EM and AT procedure codes combined (i.e. $5,000.00 for EM codes and $5,000.00 for AT codes). Total cost for an item/modification cannot be carried over from one POC year to another, i.e. Funding for a requested service/item cannot be split between 2 authorizations spanning the DMAS POC year.‏ Revised Sept 201525

26. H2014 (In-Home Residential)‏ Documentation must include the name of the In-Home Residential Support Provider and the relationship to the individual. Providers may be the members of the individual's family, but MAY NOT be the parent of minor child receiving services, individual's spouse, or a legally responsible relative or legal guardian for the individual. Services cannot be authorized when being rendered by other family members who live under the same roof as the individual, UNLESS there is objective written documentation as to why there are no other providers available to provide care. Revised Sept 201526

27. 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 and request 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. Revised Sept 201527

28. 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. Revised Sept 201528

29. 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, 2012. 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: https://www.virginiamedicaid.dmas.virginia.gov/wps/myportal/ProviderEnrollme nt. https://www.virginiamedicaid.dmas.virginia.gov/wps/myportal/ProviderEnrollme nt (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.) Revised Sept 201529

30. 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 Atrezzo Provider Portal Connect at http://dmas.KEPRO.com. http://dmas.KEPRO.com Revised Sept 201530

31. 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. Revised Sept 201531

32. Thank You Revised Sept 201532