INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT
Service Authorization
Process for EPSDT
Personal/Attendant Care
(Service Types 0090,
0098, 0091)
Presented by: KePRO
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Methods of Submission Service Authorization
Requests to KePRO
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KePRO accepts service authorization (srv auth) requests through direct
data entry (DDE), fax and phone.
Submitting through DDE puts the request in the worker queue
immediately; faxes are entered by the administrative staff in the order
received.
For direct data entry requests, providers must use Atrezzo Connect
Provider Portal.
For DDE submissions, service authorization checklists may be accessed
on KePRO’s website to assist the provider in assuring specific information
is included with each request.
To access Atrezzo Connect on KePRO’s website, go to
http://dmas.kepro.com.
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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.
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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 atrezzoissues@kepro.com.
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For service authorization questions, providers may contact KePRO at
providerissues@kepro.com.
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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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Provider Manual/Medicaid Memorandums
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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
Personal Care/Attendant Care, Private Duty Nursing
(PDN)
Covered Services under EPSDT:
• EPSDT Personal/Attendant Care-0091
• EPSDT Private Duty Nursing-0090
• EPSDT Private Duty Nursing in School
(MCO)-0098
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Service Authorization Information Specific to
Personal Care/Attendant Care, PDN
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Initial Requests for Services and Enrollment
Initial request for Services (EPSDT)
Change Requests
Need to Submit Case ID or Srv Auth # and the
procedure code that is in need of a chance, as well
as the required justification to support.
Change requests are inclusive of requests to
increase or decrease units previous authorized, or to
change dates of service currently authorized.
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Service Authorization Information Specific to
Personal Care/Attendant Care, PDN
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Discharges
Need to Submit Case ID or Srv Auth # and the
procedure code for each service being discharged,
as well as the reason for the discharge.
You must complete a new DMAS 98, submitting the
DMAS 225 is not sufficient.
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Service Authorization Information Specific to
Personal Care/Attendant Care, PDN
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Completion of DMAS 98
Page 1: Name, Age, Gender, Name of Service Provider,
Service Provider ID (Must be 10 Digits), Diagnosis,
Clinical or additional information in Blocks 15 & 16, Name
of referring Provider (when applicable) and Referring
Provider ID.
 Page 2: List type of service requested by use of the
procedure code (with modifier if applicable), Hours/ units,
frequency, cost (when applicable), SOC date, and End
date.
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Service Authorization Information Specific
to Personal Care/Attendant Care
• EPSDT Personal Care/Attendant Care
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Service Authorization Information Specific to
Personal Care/Attendant Care
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Providers must submit request to the designated
preauthorization contractor within 10 business days of initiating
care or within 10 business days of receiving verification of
Medicaid eligibility from the local DSS, unless otherwise
specified in the DMAS Provider Manual.
Please note that some services can not be retro authorized and
must be submitted by the SOC date requested. Refer to the
specific Provider Waiver Manual for the submission
requirements for each service/procedure code.
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Service Authorization Information Specific to
Personal Care/Attendant Care
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EPSDT Personal/Attendant Care: 0091
– EPSDT services are available to Medicaid members
under 21 years of age. Personal care may be
provided exclusively through EPSDT to eligible
persons who have demonstrated a medical need for
personal care that is not covered under an existing
Medicaid program for which the individual is enrolled.
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Service Authorization Information Specific to
Personal Care/Attendant Care
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Procedure/Service Codes that Require Service
Authorization:
 T1019 (Agency Directed Personal Care)
 S5126 (Consumer Directed Personal Care)
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Service Authorization Information Specific to
Personal Care/Attendant Care
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Eligible Members include individuals who are:
 Under 21 y.o. and enrolled in Medicaid FFS, Medicaid MCO, or
FAMIS Plus on dates of services requested
 Under the age of 19 y.o. and enrolled in FAMIS FFS on the
dates of service requested
 Personal Care is not a covered services by FAMIS MCOs
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Service Authorization Information Specific to
Personal Care/Attendant Care
Timeliness Requirements for Submission:
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Providers must submit documentation to KePRO within
10 business days prior to initiation of care
If request is not submitted within the required timeframe,
the service must be authorized beginning with the date
the information was received by KePRO.
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Service Authorization Information Specific to
EPSDT Personal Care/Attendant Care
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Required documentation when requesting authorization:

DMAS 98 fax form
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DMAS 7 (signed and dated by physician, physician’s assistant, or nurse practitioner)
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DMAS 7-A from provider
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DMAS 99 Community Based Care Recipient Assessment Report
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Back-up plan documented
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Detailed Schedule of current services available to individual
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NOTE****If provider is submitting in request via Atrezzo portal, the EPSDT
Personal/Attendant Care Questionnaire needs to be completed, or the provider can upload
all appropriate documents in lieu of the questionnaire
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NOTE***If additional information is needed from the provider, the case is pended for 5
business days to allow provider time to submit additional documentation to KePRO for
review.
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Service Authorization Information Specific to
Personal Care/Attendant Care
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In addition to medical necessity, the following criteria must be met in order
for personal care services to be determined as appropriate:
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The member must have a plan of care developed by a currently
enrolled personal care provider or service facilitator
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The plan of care (DMAS- 7A) should be consistent with the findings on
the EPSDT functional assessment (DMAS -7) and demonstrate the
need for personal care.
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The member must have a viable back-up plan, such as a family
member, neighbour, or friend who is willing and able to assist the
individual on very short notice in case the personal care aide does
report for work as expected.
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Individuals who do not have a viable back-up plan are not eligible for
services until a backup plan as has been established.
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Individuals receiving EPSDT personal care must have a physician
referral due to health conditions documented during an EPSDT
medical exam
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Service Authorization Information Specific to
EPSDT Personal Care/Attendant Care
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Medical Necessity
Health conditions must cause the individual to be
functionally limited in performing three or more activities
of daily living (ADL)
These categories are bathing, dressing, transfers, ambulation,
eating/feeding, toileting, and continence
The individual’s inability to perform an ADL cannot be exclusively
due to typical limitations associated with typical attainment of
developmental milestones
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Service Authorization Information Specific to
EPSDT Personal Care/Attendant Care
•EPSDT Personal Care Services may be provided in a school
setting if the service is not included in the member’s
Individualized Education Program (IEP) and the services are
deemed medically necessary
•Providers must document the medical need for coverage in the
school setting and document that the services is not included in
the member’s IEP
•EPSDT allows supervision hours when it is medically necessary
for the member to receive supervision due to a health condition.
•Disruptive behaviours such as aggression, self-injury,
elopement/wandering, impulsivity, property destruction, etc. may
require constant supervision from a personal or attendant care
aide to maintain the child’s safety in addition to the hours required
for ADL/IADL supports.
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Service Authorization Information Specific to
EPSDT Personal Care/Attendant Care
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The Following Services are Covered:
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Assistance with activities of daily living (ADLs): bathing, dressing, toileting,
transferring, eating/feeding, ambulation, and bowel and bladder continence
Assistance with meal preparation for the individual
Medically Necessary Supervision related to a health condition
The Following Services are not Covered:
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General Supervision
Respite
Performance of tasks for the sole purpose of assisting with the completion of
job requirements
Assistance provided in hospitals, other institutions, assisted living facilities,
and licensed group homes
Services included in the member’s Individualized Education Program (IEP)
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Service Authorization Information Specific to EPSDT
Private Duty Nursing
EPSDT Private Duty Nursing (PDN)
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Service Authorization Information Specific to
EPSDT Private Duty Nursing (PDN)
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Private Duty Nursing:
 A continuous medically necessary nursing service provided for
an individual in a home or community based setting.
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Must be provided by:
 RN
 LPN
 Employed by a DMAS/MCO enrolled private duty
nursing provider
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Service Authorization Information Specific to
EPSDT Private Duty Nursing (PDN)
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Service Type:
 0090-FFS Members
 0098 MCO/Carve Out school based PDN
Procedure/Service Codes that Require
Service Authorization:
 S9123-RN Nursing Services and Assessment
 S9124-LPN Nursing Services
 G0162-RN Congregate Nursing Services
 G0163-LPN Congregate Nursing Services
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Service Authorization Information Specific to
Private Duty Nursing (PDN)
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Eligible Members for 0090 include individuals
who are:
Under 21 y.o. and enrolled in Medicaid FFS,
FAMIS, or FAMIS Plus on dates of services
requested
Under the age of 19 y.o. and enrolled in FAMIS
FFS on the dates of service requested
Personal Care is not a covered services by
FAMIS MCOs
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Service Authorization Information Specific to
Private Duty Nursing (PDN)
Timeliness Requirements for Submission:
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Providers must submit documentation to the service authorization
contractor prior to initiation of care
If request is not submitted prior to the start of care, the service must
be authorized beginning with the date the information was received
by the service authorization contractor
Continuation of service reviews are required to be submitted prior
to the end of the current authorization period
NOTE**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 for review
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Service Authorization Information Specific to
Private Duty Nursing (PDN)
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Private Duty Nursing
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May be used while a child is enrolled in a waiver, if that waiver does not
provider PDN or does not provide congregate PDN
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PDN services are limited to the hours of skilled medical care and skilled
supervision as specified in the Plan of Care (POC) and limited to the number of
hours approved.
Congregate Private Duty Nursing
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Provided with more than 1 individual who requires private duty nursing resides
in the same home
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Limited to a maximum ration of one PDN to two individuals who receive
nursing via the Etch Waiver or EPSDT
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When 3 or more Waiver/EPSDT individuals share a home, service staff
ratios are determined by assessing the combined needs of the individuals
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Service Authorization Information Specific to
EPSDT Private Duty Nursing (PDN)
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Required Documents for New Requests
(0090):
 DMAS 98
 Signed DMAS 62-signed by Physician
 Home Health Certification and Plan of Care (may use DMAS
485 or equivalent to meet documentation requirements)
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Service Authorization Information Specific to
EPSDT Private Duty Nursing (PDN)
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Required Documents for New Requests
(0090):
 DDE - Questionnaire
 Signed DMAS 62-signed by Physician
 Home Health Certification and Plan of Care (may
use DMAS 485 or equivalent to meet documentation
requirements)
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Service Authorization Information Specific to
EPSDT Private Duty Nursing (PDN)
• Required Documents for MCO
Referral Requests:
 Signed DMAS 62-signed by Physician (a new
DMAS 62 is required every 6 months)
 Home Health Certification and Plan of Care (may
use DMAS 485 or equivalent to meet documentation
requirements)
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School Based MCO Referral (questions found on
the DMAS 98 or the questionnaire)
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Service Authorization Information Specific to
EPSDT Private Duty Nursing (PDN)
• Atrezzo Portal Submissions:
If Provider is submitting Request via Atrezzo
Portal, provider needs to complete EPSDT
Specialized Services Questionnaire, upload
DMAS 62, and submit any additional clinical
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Service Authorization Information Specific to
Private Duty Nursing (PDN)
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Dual Use of EPSDT PDN:
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If a child is enrolled in a Medicaid Waiver Program, the provider must
document that the waiver does not offer PDN coverage or doe not offer
congregate Private Duty Nursing coverage
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If the member’s waiver offers PDN, then the EPSDT benefit is not available.
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Members may be authorized for EPSDT PDN if enrolled in the EDCD Waiver
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Members may use any of the EDCD waiver services while receiving EPSDT
PDN. EPSDT is not use to authorize respite care
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Services may be approved for school based nursing supports. The hours used
during the school day will count toward the number of hours allowed based on
the individual’s medical need for care
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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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Out of State Providers
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Out of State Providers:
– Out of state providers must be enrolled with Virginia Medicaid in order to submit
a request for out of state services to the Contractor. If the provider is not
enrolled as a participating provider with Virginia Medicaid, the provider is still
encouraged to submit the request to the Contractor, as timeliness of the request
will be considered in the review process starting November 1, 2012. These
providers will not have a NPI number but may submit a request to the
Contractor.
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The Contractor will advise out of state providers that they may enroll with
Virginia Medicaid by going to:
https://www.virginiamedicaid.dmas.virginia.gov/wps/myportal/ProviderEnrol
lment.
(At the toolbar at the top of the page, click on Provider Services and then
Provider Enrollment in the drop down box. It may take up to 10 business
days to become a Virginia participating provider.)
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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, sales@passporthealth.com
• 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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