Obtaining State Administrative Prior Authorization - NJSAMS

Obtaining State Administrative Prior Authorization
April 12, 2016
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Prepare for contract conversion to avoid interruptions in care to consumers and payment to providersTo educate providers on the specific process of obtaining administrative authorizations for the new initiatives. These initiatives were developed for the contract conversion from slot to FFS.Substance Abuse Prevention and Treatment Initiative (SAPT) - Methadone servicesNew Jersey Statewide Initiative (NJTI) - fall other slot based servicesThese instructions apply only one time, for the transition process.
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Goals for Webinar
Medicaid and State Services –AdministrativeAuthorization-Authorizationsgenerated by IME or State to assure that existing clients have an authorization when IMEclinical review processbeginsand/or slot contractsare converted to FFS.These authorizationswill be issued for one time only.ClinicalAuthorization– Authorization by the IME after reviewing the client DSM, LOCI and Levels of FunctioningContinuing CareReview (CCR)-Continuing Care is a clinical review that is currently called the Extension Request.Prior Authorization (PA)-Any type authorizationState ServicesProvider Authorization-Authorization generated by provider directly with theState FiscalAgent.Is not reviewedor generated by the IME.
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Authorization Types
Individuals served in slots on June 30, 2016 will need PAs on July 1, 2016NJSAMS will auto generate PA numbers for Core PackagesDMHAS will designated the packageOTP Providers will need to designate the Phase ofTxProviders will obtain Enhancements on July 1, 2016, through the existing mechanisms, and will not need the IMEConsumers with an Administrative PA will need an IME clinical review at ERL/Continuing Care Review or any new LOC, Provider, Payer
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Administrative Authorizations for consumers served in slots
OnJune 1 DMHASwill make available a link to a listof individuals inslots,according toNJSAMS dataLink will be in Reports Menu of NJSAMS-Slot Conversion ListProviderswill indicate who from their list of consumers will need an authorization for treatment starting July 1Providers will get the number of PAs that correspond to their slot contract,ie. If a provider has 20Outpatient Patientslots, they will be issued no more than 20 PAs forOPfor July 1AdditionalPAs for services may be obtained based on available funding
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Admin PA forConsumersserved in slots/ What Providers Must Do
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Sample of Provider List
List must becompleted onJune15Consumers admitted to slots after June 15 can be added to the list until June 30Anauthorization fortheconsumerswho do not have a PA as of July 1, canbe secured through the IMEstarting onJuly 2
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Admin PA for clients served in slots/ What Providers Must Do
If list isnotupdated by provider,PAs can not begeneratedIf PAs are not auto generated the individual served will be treated as a new client and will need review by the IME on July 2Due to increased volume, the IME response to a PA request for consumers served in slots may bedelayed after June 30.Providers will be required to bill within the first 15 days of the new authorization
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Administrative PA for Consumers served in slots
Clients who are Medicaid enrolled will not be issued a state PA (for Medicaid covered services)Lists in NJSAMSwill indicate which clients are Medicaid enrolled, and will not allow provider to indicate yes or no to question of PAneededThe IME willwork to issueMedicaid PA numbers for individuals on the list who are Medicaid enrolled and services are Medicaid covered
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Medicaid Enrolled Individuals in Slots
MedicaidIn Medicaid PA module of NJSAMS availablestarting onMay 24, 2016Hard copy confirmation from MolinaStateIn the NJSAMS Authorization Module
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Notification of Administrative PA numbers
Admin PAs will be issuedbased on the information in NJSAMSWe will not make changes to NJSAMS from lists(ie. If you mark the list that you need an alternative LOC for an individual but you have not changed the LOC in NJSAMS, the PA will reflect what is in NJSAMS, not what is on your list)To assure that the correct PAs are issuedNJSAMS,files must be up todate:Allconsumer files represent individuals currently in treatmentFunding source chosen inNJSAMS is “DAS Slot”LOC in NJSAMS is correctTo streamline the process, please assure that NJSAMS files are correct and current ASAP
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Importance of NJSAMS Accuracy
It is the provider’s responsibility to assure that there is a PA for each eligible individual for the correct level of care and funding source.We will do our best to make sure thatPAsare issued, but ultimately it is up to providers to obtain a PA.If a PA is not obtained administratively, the request should go through the IME on July 2Wewill not pay forservices delivered afterJuly 1 without a PA (can backdate5days)
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NJSAMS Accuracy,cont
June 1 –Providerslistof consumers in slotswill be available on NJSAMS portalJune 15-Provider mustupdate the list indicatingwhich clients require PAsJune 30– Slot contract terminatedJuly1– Auto generated FFS authorizations issued for clientsJuly 1-NJSAMS unavailableJuly 2- NJSAMS becomes availableJuly 15, 2016– Provider must bill on state PA number or it will cancel due to zero utilization
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Timeline
Please submit questions and concerns to the MBHO mailbox at:MBHOInput@dhs.state.nj.usDo not submit a NJSAMS ticket for issues related to the lists and PAs issued
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Contact Information
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Questions