DHS COVID-19 PROVIDER RESOURCES // OMAP
Medical Assistance Bulletin 99-21-03:
Reinstatement of Prior Authorization Requirements for Certain Services
Issued: April 30, 2021; Effective: July 1, 2021
Important Reminder: All providers must revalidate the Medical Assistance (MA) enrollment of each service location every five years. Providers should log into PROMISe™ to check the revalidation dates of each service location and submit revalidation applications at least 60 days prior to the revalidation dates. Enrollment (revalidation) applications may be found at https://www.dhs.pa.gov/providers/Providers/Pages/PROMISeEnrollment.aspx.
Purpose
The purpose of this bulletin is to inform providers that, effective July 1, 2021, the Department of Human Services (Department) will reinstate the prior authorization requirements that were in place on February 29, 2020, and suspended in Provider Quick Tip #241, in the Medical Assistance (MA) Fee-for-Service (FFS) delivery system for all services with the exception of shift care services provided to children under the age of 21.
Scope
This bulletin applies to all providers enrolled in the MA Program who render services to MA beneficiaries in the FFS delivery system. Providers rendering services in the managed care delivery system should contact the appropriate managed care organization (MCO) regarding any questions related to prior authorization requirements. The MCOs may reinstate the prior authorization requirements for services in Provider Quick Tip #241 with the exception of shift care services. Prior authorization of shift care services continue to be suspended in both the FFS and managed care delivery systems.
Background/Discussion
On May 7, 2020, the Department issued Provider Quick Tip #241, "Prior Authorization Changes in the Medical Assistance Program for Certain Services during COVID-19 Emergency Disaster," to announce changes to the prior authorization requirements for certain services in response to the COVID-19 public health emergency. The services with prior authorization requirement changes were Inpatient Hospital Admissions, including admission to Long-Term Acute Care Hospitals, Home Health, Hospice Services, Radiology, Medical Supplies and Durable Medical Equipment (DME), Shift Nursing, Inpatient Rehabilitation Services, and Skilled Nursing Facility Services.
Procedure
Effective for the dates of services on and after July 1, 2021, the Department will reinstate the prior authorization requirements in place on February 29, 2020, and suspended in Provider Quick Tip #241, in the FFS delivery system for all services with the exception of shift care services provided to children under the age of 21.
Prior authorization requirements are reinstated for the following services in the MA FFS delivery system:
- Inpatient Hospital Admissions
- Home Health
- Inpatient Rehabilitation Services
- Skilled Nursing Facility Services
- Medical Supplies and DME
- Radiology -prior authorizations of CT scan of the chest (specifically procedure codes71250, 71260, and 71270)
Prior authorization requirements as specified in Provider Quick Tip #241 continue to be suspended for shift care services, which are billed using procedure codes S9122, S9123 and S9124.
Children under the age of 21 who were authorized through the prior authorization process to receive shift care services prior to or after the issuance of Quick Tip #241 can continue to receive the authorized hours of services without the need for reauthorization.
Children under the age of 21 who are not currently receiving shift care services will be required to receive prior authorization of these services before they can be initiated. Once services are authorized, the authorized hours of services will continue without need for reauthorization. Requests to increase the number of hours beyond what was authorized will require prior authorization. Once the increase in services is authorized, the authorized hours of care will continue without need for reauthorization. Procedure code S9122 requires authorization through the program exception process.
Note: While the authorization requirements will be suspended for claims payment purposes as specified above, services will be subject to a retrospective review for medical necessity.
Providers may access the online version of the MA Program Fee Schedule on the Department’s website.
Provider Quick Tip #241, “Prior Authorization Changes in the Medical Assistance Program for Certain Services during COVID-19 Emergency Disaster”, issued May 7, 2020, is superseded with the issuance of this bulletin, effective July 1, 2021.
For questions regarding MA FFS claims please contact 1-800-537-8862, option 2,option 6, option 1.
For questions regarding prior authorization for home health or radiology servicesin the MA FFS program please contact 1-800-537-8862, option 2, option 3, option 1.
For questions regarding authorization for medical rehabilitation services in the MA FFS program, please contact 1-800-537-8862, option 2, option 3, option 3 to leave a confidential voice mail message.
For questions regarding outpatient drug prior authorization in the MA FFSprogram please contact 1-800-537-8862, option 2, option 2.
For questions regarding skilled nursing facility services, please contact the Office of Long-Term Living at 1-800-932-0939, option 2.
Providers may utilize the Medical Assistance Desk Reference for other important provider contacts.
Providers should continue to check the Department of Human Service’s COVID-19 website and the Department of Health’s website for updates regarding COVID-19.