(AAL)Waiver - KEPRO / DMAS Home

Report
INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT
Service Authorization
for Alzheimer's
Assisted Living
Waiver (Service Type
0980)
Presented by: KePRO
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Methods of Submission Service Authorization
Requests to KePRO
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Please note that for Alzheimer's Assisted Living Waiver, all requests
must be submitted via KePRO’s Atrezzo Connect System
To access Atrezzo Connect on KePRO’s website, go to
http://dmas.kepro.com.
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Provider registration is required to use Atrezzo Connect.
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The registration process for providers happens immediately on-line
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From http://dmas.kepro.com, providers not already registered with
Atrezzo Connect may click on “Register” to be prompted through the
registration process. Newly registering providers will need their 10digit National Provider Identification (NPI) number and their most
recent remittance advice date for YTD 1099 amount.
•
The Atrezzo Connect User Guide is available at
http://dmas.kepro.com : Click on the Training tab, then the General
tab.
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Service Authorization Requests: Contact
Information for KePRO/ DMAS Provider Information
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Providers with questions about KePRO’s Atrezzo Connect Provider Portal
may contact KePRO by email at [email protected]
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For service authorization questions, providers may contact KePRO at
[email protected]
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KePRO may also be reached by phone at 1-888-827-2884, or via fax at 1877-OKBYFAX or 1-877-652-9329.
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Medicaid Memoranda and Manuals
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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.
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This link opens up a page that contains all of the various communications
to providers, including Provider Manuals and Medicaid Memoranda.
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The Internet is the most efficient means to receive and review current
provider information.
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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-Martin at 1-804-780-0076. A fee will be charged for
the printing and mailing of the manual updates that are requested.
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Service Authorization Information Specific to
Alzheimer's Assisted Living (AAL)Waiver
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Purpose:
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Allow individuals to remain in a home-like setting for a long as possible

Provide relief for caregivers.
Remain in an environment that maximized their autonomy, privacy,
and dignity even if they require a high level of services
This service is provided in an Assisted Living Facility (ALF) that is licensed
by 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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Service Authorization Information Specific to
Alzheimer's Assisted Living (AAL)Waiver
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Providers must submit documentation to KePRO within 10 business
days of initiation of care or providers verification of Medicaid
eligibility.
If request is not submitted within 10 business days, the service
must be authorized beginning with the date the information was
received by KePRO.
• Requests for Alzheimer's Assisted Living Waiver must contain the
following:
– Completed AAL Waiver questionnaire via Atrezzo Connect for
new admissions, readmissions, or continuation of care
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Service Authorization Information Specific to
Alzheimer's Assisted Living (AAL)Waiver
• 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
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Eligible Members include individuals who are:
Enrolled in Medicaid Fee-For-Service (FFS)
In the following Aid Categories:

012 Aged Auxiliary Grant Recipient (includes
dually eligible QMB)

032 Blind Aged Auxiliary Grant Recipient
(includes dually eligible QMB)

052 Disabled Auxiliary Grant Recipient (includes
dually eligible QMB)
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Criteria for Alzheimer's Assisted Living (AAL)Waiver
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The member must be:
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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 determined
by a preadmission screening team using the full UAI
Must have a diagnosis of Alzheimer's or a related dementia as
diagnosed 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 10th Edition, or a serious mental illness as
defined in 42 CFR 483.102 (b).
Must be receiving an auxiliary grant and residing in or seeking
admission to a safe, secure unit of a DMAS approved ALF
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Criteria for Alzheimer's Assisted Living (AAL)Waiver
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All admissions to the AAL Waiver are subject to preadmission screening
prior to admission to the waiver. Under no circumstances are AAL Waiver
admission 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 the
enrollment date of the waiver.
The Medicaid authorization code on the DMAS 96 must be either

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
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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 package
is not valid. The DMAS-96 form is the actual authorization form for long
term care services.
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Alzheimer's Assisted Living (AAL)Waiver
Questionnaire
• The questionnaire is used to submit all request
to KePRO for srv auth.
• Requests are submitted by direct data entry
only.
• The Alzheimer’s Assisted Living Waiver
questionnaire must be completed in it’s entirety
to request services for new admissions,
readmissions or continuation of care.
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AAL Waiver Questionnaire
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AAL Waiver Questionnaire
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AAL Waiver Questionnaire
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AAL Waiver Questionnaire
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AAL Waiver Questionnaire
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AAL Waiver Questionnaire
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General Information for All Service Authorization
Submissions
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KePRO’s website has information related to the service authorization processes for
all DMAS programs they review. Questionnaires and much more are on KePRO’s
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 the
provider 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 supervisor
for 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.
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General Information for All Service Authorization
Submissions
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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 KePRO’s 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
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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 KePRO’s Provider Portal at http://dmas.kepro.com.
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ELIGIBILITY VENDORS: How to check for Member
Eligibility
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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 Solutions – Health Services
• Foundation Enterprise Systems/HDX
• www.hdx.com
• Telephone: 1 (610) 219-2322
– Emdeon
• www.emdeon.com
• Telephone: 1 (877) 363-3666
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DMAS Helpline Information
• The “HELPLINE” is available to answer questions Monday through
Friday from 8:00 a.m. to 5:00 p.m., except on holidays.
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The “HELPLINE” numbers are:
– 1-804-786-6273
– 1-800-552-8627
Richmond area and out-of-state long distance
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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INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT
Questions???
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