Georgia’s Department of Community Health (DCH) is beginning the implementation of a phased centralized prior authorization function for traditional Medicaid and the three CMOs (Amerigroup, Peach State Health Plan and WellCare). This centralized PA will be available on the Georgia Medicaid Management Information Services (GAMMIS) web portal at www.mmis.georgia.gov.
The centralization of the PA process will be phased in for the CMOs; beginning with Pregnancy and Newborn Delivery Notifications on June 1, 2013. There will be no change in the prior authorizations requested for traditional Medicaid beneficiaries; however, CMO participating providers can now use the traditional Medicaid system to submit prior authorizations for the services identified below in Phase 1. In the traditional Medicaid portal, the prior authorization screen will be updated to include a field that allows you to choose either traditional Fee for Service Medicaid, Amerigroup, Peach State or WellCare.
6.1.2013: Newborn & Delivery Notification Forms will be completed and submitted via the Centralized PA Portal Functionality
7.1.2013: The following will be moved to the Centralized PA Portal:
1. PAs for the following Place of Services (POS) should be entered through the Centralized PA Portal:
21-Inpatient Hospital Services
22-Outpatient Hospital Services
24-Ambulatory Surgery Services
2. In State Transplants
3. Hospital Outpatient Therapy
4. Appeals & Reconsiderations Request
5. Submissions of initial and additional clinical data attachments
Exclusions During Phase 1 (Do Not Submit These PA Types During Phase 1): Services handled by CMO Third Party Vendors (dental, vision, radiology, etc) & Behavioral Health Inpatient or Outpatient PAs
Once the PA requests are submitted through the centralized portal, they will be routed to the applicable CMO for review and approval/denial. PA requests will generate a GMCF Tracking ID once submitted; this is not the Prior Authorization Number used for CMO claims submissions.
1. If the PA is approved by the CM< the CMO’s assigned authorization number will be displayed in the “Vendor Authorization ID” field with a Status of “Approved” and this number should be used on the claim.
2. If the PA is denied, a CMO assigned reference number will be displayed in the “Vendor Authorization ID” field with a Status of “Denied” and this number should be used for reconsiderations/appeals.
3. If the PA is in process, the CMO will display a status of “Pending”.
It is anticipated that additional service categories will be added to the Centralized PA functionality after the initial Phase 1 Roll-Out. Additionally, through the centralized PA portal, PA requests may be submitted a maximum of 30 days prior to elective service/admission and retrospective PA requests may only be submitted if the service/admission was emergent.
As this centralized PA function is implemented, SHP believes that it is critical for our clients to track whether the PA process time frame is significantly delayed by the centralization function in order to communicate those concerns back to the Department of Community Health (DCH).