Virginia Regulatory Town Hall
Department of Medical Assistance Services
Board of Medical Assistance Services
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6/18/22  8:52 am
Commenter: Anonymous

Community Stabilization Authorization Review Process

With Community Stabilization changing to an authorization request instead of registration, there are a couple concerns from a provider perspective:

1) MCO interpretation of medical necessity criteria has shown to be inconsistent for other services. It will be essential for this service that MNC be applied consistently. Creating an authorization form that allows minimal interpretation or subjective content would be helpful. Additionally, as MCOs are indicated as a referring entity, it will be essential for MCO Care Coordinators to have an appropriate understanding of the service definition and MNC. The provider experience has been that often Care Coordinators make referrals for a service only for that service to be denied by the MCO's utilization team. These inconsistencies would create a detriment to persons served as seemingly appropriate admissions would be interrupted if MCOs do not interpret and apply MNC consistently. With the intention of Community Stabilization being to mobilize effective community supports that do not yet exist, abruptly ending a service will place the individual at risk of returning to a higher level of care unnecessarily. The more flexibility MCOs have to interpret and apply MNC, the more commonly that will occur.

2) The time frame for MCO response to Community Stabilization authorization requests should be indicated. Categorizing Community Stabilization as an Urgent request type per NCQA or indicating a specific time frame would be helpful. Currently it is indicated that providers must submit requests within 1 business day of admission. However, there is no indication of the time frame in which MCOs must review and respond to a request. Due to the nature of service, services must start immediately to be effective. Providers are therefore expected to serve individuals with no authorization during the review time frame. While it is the provider's responsibility to ensure the individual meets MNC, flexibility on the part of the MCO to interpret and respond to requests will ultimately create an undue burden on providers. 

3) Currently, the assessment for services cannot be billed separately for Community Stabilization services. It is billed as part of service provision under S9482. If that will continue to be the case now that the service requires authorization, then the provider could not be reimbursed for time taken to assess the individual and identify if MNC are met. 

Ultimately, it would be helpful for a provider be able to render services for a limited number of units regardless of approval. 

CommentID: 122142