SUBJECT Changes to the Prior Authorization Request Form for

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        Department of Medical Assistance Services
            600 East Broad Street, Suite 1300
                Richmond, Virginia 23219

TO:                  All Intensive In-Home Providers, and Managed Care
                     Organizations Participating in the Virginia Medical
                     Assistance Programs

FROM:                Patrick W. Finnerty, Director                           MEMO: Special
                     Department of Medical Assistance Services
                                                                             DATE: 4/23/2007
SUBJECT:             Changes to the Prior Authorization Request Form for Intensive In-Home Services –
                     Effective June 1, 2007

The purpose of this memorandum is to provide information on changes to the Intensive In-Home
(IIH) prior authorization (PA) process with Virginia Medicaid’s PA contractor, Keystone Peer
Review Organization (KePRO). This information will assist providers in expediting the review
process for IIH services that require extension.

The Department of Medical Assistance Services (DMAS) has revised the request form for PA of IIH
service extensions. All IIH prior authorization requests for extension of service must be submitted to
KePRO on the DMAS-366, effective May 1, 2007.

Changes to the KePRO Prior Authorization Fax Form
Attached to this memo is the DMAS-366, Intensive In-Home Preauthorization Request Form and
Instructions. The required elements for requesting extension for service remain the same, and no
changes have been made to the prior authorization review process conducted by KePRO. Please
review the new fax form and instruction sheet attached to this memo.

Providers will have an approximate 6-week grace period to begin utilizing the DMAS-366 (Request
for Extension of Intensive In-Home Services). KePRO will accept the old DMAS-364 (Intensive In-
Home and Treatment Foster Care-Case Management Prior Authorization Request Form) through
May 31, 2007. Beginning June 1, 2007, the DMAS-364 will be used solely for Treatment Foster Care
Case Management PA requests.

Effective June 1, 2007, KePRO will only accept the DMAS-366 (Request for Extension of Intensive
In-Home Services) for IIH extension requests.
Medicaid Memo: Special
April 23, 2007
Page 2

Providers will begin receiving their authorization determinations (denials or approvals) via fax rather
than mail. Faxing will provide a quicker turn-around time to the provider with their notice of

Resource Information
    • All forms are located under “forms” on KePRO’s website or at

     • Should you have any questions regarding the prior authorization process, please send your
     inquiries via e-mail to or Remember
     do not send PHI by e-mail unless it is sent via a secure encrypted e-mail submission.

     • All other Medicaid provider issues not related to prior authorization should be addressed
     through the Provider Helpline. The numbers are 1-800-552-8627 or if you are located in
     Richmond or out-of-state call 804-786-6273.

Alternate Methods to Obtain PA, Eligibility and Claims Status Information
DMAS offers a new, enhanced web-based Internet option (ARS) to access information regarding
Medicaid or FAMIS eligibility, claims status, check status, service limits, prior authorization, and
pharmacy prescriber identification. Current and new users of the ARS are required to migrate to the
new web-based ARS to logon and register prior to May 22, 2007. Please see the Medicaid Memo
dated 1/19/2007 for more information. The website address to use to enroll for access to this system
is The MediCall voice response system will provide the same information
and can be accessed by calling 1-800-884-9730 or 1-800-772-9996. Both options are available at no
cost to the provider. Providers may also access prior authorization information including status via

DMAS publishes electronic and printable copies of its Provider Manuals and Medicaid Memoranda
on the DMAS website at Refer to the “DMAS Content Menu” column on
the left-hand side of the DMAS web page for the “Provider Services” link, which takes you to the
“Manuals, Memos and Communications” link. This link opens up a page that contains all of the
various communications to providers, including Provider Manuals and Medicaid Memoranda. The
Internet is the most efficient means to receive and review current provider information. If you do not
have access to the Internet or would like a paper copy of a manual, you can order it by contacting
Commonwealth-Martin at 1-804-780-0076. A fee will be charged for the printing and mailing of the
manuals and manual updates that are requested.

DMAS is pleased to inform providers about the creation of a new Provider E-Newsletter. The intent
of this electronic newsletter is to inform, communicate, and share important program information
with providers. Covered topics will include changes in claims processing, common problems with
billing, new programs or changes in existing programs, and other information that may directly affect
providers.     If you would like to receive the electronic newsletter, please sign up at: Please note that the Provider E-Newsletter is
not intended to take the place of Medicaid Memos, Medicaid Provider Manuals, or any other official
correspondence from DMAS.
       KePRO/DMAS now require any Medicaid Provider submitting Prior Authorization requests using
       their National Provider Identifier (NPI) or Atypical Provider Identifier (API) to provide their 9 digit
                     zip code. If you do not know your 9 digit zip codes then please visit:

                                     KePRO Intensive In-Home Preauthorization Request Form
                                         FAX: 1-877-OKBYFAX (877-652-9329) / Phone: 1-888-827-2884
1) Admission Date:                                            2) Enrollee Last Name:                           3) Enrollee First Name:
   Requested Start Date:                                  4) Enrollee Medicaid ID # :                    5) DOB (mm/dd/yyyy): / /
Requesting retroactive authorization Y   N
6) Sex:     Male       Female          7) Provider Name:                             8) Provider Fax: (      )
9) Contact Person:        10 Provider ID/NPI/API# 11) Provider Phone:                12a.) Provider Address:
                                                       (     )                       12b.) 9 digit Zip Code:               (Mandatory)
13) DSM IV:                                           14) Frequency
                 Axis I                               Requested Extension (in weeks)
                 Axis II                                  15) Psychotropic Medications
                 Axis III                                 Name          Dosage        Frequency         Compliant
                                                                                                        Yes / No
                Axis IV
          Axis V (GAF)      Current:
                            Highest in last year:

16) Current Behaviors: Please provide a narrative of the behaviors exhibited in the home over the past 30 days that warrant the requested level of care.
(Please identify frequency, intensity and duration of each behavior).

17) Required Attachments
    • Comprehensive Treatment plan (ISP)
    • Most current 30-day Progress Update

      DMAS 366 revised 03/07

                                                    (DMAS 366 – Rev 03/07)

This FAX submission form is required for Intensive In-Home prior authorization review.

Please be certain that all required information blocks contain the requested information. Incomplete forms may result in the
case being rejected or returned via FAX for additional information.

If KePRO determines that your request meets appropriate review guidelines the request will be “tentatively approved”.
Reimbursement is contingent upon passing remaining enrollee and provider eligibility/enrollment edits.
       1. Requested Start Date:
               •      Enter the date the requested services are to begin.
               •      Note whether or not this is a request for retroactive authorization.
         2. Enrollee Last Name:
               •      Enter the enrollee’s last name exactly as it appears on the Medicaid card.
         3. Enrollee First Name:
               •      Enter the enrollee’s first name exactly as it appears on the Medicaid card.
         4. Enrollee Medicaid ID Number:
               •      It is the provider’s responsibility to ensure the enrollee’s Medicaid number is valid. This should
                      contain 12 numbers.
         5. Date of Birth:
               •      Date of birth is critically important and should be in the format of mm/dd/yyyy (for example,
         6. Sex:
               •      Please place a √ or X to indicate the sex of the patient.
         7. Requesting/Service Provider:
               •      Enter the requesting/service provider name.
         8. Requesting/Service Provider Fax Number:
               •      Enter the fax number, including area code, of the requesting/service provider.
         9. Requesting/Service Provider Contact Person:
               •      Enter the primary contact for the requesting/service provider.
         10. Provider ID Number:
               •      Enter the Provider NPI/API number.
         11. Requesting/Service Provider Phone Number:
               •      Enter the phone number, including area code, of the requesting/service provider.
         12. Requesting/Service Provider Address:
               •      A. Enter the requesting/service provider’s business address.
               •      B. 9 Digit Zip Code (Mandatory): Providers must enter their 9-digit zip code to ensure their correct
                      location is identified for the NPI/API number being submitted.

      13. DSM-IV Diagnoses:
            •       Enter the DSM-IV diagnoses.
                         o   Axes I and II are required
      14. Frequency of Services:
            •       Enter the anticipated extension duration (in weeks) in the space provided.
      15. Medications:
            •       Enter the psychotropic medications that the recipient is currently prescribed.
            •       Also enter the dosage of the medication, frequency that the recipient takes the medication, and mark an
                    (X) under yes or no in the “compliant” column indicating if the recipient is compliant with the
                    medication regimen.
      16. Current Behaviors:
            In the space provided, please enter a narrative of the behaviors exhibited over the past 30 days that warrant
            the requested level of care. Please identify frequency, intensity, and duration of each behavior.
      17. Required Attachments:
                •   Please submit the following attachments with the request of prior authorization.
                         o   Comprehensive Treatment Plan (ISP)
                         o   Most current 30-day Progress Update