CIS Manual Changes for July, Georgia Medicaid Applications and Prior Auth for August

As everyone has heard and/or seen, prior authorizations for CIS will change August 1st,

requiring that CMO prior authorization requests be entered through the mmis.georgia.gov

web site instead of submitting them via fax or directly to the CMO (Amerigroup, Wellcare,

Peachstate) web site. By logging into the web portal (mmis.georgia.gov) you can see the

changes already asking you to select the type of member you are submitting the prior auth

for in the beginning of the request. Questions have been asked if the same documentation

will be required for the CMO requests as it is for the medicaid requests: yes. I do not see

the PA section changing its requirements based on CMO requests from the system. Crossing

our fingers here that all goes smoothly on this transition coming up this weekend.

Medicaid application will be changing as well. If all documentation is not received when

first submitting an application, the application will not process until all required documents

have been uploaded. Medicaid applications previously took only a couple of weeks for

approval, but with adding the additional CMO approvals onto the applications, I believe,

has slowed down the process. However most applications have been approved around 30

days from time of submission. CAQH will no longer be required for CMO applications

(Amerigroup, Peachstate) when applying for a new provider once these changes take place.

However do remember BCBS and other commercial insurance companies do require CAQH

to complete the network credentialing.

Please make sure any address information you have listed with any of your commercial

insurance companies is the correct mailing address and phone number. I've caught 4

different providers being kicked out of network with BCBS recently due to returned mail.

The most current manual for CIS was released this month. Here are some of the updates

noted from the manual:

If there are questions regarding PA submissions, providers should review the PA status on

the web portal first. (See Appendix Q) Any additional questions can be directed to GMCF via

the Contact Us link on the web portal. (See Appendix E). For claims issues and billing

questions, please contact the HP Contact Center at (800) 766‐4456. For CIS Policy

questions, please call DCH’s CIS Program Specialist at (404) 656‐5934.

If you have received a partial denial on a PA request for documentation that has expired,

you should attach the updated documents via the Change Request link to the PA that was

partially tech denied for expired paperwork.

Below are instructions for completing the required prior authorization fields on the Web

portal:

1) A PA is required only after you have used the maximum units allowed in policy. Do not

use a PA number if you are within the limit established by policy.

2) To amend a PA that has been denied due to missing information, please electronically

attach the documentation to the PA request. (See Appendix N) This information must be received within ten (10) calendar days of the date of the technical denial for missing

information. If information is received after ten (10) calendar days from the date of the

technical denial, the provider will have to resubmit the entire PA request.

Part 1 manual lists the following updates:

The Department shall terminate a provider’s enrollment in the Medicaid/PeachCare for Kids

program if the provider does not re-validate their enrollment within 60 days of being placed

on suspension for failure to re-validate their enrollment.

Other: The Division may terminate a provider’s enrollment if CMS or the Division:

(1) Determines that the provider has falsified any information provided on the application;

or

(2) Cannot verify the identity of any provider applicant.

Adjustments Related to a DCH initiated Mass Reprocessing:

HP will identify all the provider claims that are adversely impacted by the DCH enterprise

level mass adjustment. The providers will be granted 30 days from the date of the

adjustment to resubmit the impacted claim. The adverse impact must be a direct result of

the mass adjustment. Only line items on the claim directly involved in the DCH initiated

mass adjustment may be adjusted in the defined 30 day window.

Failure to adjust the claim within the 30 day time period during the DCH enterprise mass

reprocessing is not grounds for Administrative Review. Adjusting line items on the claim

outside those directly involved in the DCH enterprise level initiated mass adjustment shall

be considered fraudulent and result in claim denial and may be subject to recoupment.

As the next couple of months seem to move closer and closer upon us, here's to a smooth transition that all goes well with Medicaid, ICD‐10 and various changes headed our way!