Changes for CIS Manual 4/1/15

Here's the latest update published on the web portal for Medicaid

Also make sure you use the Attestation form that has been updated from this manual...

pg 9

801. Documentation of Medical Necessity

Providers must document medical necessity for service delivery under the CIS program.

Medically necessary, medical necessity or medically necessary and appropriate means medical services or equipment based upon generally accepted medical practices in light of conditions at the time of treatment which are: appropriate and consistent with the diagnosis of the treating physician and the omission of which could adversely affect the eligible member’s medical condition; compatible with the standards of acceptable medical practice in the United States; provided in a safe, appropriate and cost effective setting given the nature of the diagnosis and the severity of the symptoms; not provided solely for the convenience of the member or the convenience of the health care provider or hospital; not primarily custodial care unless custodial care is a covered service or benefit under the member’s evidence of coverage; and there must be no other effective and more conservative or substantially less

costly treatment, service and setting available.

This documentation includes: documentation of the medical diagnosis, the Letter of

Medical Necessity, the Plan of Care, and the provider’s progress notes. The Plan of Care (POC) and the Letter of Medical Necessity (LMN) may be combined into one document as long as all elements stated below are included and the PCP has reviewed and approved the document by affixing their signature to the document or by including an electronic signature in the document. The POC, signed by the member’s PCP, is equivalent to the PCP’s Letter of Medical Necessity. Electronic signatures are acceptable on CIS documentation. Refer to Medicaid Part I Policies and Procedures for information on electronic signature criteria.

pg 13

Prior Approval

CIS providers will soon be able to submit PA requests via the Centralized PA Portal. A banner message will be posted when this service becomes available.

pg 25

10. If you have received a partial denial on a PA request for documentation that has expired, you should attach the updated documents via the Reconsideration link to the PA that was par埽�ally tech denied for expired paperwork.

pg 36

All Reimbursement Rates for CIS program services were updated effective October 1, 2011 after the provider rate decrease, documented in the July 1, 2011 manual, was abandoned. As of April 1, 2015, the descriptions for the HIPAA Compliant CPT Codes have been removed from this manual. Please consult the latest version of the Current Procedural Terminology for the procedure code descriptions.