​DHS COVID-19 PROVIDER RESOURCES // OMAP

Provider Quick Tips #241: Prior Authorization Changes in the Medical Assistance Program for Certain Services during COVID-19 Emergency Disaster 

Issued: May 7, 2020

To reduce the burden on providers and patients during the COVID-19 pandemic, the Department of Human Services will be changing the authorization requirements for certain services. These changes will be implemented in the Medical Assistance Fee-for-Service Program (MA FFS) and the Physical Health and Community HealthChoices managed care delivery systems. This guidance should apply to in-network and out-of-network services for the Physical Health and Community HealthChoices Managed Care Organizations (MCO)s. Beginning with dates of service on or after the release of this guidance, the authorization requirements listed below are applicable for all diagnoses during the COVID-19 emergency disaster declaration. 

Please note, the change of prior authorization is not applicable to items and services reviewed through the program exception process. Items and services requiring a program exception will continue to require authorization. 

While the authorization requirements will be suspended for claim payment purposes as specified below, services will be subject to a retrospective review for medical necessity. The retrospective review applies to claims paid by MA FFS and the Physical Health and Community HealthChoices MCOs. 

This guidance will be in place while a valid disaster declaration authorized by the Governor for the COVID19 virus remains in effect. 

Services with a change to the authorization requirement:

• Inpatient Hospital Admissions — That are of an emergency or urgent need do not require prior authorization. Please note while the authorization requirement will be suspended for payment purposes, emergency and urgent admissions and readmissions will be retrospectively reviewed post payment; thus, the authorization must be submitted within 180 days of the discharge date.
  For inpatient hospitalization admissions for the Physical Health or Community HealthChoices MCOs, hospitals are required to notify the MCO of the admission within 48 hours of admission for purposes of discharge planning and ensuring continuity of care through the process the hospital would normally use to notify the MCOs.
• Long-Term Acute Care Hospitals — For the Physical Health or Community HealthChoices MCOs, prior authorization is not required for the first 7 days of care. Prior authorization will be required for services after the first 7 days. For MA FFS, long-term acute care hospitals should follow guidance for other inpatient hospital admissions.
  Long-term acute care hospitals are required to notify the Physical Health or Community HealthChoices MCO of the admission within 48 hours of admission for purposes of discharge planning and ensuring continuity of care through the process the hospital would normally use to notify the MCOs.
• Home Health — Prior authorization is not required for the first 28 days of service. Continuation of services beyond the initial 28 days will require prior authorization.
  Home Health Agencies are required to notify the Physical Health or Community HealthChoices MCO of the initiation of services within 48 hours of beginning services for purposes of discharge planning and ensuring continuity of care through the process the agency would normally use to notify the MCOs to obtain prior authorization from the MCOs.
  In MA FFS, home health visits provided beyond 28 days require the use of a UD modifier on the claim, per the PA PROMISe Provider Handbook. When the UD modifier is required on the claim, authorization for the service is also required. 
• Hospice Services — for the Physical Health and Community HealthChoices MCOs, prior authorization is not required for the first 30 days of care. Prior authorization will be required for continuation of services after the first 30 days. Prior authorization of hospice services is not required for the MA FFS program.
• Radiology — prior authorization of CT scans of the chest related to the diagnosis or treatment of COVID-19 is not required
• Medical Supplies and Durable Medical Equipment (DME) — Prior authorization is not required for the medical supplies and DME noted on the list attached to this document as specified.
• Shift Nursing — this applies to services authorized and billed using procedure codes S9122, S9123 and S9124.
  Children under the age of 21 that are receiving shift nursing, as of the date this document is issued, can continue to receive the currently authorized hours of care without the need for reauthorization.
  For children under the age of 21, requests to increase the number of hours beyond what is currently authorized as of the date this document is issued will require prior authorization. Once the increase in services are authorized, the authorized hours of care will continue without need for reauthorization.
  For children under the age of 21 who are not currently receiving shift nursing as of the date this document is issued prior authorization of these services will be required before they can be initiated. Once services are authorized, the authorized hours of care will continue without need for reauthorization.
• Inpatient Rehabilitation Services — Prior authorization is not required for the first 7 days of care. Prior authorization will be required for continuation of services after the first 7 days.
  Inpatient Rehabilitation facilities are required to notify the Physical Health or Community HealthChoices MCO of the admission within 48 hours of admission for purposes of discharge planning and ensuring continuity of care through the process the facility would normally use to notify the MCOs to obtain prior authorization from the MCOs.
• Skilled Nursing Facility Services — prior authorization is not required for the first 30 days of skilled nursing facility care. Prior authorization will be required for continuation of services after the first 30 days.
  Skilled Nursing facilities are required to notify the Physical Health or Community HealthChoices MCO of the admission within 48 hours of admission for purposes of discharge planning and ensuring continuity of care through the process the facility would normally use to notify the MCOs to obtain prior authorization from the MCOs.