Updates
Courtesy Reviews
The courtesy review option in APS CareConnection® was designed to allow providers to enter authorization requests for consumers who are pending Medicaid eligibility (MA). This allows the provider to know, at the time that services are rendered, if the consumer meets medical necessity criteria. The provider will also be able to request concurrent courtesy reviews throughout the entire course of treatment. Utilizing this option will alleviate the need to send the consumer's entire medical record to MAPS-MD for a clinical review once MA is granted.
It is MAPS-MD's expectation that all consumers admitted to the Residential Treatment Center (RTC) level of care will be granted MA. Therefore, the provider should request a courtesy review even if the consumer has not completed an application for MA. If the consumer has been admitted to the Inpatient, Partial level of care, or a Psychiatric Rehabilitation Program (PRP), then the provider should use their professional judgment to determine if the consumer is expected to obtain MA that will cover this episode of care.
Consumers who obtain MA through "spend down" provisions will have periods of Medicaid ineligibility while they accumulate unpaid medical bills that re-qualify the consumer for MA. The Inpatient, Partial Hospital, or PRP provider should assist the consumer in applying for MA and use their professional judgment to determine if the consumer is expected to obtain MA that will cover this period of time.
A courtesy review should not be requested if the consumer meets the criteria for Uninsured Eligibility and the requested service is Outpatient Mental Health Treatment services or another covered service with available uninsured treatment slots in the local community. If the consumer has pending MA, the eligibility coverage on the authorization will convert to MA when the new Medicaid eligibility span is received, and claims will process at the Medicaid benefit level. If the consumer does not meet the criteria for Uninsured Eligibility, then the provider may request a courtesy review for any level of care.
A courtesy review can be requested by choosing the answer "Yes" to the question, "Is this a courtesy review?" This question is in the Consumer Information section of the APS CareConnection® form. The provider must then complete all pertinent clinical information for the level of care being requested. Once all information is data entered, the provider must "Save" the request and then "Submit" the request in APS CareConnection®.
Courtesy reviews can also be requested by contacting a Care Manager via telephone at 800-888-1965. There is a Care Manager available 24 hours a day, seven days per week.
Inpatient Concurrent Reviews
In order to ensure smooth processing of inpatient claims, MAPS-MD will begin systematically rolling up all Inpatient pre-authorization and concurrent review authorized days to one authorization number. MAPS-MD will calculate the total number of days authorized and amend the pre-authorization request to reflect the entire stay. The system will then administratively close the Concurrent Reviews and calculate the days authorized to zero. There will be a note attached to all concurrent reviews that states:
"This Record is being administratively closed and all units have been rolled up and added to the initial request"
This function is scheduled to occur every Monday, beginning 03/21/2005. All updates will be downloaded to ACS on the following Tuesday.
Service Grid Changes There have been updates made to the APS CareConnection service grid of which you should be informed.
There are two new levels of care codes under the outpatient tab on the service grid.
- 156 This code should be used when requesting in-home respite care services. The service code that should be used when billing for this service is T1005.
- 157 This code should be used when requesting Therapeutic Nursery Services. The service code that should be used when billing for this service is H0046.
There are two new level of care codes under the CSA review tab on the service grid.
- 791 This codes should be used when requesting PRP/RRP transition visits. This code should be requested if the provider is going to bill using H2018-U4, 52.
- 792 This codes should be used when requesting PRP/RRP transition visits. This code should be requested if the provider is going to bill using H2018-U5, 52.
The level of care code 122 has been updated to allow for revenue code 0513.
The level of care code 780 has been updated to reflect the new service code that was published in the update regarding the cascading of PRP services. This new code is S9445 and should be used for billing PRP services for an individual in a supported employment program.
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