Personal care services prior authorization change

Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.

What is the change?

Effective May 1, 2022, prior authorization will be required for the following service:

• Code: (T1019) Personal care services

 

Personal care services for members under 21 who do not have the LTSS Waiver but are receiving personal care through the EPSDT benefit require precertification according to Commonwealth Coordinator Care Plus Waiver Services Provider Manual (pg. 8).

 

Payment is available only for services provided when:

 

• Individual is present.
• Approved plan of care.
• The services are authorized.
• Qualified provider is providing the services to the individual.

 

How do I request authorization?

 

Requests may be submitted by calling Provider Services at 855-323-4687, ext. 1061035152 or faxing the requests to one of the fax lines indicated below. All requests must include clinical documentation showing a medical reason why the member needs to have the service.

 

Documentation requirements:

 

• DMAS 7A, or equivalent plan of care, and DMAS 99
• Records of the Department of Education’s last Individual Education Plan (IEP) if a member is receiving or seeking personal care of private duty nursing (PDN) services delivered in a school setting and paid for by Medicaid.
• Recent clinical documentation examples, including hospital or facility discharge summaries, last three physician visit notes (primary or special care), etc.:

 

• If a reauthorization review, include the most recent two weeks of personal care services progress notes.
• If a new request, examples include hospital or facility discharge summary, last three physician visit notes (primary or special care), etc.

Fax lines

 

Early and Periodic Screening Diagnostic Treatment Personal Care Assistance (EPSDT PCA) expedited and new waiver requests	888-235-8390
EPSDT PCA standard requests	844-864-7853

 

If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.

AVAPEC-3385-22