|
|
MAPS-MD Issues Bulletin
October 2001
Authorization Web-site
Each provider who has a Medicaid provider number will receive a login name and password for the new authorization web-site. This web-site is intended to allow providers to verify authorizations that have been issued. Instructions for accessing and utilizing the web site are available on the MAPS-MD web site (www.MAPS-MD.com). Providers may begin accessing the site as soon as a password has been assigned.
Reminder: Attachments to Claims
Please note that the only attachments to paper claims submitted to MAPS-MD should be documents required by the state for payment such as EOBs, DJJ orders of commitment for RTC claims, etc. Providers must not attach additional information such as charts, medical records, or progress notes when submitting a claim for processing to the MAPS-MD Claims Department.
How to appeal a decision that is not medically necessary:
1. Telephone Pre-certification:
MAPS-MD requests that all clinical reviews occur with either the provider or the team members involved in the requested services.
During a telephone pre-certification for services, a MAPS-MD Care Manager may determine that the clinical information presented does not meet the medical criteria for a particular level of service. In such cases, the MAPS-MD Care Manager will inform the caller that they are unable to authorize this service and will refer this request to a MAPS-MD Physician Advisor for further review. The MAPS-MD Physician Advisor will call the provider to review the request for service and make a determination. The Physician Advisor will inform the caller of his/her decision over the phone, and in writing, by letter. If the Physician Advisor determines that the medical necessity criteria were not met, a letter will be sent stating this. The provider may assist the consumer in submitting an appeal of the decision.
How do you make an appeal for authorization of a telephone pre-certification for a non-medical decision?
A provider can request another Physician Advisor provide an additional independent review of the case. Alternately, the provider may submit a letter delineating the basis of the appeal. Additional clinical information to support a provider’s request is suggested.
2. Authorization Plan:
MAPS-MD Care Managers review all authorization plans submitted for concurrent review. If the MAPS-MD Care Manager determines that the frequency or intensity of service requested exceeds the "least intensive level of care," the manager will call the provider to discuss the request and explore alternatives. If the Care Manager and provider are unable to reach an intensity of service that is acceptable to both the Care Manager and the provider, the authorization plan will be sent to a Physician Advisor for review and determination. The Physician Advisor will make a determination and the provider/consumer will be notified by mail.
How do you make an appeal for authorization for an authorization plan that is determined to be not medically necessary?
The preferred method of appealing a determination that a given level of service not medically necessary is to submit a letter supporting why a particular level of care or intensity of care is necessary. Enclosing the treatment plan that was determined to be not medically necessary will facilitate the process.