Prior Authorization Announcements and News
Greetings WV Medicaid Providers Submitting Prior Authorization Requests!
APS Healthcare would like to first take the opportunity to thank you for your patience and feedback regarding the APS CareConnection® (C3) system for WV Medicaid Prior Authorizations. We hope you are becoming more familiar with navigating the system. With that being said, we would like to provide some additional important information about the C3 system, which will help reduce your number of administrative closures and resubmissions. This will improve the efficiency in receiving your determinations.
We would like to reiterate the importance of your computers’ compatibility with the APS CareConnection® system. It has come to our attention that if every user is not working on a computer that has IE8, (Internet Explorer 8), this can produce some problems with submitting your requests. Instructions on how to make your computers compatible with our system are available by clicking here. (Please note, following these instructions does not impair your computer system, and does not bother your other programs that are on the computer). Please make sure that all users of our system have access to these instructions. This will help prevent requests from being what we call “stuck in cyberspace”. This is when a request has been submitted, but stays in Pending status, and never goes to queue to be reviewed.
Another important thing to remember is that you have to have patience when submitting a request. Please remember to wait until everything is populated on the Summary and Submit page, BEFORE clicking the Submit button. Clicking Submit before being able to see the information on the page could be another contributing factor to “stuck” requests. Also, waiting for the entered information will allow you the opportunity to review the request, to make sure dates and all information are correct, and to make sure you didn’t leave anything off that might be pertinent to the review.
Next, we would like to inform you about timelines for sending in additional clinical information, whether it be faxed, or mailed additional information, for any case, to WVMI. In order for your requests to be processed in a timely, efficient manner, WVMI needs to receive information in a timely manner. If you enter requests via the CareConnection® system, and want to fax the clinical information to WVMI, the faxed information needs to be received by WVMI within 2 business days from the submission of the request. If you enter a reconsideration request into the system, and mail the additional clinical information, WVMI needs to receive this information within 5 business days. If the information is not received within the allotted timeframe, your request will be closed administratively, and you will have to re-submit your request, which could cause you to miss the 72 business hour timeline, for a timely submission. Leniency will NOT be given in these cases!
APS would like to stress that it is the provider’s responsibility, and is IMPERATIVE that the provider check each member’s eligibility. Although, both APS and WVMI, check for sufficient coverage, we are only responsible for determining whether or not a procedure meets medical necessity. This is especially important for PT, OT, Speech, and Audiology because your authorizations run to the end of the calendar year; however, this DOES NOT mean that each member’s eligibility runs through to the end of the year. That is the provider’s responsibility to check.
It is also the provider’s responsibility to check for determinations of their requests, via the CareConnection® system. WVMI and APS will not give authorizations over the phone. APS will, however, continue to assist you by teaching you how to find your determination. The instructions for this are available by clicking here.
Finally, please make sure you are entering the correct dates on requests. We want to clarify that when submitting Acute Inpatient or Inpatient Rehab <21 requests, please make sure the Authorization Start Date and the Admission Date are the SAME date! When submitting therapy requests, (PT, OT, Speech, Audiology), if you have more than one procedure to get authorized, the Authorization Start Date should be the Start Date for the earliest service. You do not need to enter the date the request was entered because that date will automatically populate once the request is submitted. APS has to submit an IT request ticket to our Corporate Data Management team in order to have the dates changed, and this delays your ability to seek reimbursement for services rendered. So, in order to help us help you more efficiently, let’s please be sure to enter the correct dates on the requests.
If anyone is still in need of assistance and/or training with the APS CareConnection® system, please let us know. We can set up times to do trainings via webinars for your facility, or when time permits, we can work with you by phone and help you enter a request step by step, if you would prefer.
Thank you for time attention to the above matters. As always, we are here to help you in any way possible, so please feel free to contact us with any questions, comments, or concerns you may have by calling: 1-800-346-8272, or by emailing: wvmedicalservices@apshealthcare.com.
CPT codes 76942, 77002, 77003, 77012 and 77021 describe radiologic guidance for needle placement by different modalities. Beginning 3-1-2012, WV Medicaid will allow one unit of service per day for any of these codes regardless of the number of needle placements performed. Prior authorization for over the service limit may be obtained through our Utilization Management Contractor. Requests for these codes must be submitted to WVMI for service start dates on or after 3-1-2012. To request further information or address questions about this change to APS Healthcare, Inc, at wvmedicalservices.@apshealthcare.com.
If you are a WV Medicaid enrolled Speech Therapy and Audiology provider who refers and/or provides services to West Virginia Medicaid members that require prior authorization AND completes the prior authorization requests to the Utilization Management Contractor, you must Self Register/Enroll prior to Monday, January 30, 2012. The registration process is available now at https://c3wv.apshealthcare.com. All other providers are encouraged to not enroll until three weeks prior to their released/scheduled implementation date.
Greetings Acute Inpatient and Inpatient Rehab<21 Providers!
APS Healthcare, in conjunction with WVMI, would like to thank you all for your input and feedback about the West Virginia Medicaid Prior Authorization Retrospective Review Policy that currently requires a timely 24-hour prior authorization submission for all admissions, including weekend and/or holiday admissions, which must be submitted on the first business day following the weekend or holiday. Due to the repeated expression of difficulty with meeting this requirement, APS has provided the Bureau for Medical Services (BMS) your provider/submitter comments and concerns about the current policy. After careful consideration, BMS has listened to your feedback, and has agreed to eliminate the 24-hour timeline, and instead, adopt a 72-hour prior authorization timeline in its place. Although leniency will still be granted through December 31, 2011, providers must endeavor to submit all requests as timely as possible until then.
With this submission time change, providers/submitters have the additional time that was requested; therefore, leniency should no longer be needed beyond the current deadline of December 31, 2011.
BMS has indicated that they are pleased to be able to assist you with this matter, and hopes that it will help the transition become a little smoother for all Acute Inpatient and Inpatient Rehab under 21 providers. APS has also indicated appreciation of your feedback and hopes that you continue to provide your opinions regarding matters that are of concern, as it can be very beneficial for you.
If you have any questions, comments, and/or concerns, please do not hesitate to call APS Healthcare at 1-800-346-8272, or email them at wvmedicalservices@apshealthcare.com.
Based on provider feedback the Bureau for Medical Services has agreed to modify the scheduled December 12, 2011 implementation of the direct data entry system APS Medical CareConnection® for physical and occupational therapy services. The training and Production sites WILL be available on December 12, 2011 BUT WVMI will continue to accept physical and occupational therapy requests on their existing system until further notice. Physical and Occupational Therapy service providers may utilize the training site to familiarize their practices with the new system. Any provider who wishes to utilize the new system to request services may do so beginning December 12, 2011 but should contact APS at 1-800-346-8272 OR e-mail them at wvmedicalservices@apshealthcare.com to let them know your plan to “go-live” in the system.
Progress will be evaluated and a date in which providers MUST utilize the new system will be released by January 16, 2012. APS will continue to offer technical training on the system during the next several weeks and additional training sessions will be posted on the APS (apshealthcare.com) and WVMI (WVMI.org) websites. APS will continue to offer training and technical assistance to providers to facilitate a smooth transition to the new system. Physical and Occupational Therapy services providers who need assistance can make special arrangements for training or technical assistance by contacting us at 1-800-346-8272 OR by e-mailing us at wvmedicalservices@apshealthcare.com.
APS Healthcare in conjunction with WVMI would like to inform you of some very important upcoming information.
The scheduled Go-Live date for PT/OT prior authorization requests in the new C3 direct data entry system is December 12, 2011. Here is important information about registration and training.
Providers are required to register in the C3 system prior to Go-Live.
- You must read the CareConnection® Overview & Enrollment Guide (also access the intro letter).
- After reading the guide, you must print, sign, and fax a hard-copy of the required Provider Portal Signature Page (Located in the attachment in Section R on page 26)
- You must successfully enroll and link all “WV Medicaid Molina Enrolled Providers” by NPI to your registered organization
- You must have one training submission remitted (details for this prerequisite will be provided the week of December 5, 2011)
- You must receive the “Go-Live” Memorandum via email from APS Healthcare after fulfilling all required registration processes. This memo will be granting your organization with full access to the production site. Without this memorandum your organization’s prior authorizations will not be processed.
Outpatient Physical and Occupation therapy services will be reviewed under the existing BMS Manuals and criteria. Changes and trainings regarding the new manual will be forthcoming and training updates will be provided at the time the new manual is finalized.
Training Webinars
APS in conjunction with WVMI will be hosting training Webinars. The first week's will be training for the registration process only.
The next week’s webinars will be a quick overview of registration, but will be mostly technical training, showing how to submit a prior authorization request in our system. Here are related documents with dates and instructions.
In closing, if you have any questions or need assistance, please call APS Healthcare at 1-800-346-8272 or email wvmedicalservices@apshealthcare.com
We look forward to working with each of you and will help you in any way possible to ensure a smooth transitions process.
IMPORTANT: Many inpatient providers are still not registered and many have not tested. Please review the information below to prepare for October 31, 2011. You cannot simply begin to use the site on October 31, 2011- you must take the actions below to ensure a successful transition!
The APS Medical CareConnection® DDE System Production URL (C3wv.apshealthcare.com) will be available to make requests and implementation will begin October 31, 2011.
APS' West Virginia C3 Provider Portal Manual For Providers is now available. To access it, click here. You may
access it by clicking on this link. For future reference, you can find it anytime in the training resources library on the prior authorization page.
APS has announced the following dates and login information for Medical CareConnection DDE System training.
Webinars are scheduled for October 25 at 11:00 a.m. and October 27 at 2:30 p.m. For complete information and login information,
download the Webinar document from APS.
APS has issued a memo titled, "Implementation Go-Live for APS Medical CareConnection® DDE System."
Download the memo here or read the text of it below.
First and foremost thanks to all of you who have attended webinars, tested, and spoken with us about your needs related to implementation. We have evaluated the progress to date and will implement the following plan for “go-live”:
Based on provider feedback the Bureau for Medical Services has agreed to delay the scheduled October 17, 2011 implementation of the direct data entry system APS Medical CareConnection® for inpatient hospital services and inpatient rehabilitation <21 services. The site WILL NOT go-live on October 17, 2011 AND WVMI will continue to accept inpatient requests on their existing system until further notice. A training site will be prepared for providers who have registered with APS to allow for testing the week of October 17-21 2011.
Effective October 31, 2011, at noon, WVMI will no longer be able to accept phone reviews, for acute care (inpatient) hospital admissions, unless the case is medically urgent., as well as all inpatient rehab <21 cases.
Medically urgent is defined as:
- A delay could seriously jeopardize the life or health of the consumer or,
- The ability of the consumer to regain maximum function or,
- In the opinion of a physician with knowledge of the consumer’s medical condition, would subject the consumer to severe pain that cannot be adequately managed without the care or treatment that is the subject of the case.
Download the files for more information.
Utilization Management System Presentation and FAQs Available
APS Healthcare has made available a copy of its
training presentation and
frequently asked questions related to the Utilization Management system. Click the links to download.
As you may be aware IRG d/b/a APS Healthcare, Inc. (APS) is now the primary Utilization Management Contractor (UMC) for prior authorization of Medicaid medical and behavioral health services.
In order to improve the efficiency and timeliness of processing medical prior authorization requests, APS has developed web-based complete CareConnection (C3) software system for the direct data entry of West Virginia Medicaid prior authorization requests. We are pleased to announce that initial training will be conducted to introduce medical providers to the features of this system.
Molina Medicaid Services has issued a letter to provide you an additional reminder that the changes for the Bureau for Medical Services (BMS), Dental Services Manual will be effective 4/1/2011. The letter lists the following specific changes.
Effective April 1, 2011, the UMC forms and prior authorization requirements contained in Chapter 505 Dental Services manual effective 11/1/10 will be in place. Previous UMC forms will not be accepted after April 1, 2011 and all services requiring prior authorization in the updated manual will now be subject to review by WVMI.
Retrospective Review is avaiable for the following.
- Retrospective review is available following weekends or holidays or at times when the Utilization Management Contractor review process is unavailable.
Effective 10/08/10, phone reviews will only be accepted for medically urgent nebulizer requests for children 3 years of age or under. If you have any questions, please contact Stacy Holstine, Project Manager, at 1-800-642-8686, ext. 3279, or Melissa Nichols, Support Staff Supervisor, at ext. 3233.
All Behavioral Health Review for WV Medicaid is now being handled by APS Healthcare. You may contact APS’ clinical review line at 1-800-378-0284 or 304-346-6732.