Winter 2010

Reminder About Act 62 Changes

As we mentioned in the summer issue of Provider Focus, the Autism Insurance Act (“Act 62”) was signed into Pennsylvania law in the middle of last year, changing the way autism services are covered through Medicaid and private health insurers. We now want to take a moment to update you on changes to the process for handling members with the Act 62 benefit that went into effect on January 1, 2010, which we notified you about by mail on December 1.

Eligibility Verification

The state has made eligibility verification system (EVS) changes to reflect the Act 62 eligibility for our members, in addition to how it currently shows third-party liability (TPL). These changes enable you to identify the impacted members easier and faster, allowing you to pursue approvals from the appropriate carrier when needed. As always, it is the provider’s responsibility to check EVS before services begin and throughout treatment. If your agency is not familiar with this, please contact our Network department at 877-769-9779 for assistance.

Authorization Process

HealthChoices is the secondary coverage for members who have the Act 62 benefit, so all requests for services—including behavioral specialist consultant (BSC), mobile therapy (MT) and therapeutic support staff (TSS)—must first be presented to the primary plan for approval. 

We suggest that providers continue to request authorizations from HealthChoices concurrently with the primary plan’s authorizations. This will help prevent a service lapse in situations when the primary determines that the services no longer meet medical necessity criteria, services are provided in place of services not covered, or the member reaches the $36,000 cap. 

Providers now are required to seek authorizations from the commercial carrier first—prior to HealthChoices authorizations. HealthChoices will not be able to issue approval for BSC, MT, or TSS services without an approval/denial decision by the primary plan. As of January 1, 2010, we need written documentation of the primary decision prior to approving the packet. We will accept packets sent to Magellan for HealthChoices authorization within two weeks of the primary’s decision, and will honor the requested start date of services. We have requested clarification from the state regarding the option of accepting verbal notification of the denial, and we will let you know when this request is answered.

Authorization Time Frames

We have found through this transition that commercial authorization periods tend to differ from the standard HealthChoices authorization period, and we need to align our approval time frame with those of commercial plans. In light of this, please follow the process outlined below:

  1. For children with Act 62 benefits, we suggest that providers submit a packet with recommendations for up to a one-year authorization period when clinically appropriate. We will review this request for medical necessity and make a medical necessity determination.
  2. Once Magellan has verified the commercial plan’s authorization decision, we will issue an approval for any appropriate HealthChoices services for the same time period as the commercial plan’s approval.
  3. When the commercial authorization period is up for renewal, follow the primary’s reauthorization process. When a decision has been made by the commercial plan on the next authorization request, submit a new Treatment Authorization Request (TAR) --Appendix C in the Pennsylvania HealthChoices Provider Handbook Supplement -- for the new, corresponding time period and requested authorization. The TAR cannot exceed the originally requested units without a new packet being submitted for review. 

Magellan will not require new packets throughout the year—simply indicate on the TAR the date that the original packet was submitted. We will honor that evaluation and packet for 365 days of services authorizations. This will allow providers to continue to have HealthChoices authorizations for any services not covered by the commercial plan or when the member reaches the $36,000 cap.

Contracting and Claims Payment

As of January 1, 2010, the Pennsylvania behavioral health - managed care organizations (BH-MCOs) now are expected to have the required explanation of benefit (EOB) documents on record. For members who have Act 62 benefits, we will need EOBs in order to pay co-payments and deductible balances due after applying the commercial coverage payment. Magellan will pay BHRS claims based on what is authorized and your current HealthChoices contracted rates, services and codes.

Magellan hosted provider and family town hall meetings in December and January to review the changes outlined above, to answer questions and to share information. If you missed these town hall meetings or have additional questions, please contact Children’s Services Manager Tara Walsh Karbiner, LCSW, at TAKarbiner@MagellanHealth.com or Field Network Director Scott Donald at SDDonald@MagellanHealth.com.

Thank you for your cooperation and ongoing commitment to providing quality services.