Yes, beginning April 1, 2008, all written prescriptions for Medicaid recipients must be on paper with at least one tamper-resistant feature as outlined by CMS and defined by DC Medicaid in the tamper-resistant prescription pad (TRPP) guidance issued February 5, 2008. Beginning October 1, 2008, the paper must meet all three baseline characteristics.
If Medicaid is not the primary payer on admission, then no authorization is required.
If the IVR report of ineligibility is not accurate, inform the recipient of his or her right to obtain free legal assistance by contacting: Terris, Pravlik, & Millian, LLP, 1121 12th Street, N.W. Washington, DC, (202)682-0578.
Eligibility is never purged; therefore, it goes back many years.
Prior Authorization status may be received by selecting 'PA Inquiry' from the Inquiry Options found in the Web Portal and entering the PA number.
Lock-in indicates the recipient can receive services only from a certain pharmacy or physician provider.
Vaginal deliveries and unplanned C-sections will not require an authorization.
Qualis nurses will use the most current version of the Interqual criteria set as a screening tool. Any potential denials will be forwarded to a physician reviewer for a peer review determination.
There will be no telephonic reviews. All requests will be completed within one business day of receipt of all required information. You will receive a fax verifying receipt of your request at the time received. If the Qualis reviewer has questions about the information submitted, they will contact the requestor for further information.
The fee schedule is systemically updated the last Friday of each month. If you have questions, contact Provider Inquiry at (202) 906-8319 (inside DC metro area) or (866) 752-9231 (outside DC metro area).
Undocumented immigrants admitted for an emergent situation is not included in the review process. Facilities should continue to report information for these individuals directly to ESA.
Yes. Should a provider fail to provide the clinical information for the ER Admission Review, the entire stay referenced on the submitted claim will be denied due to lack of a timely request for authorization.