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.
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.
Electronically submitted claims (i.e., claims submitted using billing software or via a clearinghouse), must be transmitted by 3:00 pm on Fridays to ensure processing in weekly payment cycle. For assistance and questions regarding electronically submitted claims, please contact Conduent’s EDI Department at (866) 407-2005.
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.
Upon successful login, prior Authorization status may be obtained by selecting 'PA Inquiry' from the Inquiry Options found in the Web Portal and entering the PA number or recipient ID.
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.
Vaginal deliveries and unplanned C-sections will not require an authorization.
The fee schedule is systemically updated weekly. If you have questions, contact Provider Inquiry at (202) 906-8319 (inside DC metro area) or (866) 752-9233 (outside DC metro area) or via email at providerinquiry@conduent.com.
Comagine 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.
If Medicaid is not the primary payer on admission, then no authorization is required.
Registration and navigational instructions for the web portal can be found on the left-hand side of the web portal under the heading “Training Material/CBT”. Please review the Web Portal Quick Reference Guide for instructions.
If you need additional help, contact the Conduent Provider Inquiry line at (202) 906-8319 (inside DC metro area) or (866) 752-9233 (outside DC metro area) or via email at providerinquiry@conduent.com.
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 Comagine reviewer has questions about the information submitted, they will contact the requestor for further information.
Lock-in indicates the recipient can receive services only from a certain pharmacy, long term care/ICF or physician provider.
