DMA Has Sent the Following Data to Doctors About the April 1, 2010 Implementation of Independent Assessment, Prior Authorization, and New Clinical Coverage Policy for Medicaid Personal Care Services (PCS) and PCS-Plus

Independent Assessment

The Carolinas Center For Medical Excellence (CCME) will conduct new referral assessments and continuing service and change of status reassessments for PCS and PCS-Plus, effective April 1, 2010.  Independent Assessments will determine recipient eligibility and authorized service levels.  Prior approval of PCS claims will be required, and claims for services that exceed levels authorized by CCME will be denied.

Transition Period

Up until April 30, 2010, PCS providers will continue to obtain physician referrals and Plan of Care (POC) authorizations for recipients whose assessments they conduct through April 30, 2010.

Beginning May 1, all PCS assessments will be conducted by CCME, and PCS provider agencies will not seek referrals or authorizations for these recipients. Also, Individuals applying for admission to PCS must obtain a referral through their primary care or attending physician and must schedule an office visit if they have not been seen in the previous 90 days

Physicians will complete and submit by mail or fax a one-page referral to CCME, who will contact patients to schedule the assessments.

Physician Attestation of Medical Necessity

The legislative mandate requires physician attestation of medical necessity for the service.  The physician’s signature on the referral form authorizes an independent assessment of the patient by CCME and is an attestation to the medical necessity of assistance with the patient’s Activities of Daily Living (ADLs).

New Clinical Coverage Policy

The new PCS and PCS-Plus Clinical Coverage Policy 3C will be available on the DMA website (http://www.ncdhhs.gov/dma/mp/) in April.  The policy includes changes in Non-Covered Tasks.  Providers must revise recipient Plans of Care (POCs) to comply with new policy requirements.  POC revisions made in response to changes in Non-Covered Tasks may be signed as RN updates; DMA will not require physician signature or approval of these changes.

Inquiries

Patients seeking admission, and providers and physicians with questions, may contact CCME using the Independent Assessment Help Line, 1-800-228-3365, or by e-mail, PCSAssessment@thecarolinascenter.org.

Additional questions or concerns may be directed to:

Mr. Joseph Breen
NC PCS and PCS-Plus Program Manager
Division of Medical Assistance
(919) 855-4365
Joseph.Breen@dhhs.nc.gov