FAQ – Medicaid Provider Centralized Prior Authorization ... - WellCare

FAQ – Medicaid Provider Centralized Prior Authorization Process
Phase I
Answers to your most common questions regarding the centralized prior authorization (PA) process have
been listed below. Contact the specific CMO Provide Services department if your question is not listed.
Georgia Centralized Portal Prior Authorizations
1. What type of documents or PAs should be submitted on the Centralized PA Portal
beginning 6/1/2013?
Newborn Delivery Notification and Pregnancy Notifications are the two document types that should
be submitted using the Centralized PA Portal. The Newborn Delivery Notification will be used to
create the maternal delivery authorization. The Pregnancy Notification will be used to create the
maternal global OB PA in the CMO’s systems.
2. How do I submit the Newborn Delivery and Pregnancy Notification Form?
When you log into the Georgia Web Portal follow the steps below:
• Select Prior Authorization
• Select Provider Workspace
• Select Enter a New Authorization
• Select Newborn Delivery Notification Form or Pregnancy Notification Form
• Complete all required information
Note: The admit date in the Newborn Delivery Notification is the actual date that the mom was
admitted to the hospital. All of the newborn delivery information will be located under the heading
“Baby#: New”: If the mom delivered more than one baby, you can simply select “add another
baby” located on the right side of the screen.
3. Will I also need to submit a request for a maternal delivery PA?
No. The Newborn Delivery Notification will be used to create the maternal delivery authorization in
the CMO’s system. You will not need to submit a request for the maternal delivery authorization.
The PA number for the maternal delivery will be placed on the Centralized PA Portal site for your
use when submitting the maternal delivery claim. This process will be the new process for
requesting a maternal delivery PA. Providers will always need to submit the newborn delivery
information before the CMOs can create a maternal delivery PA.
4. How will the Pregnancy Notification be used?
The Pregnancy Notification will be used to create the maternal global authorization and to notify the
CMOs that a member has a high risk pregnancy. The OB members with high risk pregnancies will
be enrolled into the CMOs case management program. Low risk members may be contacted by
the CMO to discuss their pregnancy needs.
5. Who should submit a Prior Authorization request using the Centralized portal beginning on
7/1/2013?
Any participating Georgia Medicaid provider requesting an inpatient or outpatient hospital or an
ambulatory surgery service PA (Place of Service (POS): 21, 22, 24 respectively) should submit
their request using this new process during Phase I. PAs for in-state transplants, hospital
outpatient therapy, reconsideration request and submission of initial and additional clinical data
should be submitted on the centralized portal. The CMO portal should not be used after 7/1/2013
to submit the PA types listed.
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FAQ – Medicaid Provider Centralized Prior Authorization Process
Phase I
The exception to this process is for inpatient Behavioral Health (BH) services. You will need to go
to the CMO’s web portal to enter these PA request. BH services are not a part of the Phase I
Centralized Web Portal implementation.
6. Are there any PA submission exceptions for any service types or POS 21, 22, 24?
The exception to this process is for inpatient Behavioral Health (BH) services and services handled
by CMO third party vendors (dental, vision, radiology etc). You will need to go to the CMO’s web
portal to enter BH request and the vendor’s portal to enter these types of PA request. BH and
vendor services are not a part of the Phase I Centralized Web Portal implementation.
7. What type services should be submitted using this new Centralized Prior Authorization
process?
All inpatient service, outpatient services performed in a hospital setting only and ambulatory
surgery requests should all be entered into the Centralized PA portal. These services have a
Place of Service (POS) code of 21, 22 and 24 respectively. PAs for in-state transplants, hospital
outpatient therapy, reconsideration request and submission of initial and additional clinical data
should be submitted on the centralized portal. The CMO portal should not be used after 7/1/2013
to submit the PA types listed.
8. Will I be able to determine if a service requires a PA by a specific CMO?
Yes. When you enter the Georgia centralized PA portal, you will have an opportunity to review the
CMO’s specific authorization rules by selecting a designated hyperlink option located directly on
the portal site. As a reminder, all CMO out-of-network providers must obtain a prior authorization
before providing non-emergency services even if you are a participating Georgia Medicaid program
provider.
9. If I need to request a PA for radiology or other services where the CMO has a contracted
vendor (Vision, dental, BH) and the service is performed in an outpatient hospital setting,
should I use this process?
No. You should visit to the CMO’s website to identify their specific vendor responsible for
administering services and follow the published protocols for submitting a request for prior
authorization related to these vendor contracted services. These services are not included in
Phase I of this process.
10. If I use this process, is my request a guaranteed of payment?
No.
11. Are Behavioral Health (BH) inpatient admissions or outpatient services a part of Phase I of
the Centralized Prior Authorization Process?
No.
12. Can I use the Centralized Prior Authorization portal to submit newborn delivery
information?
Yes, you should enter all newborn delivery information into the centralized PA portal. This
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FAQ – Medicaid Provider Centralized Prior Authorization Process
Phase I
information will be entered on the Newborn Delivery Notification form located under the delivering
mother’s PA. To complete this process you should go to the portal, select Newborn Delivery
Notification Form and enter the delivering mother’s Medicaid number and provider information.
Complete all of the required information requested for the mom at the top of the request. The
“admit date” is the actual date that the mom was admitted to the hospital. All newborn information
will be entered in the fields at the bottom of the page under “Baby#: New”.
13. Can I use the Centralized Prior Authorization portal to identify high risk pregnancies that
need case management?
You can complete the Notification of High Risk Pregnancy form. This will alert the CMO’s Case
Management department that you have a member who may need to have help with coordinating
their care during this pregnancy.
14. Can I submit a Prior Authorization request using the Centralized PA web portal if I am not a
participating network provider with any of the CMOs?
CMO out-of-network providers who are, yet, participating in the Georgia Medicaid program can
submit PA using this process. Approval of these requests is not guaranteed. The CMO may opt to
steer the requested service to an in-network provider if applicable. If prior authorization is not
obtained for out-of network services, reimbursement will be denied.
15. Who can I contact to get additional information about the Centralized PA web portal
process?
You may go to the DCH provider portal at www.mmis.georgia.gov to obtain more information. You
can contact the specific CMO using the contact information listed below:
CMO Name Provider Services Web Site
WellCare 1-866-300-1141 https://georgia.wellcare.com/provider/resources
Peach State 1-866-874-0633 http://www.pshpgeorgia.com/provider-quick-reference-information/
Amerigroup 1-800-454-3730 https://providers.amerigroup.com/pages/ga-2012.aspx
16. What identification number do I need to use to submit my claim? The tracking number or
the authorization number?
As you do today, you must use the CMO Authorization Number provided instead of the Reference
Tracing Number to submit your claims payments to the CMO.
17. What number should I use if my PA was denied and I want to submit an Appeal?
You should use the “Reference Number” listed on the Centralized PA portal or the number listed on
the denial letter that is sent to you by the CMO. Do not use the Centralized PA portal to submit
your appeal. Follow the CMO’s current outlined appeal submission process.
18. What types of PAs are appropriate to be submitted via fax or telephone?
PA telephone or fax request are appropriate to facilitate hospital discharge, to maintain the health
and well being of the member, or when emergency services are required. Telephone or fax PAs
are not appropriate for services that can otherwise be processed and authorized by using the
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FAQ – Medicaid Provider Centralized Prior Authorization Process
Phase I
Georgia Centralized PA web portal.
19. What if the CMO request additional information related to a PA that was entered on the
GMCG portal?
For the CMO PA reviewer to determine if a service or procedure is medically reasonable and
necessary, the PA vendor may request more information from the provider. The CMO must
receive this information within 24-48 hours of the request, unless otherwise specified, or the PA
request is systematically denied.
Benefits and Eligibility
20. Must I verify member eligibility prior to the delivery of healthcare services?
Yes. You must verify eligibility whenever a Medicaid member presents to your office or facility. You
can check member eligibility by going to www.mmis.georgia.gov.
Claims
21. If there is coordination of benefits applicable, what insurance coverage is primary?
Medicaid is always the payer of last resort. Worker’s Compensation, automobile coverage and any
other liability insurance or payment is always primary.
22. If Medicaid is secondary, is it necessary to get authorization from the CMOs?
Yes. The CMOs require that you obtain an authorization from our prior authorization department
regardless of whether the CMO is the member’s primary or secondary insurance.
23. Why didn’t I get paid correctly for services that have been authorized?
There are a number of possible answers. In some cases, the services authorized are different than
the services billed. This can occur because individual CPT or HCPCS codes differ between
authorization entry and claim billing.
Also, dates of service authorized may vary from the dates of service shown on the form. It is
important to make sure that both the persons calling for prior authorization and the billing staff have
a common understanding about exactly what services have been authorized and delivered.
24. When, if ever, am I allowed to bill the member for balances due?
The general rule to follow for the CMO Medicaid line of business is that the member cannot be
balanced billed. If you disagree with a claim payment decision, you should appeal the claim
decision to the CMO and not attempt to collect any monetary funds directly from the member. The
member may be billed only if 1) the member knows that the service he or she is requesting is not a
covered benefit and agrees to have the service performed by the provider.
25. If a member has other insurance, what is Medicaid’s payment liability?
Medicaid is always the payer of last resort. If a member has other active coverage, such as
Medicare or Blue Cross, the Medicaid liability is limited. Specifically, payment will be made only up
to the contracted Medicaid rate. So if a primary insurer has paid more than Medicaid would have
paid if its coverage were primary, then no additional reimbursement will be made.
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FAQ – Medicaid Provider Centralized Prior Authorization Process
Phase I
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