INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT
How to submit an Inpatient Service
Authorization Request
Presented To:
Inpatient Providers
INPATIENT SERVICES
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INPATIENT ACUTE-MEDICAL--SURGICAL SRV AUTH SERVICE TYPE
0400
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INPATIENT REHABILITATION – SRV AUTH TYPE 0200
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Service Authorization and General Background
Information
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Service authorization (Srv Auth) is the process to approve specific services
for an enrolled Medicaid, FAMIS Plus or FAMIS individual by a Medicaid
enrolled provider prior to service delivery and reimbursement.
The purpose of service authorization is to validate that the service
requested is medically necessary and meets DMAS criteria for
reimbursement.
Service authorization does not guarantee payment for the service;
payment is contingent upon passing all edits contained within the claims
payment process, the individual’s continued Medicaid eligibility, the
provider’s continued Medicaid eligibility, and ongoing medical necessity for
the service.
KEPRO will approve, pend, reject, or deny all completed Srv Auth
requests.
If Clinical information is missing from the Srv Auth request after the initial
evaluation, the clinical reviewer will pend the case for one business day
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Service Authorization and General Background
Information
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The clinical reviewer will send a message via Atrezzo as well as faxing a
letter to the Provider requesting additional information.
The Provider has one business day to provide the requested information.
If the additional information requested does not meet the criteria to
determine medical necessity then the request is sent to the KEPRO
Physician to make a medical necessity determination.
The KEPRO Physician will provide a decision within one business day of
receiving the request to review for medical necessity.
The provider will be notified of the decision by a message entered into
Atrezzo, as well as the Atrezzo case notes.
If the MD decision is to approve the case a system generated approval will
be received by the provider.
If the MD has denied the case a letter will be faxed to the provider with the
details of the MD decision. The clinical reviewer will also send an Atrezzo
message, and will document the decision in the Atrezzo case notes.
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Service Authorization and General Background
Information continued
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It is the provider's responsibility to verify member eligibility and to check
for managed care organization (MCO) enrollment.
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For MCO enrolled members, the provider must follow the MCO's Srv Auth
policy and billing guidelines.
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Member Eligibility Verification is Provider
Responsibility
VIRGINIA MEDICAID WEB PORTAL
It is the Provider’s Responsibility to verify Member eligibility
• 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.
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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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Communicating with DMAS and KEPRO
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Provider manuals are located on the Virginia Medicaid Web Portal. The Virginia
Medicaid Web Portal can be accessed by going to:
www.virginiamedicaid.dmas.virginia.gov.
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The DMAS/KEPRO website http://dmas.KEPRO.com has information related to the
service authorization process for Inpatient Acute Admissions and Intensive
Rehabilitation services . To access the fax form for Intensive Rehabilitation services
select the forms tab and utilize the DMAS 362. For educational material, click on the
Training tab.
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A service specific checklist for Inpatient Med/Surg and Intensive Rehabilitation may be
found by clicking on “Service Authorization Checklists” on KEPRO’s website.
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For service authorization questions, providers may contact KEPRO at
providerissues@KEPRO.com.
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KEPRO can also be reached by phone at 1-888-827-2884, or via fax at 1-877OKBYFAX or 1-877-652-9329.
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Submission Methods
Inpatient Acute ( 0400)
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KEPRO will accept requests through direct data entry (DDE) only through Atrezzo
Connect (refer to slide 10 for registration requirements).
Intensive Rehabilitation ( 0200)
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KEPRO will accept requests through DDE, fax, and telephone
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Atrezzo Connect registration requirements
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To access Atrezzo Connect on KEPRO’s website, go to http://dmas.KEPRO.com.
Provider Registration is Required to use Atrezzo Connect
The registration process for providers happens immediately on-line.
From http://dmas.KEPRO.com ,providers not already registered with Atrezzo
Connect may click on “First Time Registration” 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.
The Atrezzo Connect User Guide is available at http://dmas.KEPRO.com: Click on
the Training tab, then the General tab.
Providers with questions about KEPRO’s Atrezzo Connect Provider Portal may
contact KEPRO by email at atrezzoissues@KEPRO.com.
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Atrezzo Connect registration requirements
Registration Process for New Providers who have not billed
In order to successfully register for KEPRO’s Provider Portal, a Provider must have a
registration code. Registration code consist of YTD 1099 dollar amount or Date of last
remittance advice from DMAS. When a new provider is ready to register, contact
KEPRO Customer Service at 1-888-827-2884. A Provider service representative will
provide the required value for successful registration. Upon acquiring the registration
code, registration will need to be complete within the current week. A new registration
value will be associated with each NPI number until completion of Atrezzo Provider
portal registration.
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Service Authorization Requests: General Information
Inpatient Admissions (0400,0200)
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On admission to Inpatient Acute Services the member must meet criteria for inpatient hospitalization
and have a treatment plan in place that requires an inpatient level of care.
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All admissions must be submitted within 1 business day of the admission. A business day is defined
as 12:00 am – 11:59 pm Monday – Friday with the exception of State recognized holidays.
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Medicaid defines “observation beds” as outpatient services and does not require service authorization
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To initiate service authorization of the admission the provider must provide the member’s name; the
identification number; the admission diagnosis and ICD-9-CM diagnosis code(s); the medical
indication for hospitalization; and the plan of care
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KEPRO will apply InterQual® ISD criteria. Service authorization is required for the initial admission to
Inpatient acute medical/surgical services. Intensive rehabilitation admissions require service
authorization for the initial admission and continued length of stay.
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Service Authorization Requests: General Information
Inpatient Admissions (0400,0200)(continued)
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Retrospective review will be performed when a provider is notified of a
patient’s retroactive eligibility for Virginia Medicaid coverage. Prior to billing
Medicaid the provider must have a Srv Auth.
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KEPRO will not accept reviews for members who have Medicare Part A. If
Medicare denies the requested stay and/or if the Medicare benefits are
exhausted, the provider must submit a Srv Auth request for retrospective
review.
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Service Authorization Requests: Specific Information
for Inpatient Med/Surgical Admissions (0400)
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For Organ Transplants, Gastric Bypass Surgery, Cosmetic Procedures including
Breast Reduction, the procedure must be authorized in addition to the inpatient
hospital admission.
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Admissions require service authorization by KEPRO.
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KEPRO will provide a service authorization number for the admission date. Under
the DRG reimbursement methodology, no continued stay reviews will be conducted
for members receiving general acute medical/surgical services.
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For those members who do not meet InterQual criteria on admission but do meet
the criteria later in the hospitalization, the Provider must request service
authorization within one business day of the patient’s meeting the criteria.
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Service Authorization is not required for normal maternity/newborn inpatient care.
This includes normal vaginal deliveries with a length of stay less than or equal to
three days from the date of admission;
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Service Authorization Requests: Specific Information
for Inpatient Med/Surgical Admissions (0400)
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Caesarian section deliveries, with a length of stay less than or equal to five days
from the date of admission; and newborns who are in the normal nursery
with a length of stay less than or equal to five days from the infant’s date of birth.
Service authorization will be required for the entire newborn stay if the infant is in
any other nursery setting for any part of the stay.
KEPRO must service authorize maternity and newborn stays which do not fall within
these parameters, and the service authorization must be on file with DMAS prior to
billing for the stay.
Certain procedures done as outpatient do require service authorization if the
patient is subsequently admitted to the hospital due to postoperative
complications, the provider must obtain authorization within 1
business day of Inpatient admission.
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Service Authorization Information Specific
Information for Intensive Rehab Admissions (0200)
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All new requests for Service Authorization must be received through KEPRO
within 72 hours of admission. All requests received after 72 hours of
admission will be denied untimely up to the date the request is received.
The request may be approved starting with the date the request was
received should the member continue to meet medical necessity. The
review analyst will assign an initial length of stay.
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If services are to extend beyond the authorized length of stay the provider
must submit additional clinical to KEPRO prior to the end date of the
existing authorization in order to ensure timely submittal.
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For initial and continued stay denials providers must continue to submit
clinical information for the remainder of the stay in order to remain timely.
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Out of State Service Authorization Requests:
Specific Information for Intensive Rehab (0200)
Effective March 1, 2013 out of state providers need to determine and document evidence that one of the following items
is met at the time the service authorization request is submitted to the service authorization contractor:
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.
Authorization requests for certain services can also be submitted by out-of-state facilities. Refer to the Out of
State Request Policy and Procedure on Pages 8 & 9 for guidelines when processing out of state requests,
including 12VAC30-10-120.
The provider needs to determine item 1 through 4 at the time of the request to the Contractor. If the provider is
unable to establish one of the four KEPRO will:
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Pend the request utilizing established provider pend timeframes
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Have the provider research and support one of the items above and submit back to the Contractor their
findings
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Resource Information
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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. Provider may contact DMAS Provider helpline at 1-800-552-8627 for questions
regarding billing, appeals and services not requiring authorization by KEPRO. Providers may also
access service authorization information including status via KEPRO’s Provider Portal at
http://dmas.KEPRO.com.
Medicaid Memoranda and Manuals
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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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