Alzheimer Waiver

8/12/2019 Alzheimer Waiver

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Service Authorization

for Alzheimer'sAssisted Living

Waiver (Service Type

0980)

Presented by: KePRO

INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT

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Service Authorization Requests: Contact

Information for KePRO/ DMAS Provider Information

Providers with questions about KePROs Atrezzo Connect Provider Portalmay contact KePRO by email at [email protected].

For service authorization questions, providers may contact KePRO at

[email protected].

KePRO may also be reached by phone at 1-888-827-2884, or via fax at 1-

877-OKBYFAX or 1-877-652-9329.

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mailto:[email protected]:[email protected]:[email protected]:[email protected]


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Medicaid Memoranda and Manuals

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-Martinat 1-804-780-0076. A fee will be charged for

the printing and mailing of the manual updates that are requested.4


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Service Authorization Information Specific to

Alzheimer's Assisted Living (AAL)Waiver

Purpose: Allow individuals to remain in a home-like setting for a long as possible

Remain in an environment that maximized their autonomy, privacy,and dignity even if they require a high level of services

Provide relief for caregivers.

This service is provided in an Assisted Living Facility (ALF) that is licensedby the Department of Social Services with a safe and secure unit. ALF

providers must be approved by the Long Term Care Division of DMAS in

order to become an enrolled Medicaid AAL Waiver Provider.

Only DMAS approved ALF providers are able to admit individuals into

Alzheimer's Waiver

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Providers must submit documentation to KePRO within 10 businessdays of initiation of care or providers verification of Medicaid

eligibility.

If request is not submitted within 10 business days, the servicemust be authorized beginning with the date the information wasreceived by KePRO.

Requests for Alzheimer's Assisted Living Waiver must contain the

following:

Completed AAL Waiver questionnaire via Atrezzo Connect fornew admissions, readmissions, or continuation of care

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AAL Waiver Procedure Code= T2031

Service Limit

The authorization is for a span of up to 365 days, 1 unit per day

frequency

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Member Eligibility for Alzheimer's Assisted Living

Waiver

Eligible Members include individuals who are: Enrolled in Medicaid Fee-For-Service (FFS)

In the following Aid Categories:

012 Aged Auxiliary Grant Recipient (includesdually eligible QMB)

032 Blind Aged Auxiliary Grant Recipient(includes dually eligible QMB)

052 Disabled Auxiliary Grant Recipient (includesdually eligible QMB)

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Criteria for Alzheimer's Assisted Living (AAL)Waiver

The member must be: Elderly as defined by 1614 of the Social Security Act or

Disabled as defined by 1614 of the Social Security Act

Must meet criteria for admission to a nursing facility as determinedby a preadmission screening team using the full UAI

Must have a diagnosis of Alzheimer's or a related dementia asdiagnosed by a licensed clinical psychologist or a licensed

physician. The member may not have a diagnosis of mental

retardation as defined by the American Association on Mental

Retardation in Mental Retardation-Definition, Classifications, and

Systems of Supports 10thEdition, or a serious mental illness as

defined in 42 CFR 483.102 (b).

Must be receiving an auxiliary grant and residing in or seekingadmission to a safe, secure unit of a DMAS approved ALF 9


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Criteria for Alzheimer's Assisted Living (AAL)Waiver

All admissions to the AAL Waiver are subject to preadmission screeningprior to admission to the waiver. Under no circumstances are AAL Waiveradmission to be approved without the necessary and required

preadmission screening documentation in place (this includes DMAS 96

and UAI)

The physician signature on the DMAS 96 must be on or prior to theenrollment date of the waiver.

The Medicaid authorization code on the DMAS 96 must be either 16 Alzheimer's Assisted Living Waiver

01 Nursing Facility Placement

04 Elderly or Disabled with Consumer Direction

If there is not DMAS 96 form present, the preadmission screening packageis not valid. The DMAS-96 form is the actual authorization form for long

term care services.

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Questionnaire

The questionnaire is used to submit all requestto KePRO for srv auth.

Requests are submitted by direct data entryonly.

The Alzheimers Assisted Living Waiver

questionnaire must be completed in its entiretyto request services for new admissions,

readmissions or continuation of care.11


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AAL Waiver Questionnaire

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General Information for All Service Authorization

Submissions

KePROs website has information related to the service authorization processes for

all DMAS programs they review. Questionnaires and much more are on KePROs

website. Providers may access this information by going to http://dmas.kepro.com.

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 theprovider time to submit additional documentation to KePRO for review

Do not send responses to pends piecemeal since 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 supervisorfor 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.18
http://dmas.kepro.com/http://dmas.kepro.com/


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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.

Requests will be rejected if required demographic information is absent.

Providers should take advantage of KePROs web based

checklists/information sheets for the services(s) being requested. These

sheets provide helpful information to enable providers to submit

information relevant to the services being requested. 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.

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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.

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 KePROs Provider Portal athttp://dmas.kepro.com.

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http://www.virginiamedicaid.dmas.virginia.gov/http://dmas.kepro.com/http://dmas.kepro.com/http://www.virginiamedicaid.dmas.virginia.gov/


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ELIGIBILITY VENDORS: How to check for Member

Eligibility

DMAS has contracts with the following eligibility verification vendors

offering internet real-time, batch and/or integrated platforms.

Eligibility details such as eligibility status, third party liability, and service

limits for many service types and procedures are available.

Contact information for each of the vendors is listed below:

Passport Health Communications, Inc.

www.passporthealth.com, [email protected]

Telephone: 1 (888) 661-5657

SIEMENS Medical SolutionsHealth Services

Foundation Enterprise Systems/HDX

www.hdx.com

Telephone: 1 (610) 219-2322

Emdeon

www.emdeon.com

Telephone: 1 (877) 363-3666 21
http://www.passporthealth.com/mailto:[email protected]://www.hdx.com/http://www.emdeon.com/http://www.emdeon.com/http://www.hdx.com/mailto:[email protected]://www.passporthealth.com/


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DMAS Helpline Information

The HELPLINE is available to answer questions Monday throughFriday 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.

Please have your Medicaid Provider Identification Number

available when you call.

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Questions???

INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT

23

Alzheimer Waiver

Documents

Transcript of Alzheimer Waiver