EPSDT Serv Auth Info
DD Manual Appendix B
Manual Pg 1
Purpose of Service Authorization: The purpose of service authorization is to validate that the service requested is medically necessary and meets DMAS criteria for reimbursement. All requests for SA shall be submitted to Department of Behavioral Health and Developmental Services (DBHDS) by the individual’s support coordinator through the DBHDS Waiver Management System (WaMS). Service authorization does not guarantee payment for the service; payment is contingent upon passing all edits contained within the claims payment process, the individual’s continued Medicaid/FAMIS eligibility, the provider’s continued enrollment as a DMAS provider, and ongoing medical necessity for the service. Service authorization is specific to an individual, a provider, a service code, an established quantity of units, and for specific dates of service. Service authorization is performed by DMAS or by a contracted entity.
This section of the manual seems to be more restrictive than the regulations (12VAC30-122-80):
The first sentence in this section: “medically necessary” is not mentioned in the regulations.
payment to the provider is “contingent upon passing all edits contained within the claims payment process…, and ongoing medical necessity for the service” is not detailed in the regulations.
Manual Pg 1
General Information Regarding Service Authorization: Various submission methods and procedures are fully compliant with the Health Insurance Portability and Accountability Act (HIPAA) and other applicable federal and state privacy and security laws and regulations. Providers will not be charged for submission, via any media, for SA requests. The SA entity will approve, pend, reject, or deny all completed SA requests. DBHDS will be authorizing the following services under EPSDT:
0090, 0098 - EPSDT Private Duty Nursing (Congregate RN and LPN)
0092 – EPSDT Assistive Technology
The term “SA entity” is used all throughout this manual. Also, the term “SA contractor” is used.
Please clarify who/what the “SA entity” is for providers.
Please clarify who/what the “SA Contractor” is for providers.
Please explain the difference for them
Please provide the service authorization requirements for each of them.
Manual Pg 2, paragraph 1, 3rd sentence
“It is the provider’s responsibility….”
The term “provider” is used interchangeably throughout the manual. It is used to describe various providers of services from an Agency provider to a direct care provider. These providers have very distinct roles and responsibilities. It would be helpful if the manuals detailed which providers in particular are being referenced. This will be helpful later to all providers of services when they are being held accountable to requirements that may not fit their service model.
This supplement details Assistive Technology and Private Duty Nursing through the individuals EPSDT benefit. On the table of contents, Personal Care Services is mentioned, but there is not a detailed section of it’s benefits. Exhibit 1 is 1 of 2 mentions for Personal Care “These EPSDT Services are available to members enrolled in the FAMIS Fee-for-Service (FFS) benefit: Assistive Technology, Private Duty Nursing, Hearing Aids, “traditional” Inpatient services, Behavioral Therapy and Personal Care.” Personal Care Services through an individual's EPSDT benefit on one of the DD Waivers (CL/FIS) should have a detailed Service Authorization Information Section for provider reference.