INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT
Service Authorization Processing for
EPSDT Assistive Technology ( 0092)
KePRO
Presented By:
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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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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 10-digit 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
• Providers with questions about KePRO’s
Atrezzo Connect Provider Portal may contact
KePRO
• by email at atrezzoissues@kepro.com. For
service authorization questions, providers may
contact KePRO at providerissues@kepro.com.
KePRO may also be reached by phone at 1888-827-2884, or via fax at 1-877-OKBYFAX or
1-877-652-9329.
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Service Authorization Information Specific to
Assistive Technology (AT)- Procedure Code555
T5999
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T5999 is the only code used to request EPSDT Assistive Technology.
Assistive Technology services are available only for Medicaid members under
age 21 through EPSDT.
AT services are not covered by DMAS for members age 21 and older unless
enrolled in specific waivers.
Only DME providers (provider type 062) or AT providers (provider type 056
and specialty 016 or 046) may submit AT requests for service authorization.
Providers must submit requests when they are aware of the need for AT
There is no retroactive authorization, except in cases where retroactive
Medicaid eligibility determination is made.
Providers should expect a response from KePRO within 3 business days of
receipt.
KePRO will utilize DMAS criteria as outlined in DMAS’ EPSDT Supplement B
for AT.
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Service Authorization Information Specific to
Assistive Technology (AT)—Web Portal
Submissions
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Complete web based checklist EPSDT Assistive Technology and attach to
request in Atrezzo
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Upload Letter of Medical Necessity signed and dated by physician; OR
licensed therapist evaluation report signed and dated by physician.
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Attach Letter of Medical Necessity to request in Atrezzo
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Include Provider’s Invoice Cost
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EPSDT ASSISTIVE TECHNOLOGY CRITERIA AND
SRV AUTH PROCESSING GUIDELINES (T5999)
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Assistive Technology through the EPSDT program is used to correct or
ameliorate physical or mental conditions identified during EPSDT
screening services, the child may be referred by the EPSDT screener or
PCP for Assistive Technology services.
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Assistive Technology is defined as specialized medical equipment,
supplies, devices, controls, and appliances not available under the Virginia
State Plan for Medical Assistance.
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Assistive Technology items directly enable individuals to increase their
abilities to perform ADLs or to perceive, control, or communicate with the
environment in which they live.
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Assistive Technology items are expected to be portable.
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Definition of Assistive Technology
To meet the definition of Assistive Technology, requested items must
meet all of the following requirements. Assistive Technology must:
• be able to withstand repeated use;
• be primarily and customarily used to serve a medical purpose and be
medically
• necessary and reasonable for the treatment of the individual’s disability or
to
• improve a physical or mental condition;
• generally be not useful to a person in the absence of a disability, physical
or
• mental condition; and
• be appropriate for use in both the home and community.
Equipment or supplies already covered by the Virginia State Plan for
Medical Assistance may not be requested for reimbursement under
EPSDT.
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EPSDT Assistive Technology –Definition and
Criteria
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Only Assistive Technology items that are determined to be medically
necessary may be covered for reimbursement by DMAS.
A reasonable and medically necessary part of a treatment plan;
Consistent with the member’s diagnosis and medical condition, particularly
the functional limitations and symptoms exhibited by the member;
Not furnished solely for the convenience of the family, attending physician,
or other practitioner or supplier;
Consistent with generally accepted professional medical standards (i.e.,
not experimental or investigational);
Provided at a safe, effective, and cost-effective level that is suitable for use
by the enrollee.
Assistive Technology must involve direct patient care and be for the
express purpose of diagnosing, treating or preventing (or minimizing the
adverse effects of) illness, injury or other impairments to an individual’s
physical or mental health.
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Assistive Technology Definition/Criteria
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Home/Environmental modifications do not meet the definition of Assistive
Technology and are not covered under EPSDT services.
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Environmental modifications are defined as physical adaptations to an
individual’s home, primary place of residence, vehicle, or workplace.
Examples of environmental modifications include but are not limited to
devices that are permanently affixed to the walls of the home such as grab
bars, ramps, barrier free lifts, and widening of doorways.
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Items intended to be used in a school setting that are needed for
educational purposes are not covered.
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For information regarding Medicaid covered school services, please see the School Health
Services Manual located on the DMAS web portal at
https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderManual.
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Service Authorization Requirements
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All Assistive Technology items must be authorized prior to the assistive
technology service being rendered/delivered.
Each Assistive Technology item must be recommended and determined
appropriate to meet the individual’s needs by a qualified professional such as
an occupational therapist, physical therapist, speech language pathologist,
physician, or behavioral consultant.
Medical documentation must include clear documentation of the member’s
needs. Documentation for each requested Assistive Technology item must
identify:
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The medical need for the requested Assistive Technology;
The diagnosis related to the reason for the Assistive Technology request;
The individual’s functional limitation and its relationship to the requested Assistive Technology
item; How the Assistive Technology item will treat the individual’s medical condition
The quantity needed and the medical reason the requested amount is needed;
The frequency of use and the estimated length of use of the item
Any conjunctive treatment related to the use of the item;
How the needs were previously met identifying changes that have occurred wihich necessitate
the AT request;
Other alternatives tried or explored and a description of the success or failure
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Service Authorization Requirements Continued
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How the Assistive Technology item is required in the individual’s home
or community environment;
The individual’s or caregiver’s ability, willingness, and motivation to use the Assistive
Technology item.
Requests for new Assistive Technology devices must contain the
following:
Physician Letter of Medical Necessity
Therapist’s evaluation report (If signed by the physician this can serve as
the Letter of Medical Necessity)
Quote from supplier to document provider’s wholesale cost or cost
description for requests to exceed allowed reimbursement rates. Provider
to submit quote, showing cost and if request approved, then mark up cost
30%.
Provider to document why a specific device is medically justified over a
standard, less expensive device.
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Service Authorization Information Specific to
Assistive Technology (AT) FAX Submissions
The DMAS fax form utilized will be the DMAS 363.
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Per the DMAS 363 fax form, assistive technology providers will need to
specifically select #13 for correct service type.
Additional documentation to medically justify the request is needed in fields
#14, 15, 16.
REQUIRED INFORMATION WHEN SUBMITTING BY FAX:
DMAS 363 Outpatient Services Authorization Request Form
Letter of Medical Necessity signed and dated by physician and licensed
therapist evaluation; OR
licensed therapist evaluation report signed and dated by physician
Provide Provider’s Invoice Cost
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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. Fax forms, web based
service authorization checklists, trainings, 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. 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.
There is no retroactive authorization period for Assistive Technology
Requests
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 AT Requests
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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.
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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Out of State Provider Requests
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Procedures and/or services may be performed out of state only when it is
determined that they cannot be performed in Virginia because it is not
available or, due to capacity limitations, where the procedure and/or
service cannot be performed in the necessary time period.
Services provided out of state for circumstances other than these specified
reasons shall not be covered.
1. The medical services must be needed because of a medical emergency;
2. Medical services must be needed and the recipient's health would be
endangered if he were required to travel to his state of residence;
3. The state determines, on the basis of medical advice, that the needed
medical services, or necessary supplementary resources, are more readily
available in the other state;
4. It is the general practice for recipients in a particular locality to use
medical resources in another state.
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Out of State Provider Requests continued
The provider needs to determine items 1 through 4 at the time of the
request to the Contractor. If the provider is unable to establish item
number 3 or 4 the Contractor will:
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Pend the request for 20 days
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Have the provider research and confirm items 3 or 4 and submit back to
the Contractor their findings
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This process is supported by 12VAC30-10-120 and 42 CFR 431.52.
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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 1-800-7729996. 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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Medicaid Memoranda and Manuals
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COPIES OF MANUALS
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.
This link opens up a page that contains all of the various communications
to providers, including Provider Manuals and Medicaid Memoranda.
The Internet is the most efficient means to receive and review current
provider information.
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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ELIGIBILITY VENDORS: How to check for Member
Eligibility
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:
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Passport Health Communications, Inc.
www.passporthealth.com
sales@passporthealth.com
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Telephone: 1 (888) 661-5657
SIEMENS Medical Solutions – Health Services
Foundation Enterprise Systems/HDX
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www.hdx.com Telephone:1
Emdeon
www.emdeon.com
Telephone: 1 (877) 363-3666
(610) 219-2322
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DMAS PROVIDER Helpline Information
• “HELPLINE”
• The “HELPLINE” is available to answer questions Monday through
Friday from 8:00 a.m. to 5:00 p.m., except on holidays. The
“HELPLINE” numbers are:
• 1-804-786-6273
• 1-800-552-8627
distance)
Richmond area and out-of-state long distance
All other areas (in-state, toll-free long
• Please remember that the above “HELPLINE” is for provider use
only. Please have your Medicaid Provider Identification Number
available when you call.
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