Prior Authorization Guidance received from the Cabinet for Health and Family Services, Department of Medicaid Services - Effective 2/1/2021
- Prior authorization requests are removed for all Medicaid services for all Kentucky Medicaid enrolled providers, except pharmacy (including physician administered drugs). For MCOs, this includes both participating and non-participating providers
- Notification requirements will remain in place for inpatient services in order to facilitate care management, COVID reporting/tracking, and discharge planning
- The Concurrent Review process will remain in place for non-COVID diagnoses to support discharge planning, placement of members, care management, and facility capacity
- In order to facilitate provider payment, requirements for prior authorization of non-Kentucky Medicaid enrolled providers will remain in place
- This guidance has been extended through 1/31/2021 and will be reassessed late December to determine the need to extend
1. Does the auto approval include requests from par and non-par providers?
The directive includes prior authorization requests from both participating and non-participating network providers enrolled in Kentucky Medicaid. MCO payment terms remain applicable.
2. Does the directive include pre-authorization, retro, and concurrent inpatient requests?
The directive includes preauthorization requests for inpatient admissions with service dates of 11/17 until the mandate is lifted. Retroactive reviews with dates prior to 11/17 will remain within scope for review. Concurrent (continued stay) review processes will remain in place. Notification of inpatient admissions are required.
3. Does the directive include post-acute care? LTAC, In-Patient Rehab, SNF?
Authorization requests for In-Patient Rehab and Skilled Nursing and Long-Term Acute Care are removed.
4. What is the formal effective date of the policy?
The effective date of policy will be retroactive to include dates of service starting 11/17/2020.
5. Is there an anticipated review date or criteria for the removal of the directive?
DMS will continuously monitor aggregated pandemic data, public health data and facility capacity and will provide adequate notice before lifting the directive.
6. Is the hospital required to contact the Managed Care Organization (MCO) of an admission?
Notification requirements will remain in place for inpatient services in order to facilitate care management, COVID reporting/tracking, and discharge planning.
7. Does this include PA for transplants?
Prior authorizations will not be required for transplants.
8. Will MCOs be able to retrospectively review for medical necessity after the directive is lifted?
Providers must continue to operate within their scope of practice and follow appropriate licensure and applicable guidelines related to the care and treatment of patients. Claims identified as potential for fraud, waste or abuse may be retrospectively reviewed.