Since originating this policy on Oct. 1, 2022 and receiving feedback from interested providers, Partners Health Management has created this FAQ resource. The original provider communication with details about the UM Prior Authorization Pass-through is available at https://providers.partnersbhm.org/provider-alert-nc-child-and-family-improvement-initiative-creates-rapid-access-to-residential-supports-for-children-and-youth/
- How should providers notify the UM reviewer at the LME/MCO that the Service Authorization Request (SAR) is a pass-through SAR?
The UM reviewer will review to determine whether there is a prior authorization on file for the member. If one is on file, a concurrent request (CR) will be initiated. If one is not on file, a notice of admission prior authorization (PA) will be issued without clinical review. Providers may include a note regarding notification authorization in the clinical justification section, although this is not a requirement.
- The SARs are all the same. How does the reviewer know it is a notification SAR versus a regular SAR before reviewing it whether the request is for an initial authorization or a concurrent authorization?
The UM staff review of a SAR will confirm whether the request is initial or concurrent. Per the response in item #1 above, providers are not required to note whether a SAR is a notification SAR. The UM reviewer will know when the pass-through applies to an eligible service.
- What is our protection against a recoupment if an LME/MCO determines after the fact that the pass-through did not meet medical necessity?
Medical Necessity requirements, as stated in Clinical Coverage Policy 8D-1, have not changed and apply to all SARs. Providers are encouraged to work closely with the parent/guardian, referring entity, and health plan staff upon receipt of a referral to ensure that documentation supports the medical necessity criteria defined in Clinical Coverage Policy.
- What is the effective date in reference to the referral form and the pass-through authorization?
The pass-through policy was effective Oct. 1, 2022. A Standardized Referral Form was also released on Oct. 1, 2022. The statewide referral form is for use by all Residential Providers and Therapeutic Foster Care (TFC) providers who contract with the LME/MCO.
- Frequently during emergency placements, we will have a Comprehensive Clinical Assessment (CCA) completed the day of or the day before a placement but do not have the actual written copy of the CCA. Can we submit a SAR stating that a CCA was completed and that we will send it once the written copy is received, or do we have to attach the CCA to the SAR within two days of placement?
Notification of admission does not require clinical justification or documentation at the time of the admission. Providers do not have to submit a CCA with the pass-through SAR. However, the pass-through SAR does not negate the responsibility for having the CCA in the file. Providers will submit the CCA if they request a length of stay LOS beyond the initial notification pass-through.
- If your facility was allowed to use a Master Treatment plan as opposed to a Person-Centered Plan (PCP), will the facility still be able to use the Master Treatment Plan with a signature page?
The facility may use a Master Treatment Plan or a Person-Centered Plan if the plan meets the requirements of a treatment plan in Clinical Coverage Policy 8D-1.
- Is a PCP required for the pass-through SAR/TAR for TFC/IAFT and PRTF clients under age 14?
A treatment plan is not required to be submitted to the LME/MCO for prior authorization. However, a treatment plan does need to be completed and in the record.
- Is the statewide referral system the same as Bedboard?
No, the statewide referral system is implementing a statewide referral form for children’s residential placements that all providers should transition to by Jan. 1, 2023.
- I was informed that PRTFs within 30 miles of the borders of NC and contracted with LME/MCOs are considered “in-network” and can do a pass-through. Is this correct?
Out-of-state placements within 40 miles of the NC border with providers that are contracted with the LME/MCOs are considered in-state and in-network providers, respectively. The PA pass-through applies to them also.
- Is pass-through authorization a once per lifetime benefit? If a child moves laterally from another provider, does the new provider get 180-day pass-through from admission? If a child discharges from the current agency and later returns, does the provider get 180-day pass-through from second admission? Is there an identified period that must lapse between discharge and readmission? In the case of a lateral move, how would the second provider submit for authorization? How would we know what is available for the remaining days in the pass-through?
The pass-through authorization is once per episode of treatment with a specific provider. If a member is entering a new episode of treatment with a new provider, he or she is eligible for a new pass-through. Discharge signifies the end of an episode of care. New admissions are defined as a new episode of care and an initial request. The previous pass-through time period will not apply to a new placement.
- Will providers receive a printed verification of authorization (for the pass-through) as they do now?
If approving a notification SAR, the LME/MCO will make approval verification available electronically.
- Will the pass-through authorization apply to day treatment services as well? We have been considered Group Living Moderate YP770 and not Level III. We only request day treatment services and are wondering whether the pass-through authorization will apply to our residential/day treatment services.
No, the pass-through authorization does not apply to day treatment services.
- Can we resubmit SARS for which we received a 1-month pass through and request 60 days instead?
The PA pass-through does not modify previously authorized dates of service. All submissions beyond the initial authorization will receive a Concurrent Request.
- Does the pass-through guarantee payment for 60 days if we have a CCA that recommends PRTF? In the past we have had CCAs from a licensed professional recommending our level of care, but they have been denied as the LME/MCO held that medical necessity was not met.
Authorization is never a guarantee of payment. All claims must include an active authorization but also be “clean claims” for payment to occur. Medical necessity requirements are still required to be met within the CCA.
- How is a TFC provider to know that a client does not already have a current pass-through authorization that was issued to another provider?
The pass-through will apply to a new episode of care and a new provider, so it is not incumbent on the new provider to be aware of a previous pass-through. If there is a need for this information for other reasons, providers are encouraged to request a Release of Information from the parent/legal guardian to request prior treatment/authorization history.
- Where in the Alpha portal do we select that we are requesting a pass-through authorization?
Specific to Alpha – There is no separate pass-through option, so please submit an initial authorization and the correct procedure code, and the UM reviewer will know whether the placement is eligible for the pass-through. Please indicate in the clinical section, “notification SAR for pass through.”
- How quickly does the SAR get processed for the pass-through? Is there ever any reason to ask for an expedited SAR now?
Pass-through notification SARS do not need to be expedited because there is no wait for a prior approval to admit the member.
- Is Black Mountain Licensing included in the conversation? They have documentation requirements prior to placement that may block use of the LME/MCO pass-throughs.
The pass-through does not negate requirements for any licensing components and assumes that the licensing requirements have already been met.
- Is submission of the standardized referral form required for the pass-through SAR/TAR?
The standardized referral form is never required for a SAR or TAR. The pass-through process and the use of the standardized referral form are distinct.
- What if a provider requests an enhanced rate for a residential placement eligible for the pass-through?
These are two distinct business processes. The placement would be eligible for the pass-through. The request for an enhanced rate would require formal approval.