Prior Authorization Errors Related to Closures due to Death and Permanent Nursing Facility Placement of Members
Prior Authorization (PA) Errors commonly happen when providers are not notified timely of a Member’s death or nursing facility placement. At the time of a Member’s death or “Long Term Care” (LTC) nursing facility placement, ADvantage eligibility ends and funding for services can not be authorized. This can be fiscally burdensome to providers that have not been notified, as they must void their paid claims with the Oklahoma Health Care Authority and payback all funds. Most commonly it is Durable Medical Equipment (DME) and Home Delivered Meal (HDM) providers that are affected. It is imperative that the Case Manager, as the service coordinator, notify the ADvantage Administration (AA) and all contract providers immediately when a Member’s eligibility for ADvantage Service ends. Per the Conditions of Provider Participation, it is also the responsibility of any contract provider to immediately alert the Case Manager when they become aware that a Member has passed away or has been admitted to a nursing facility.
It is vital that the Case Manager notify the AA of a Member’s death or permanent placement in a nursing facility. Within one working day of discovery, the Case Manager faxes the Discharge Evaluation (02CB015E/ADv15) to the AA Claims, Closures, and Reactivations (CCR) Unit fax at 918-933-4981. The Discharge Evaluation form must be signed by the Case Manager and document the date of death or exact date the Member went into “Long Term Care” status in the nursing facility. Discharge Evaluation forms reporting closure due to a nursing facility placement must list the name of the nursing facility and the facility’s telephone number. If the Case Manager is not able to fax the Discharge Evaluation, they may call the AA Resource Center at 1-800-435-4711 to report the death or LTC nursing facility placement of a Member, and then follow up with sending the Discharge Evaluation to the AA.
We hope that the procedures above will drastically reduce the number of PA Errors that are currently being received at the AA daily. This should also reduce the fiscal burden to contract providers in the future.
If you have any questions regarding the information provided above, please contact us at Provider Questions via your Smarter Mail account.