Prior Authorization and Authorization Requirements for PACE (Program of All-inclusive Care for the Elderly), Family Care Partnership and Family Care Program.

To understand what services (Medical and LTC) require authorizations please review the following document:

Authorizations and Forms for Medicare's Patient Driven Payment Model (PDPM)

To be in compliance with Medicare’s Patient Driven Payment Model (PDPM) beginning October 1^st, 2019, Community Care’s prior authorization practice for post-acute facility Part A Medicare skilled nursing stays is changing for all Medicare beneficiaries enrolled in Community Care’s PACE and Family Care Partnership programs. Skilled Nursing facilities will be required to complete Community Care’s “Post-Acute Facility Prior Authorization Request Form” (found in Forms section below) when admitting a PACE or Family Care Partnership member under a Part A Medicare stay. Completed forms must be sent to Community Care’s Utilization Management department before any authorization will be completed. Once a Medicare Part A stay is authorized by Community Care, Providers must then complete Community Care’s “Post-Acute Facility Continued Stay Review Form” weekly during the Part A stay providing updates to the progression of the member’s initial plan of care.

Authorizations for Family Care Members Where Medicare is Primary (Click for Information)

by Community Care, Inc. | Sep 03, 2019

Beginning November 1^st, 2018 Community Care, Inc. will no longer require prior authorization for services where Medicare or other non-Medicaid insurance providers are the primary insurer and Family Care is responsible only for deductibles , coinsurance or cost shares. This includes most DME, therapy, mental health services, and Medicare SNF Part A stays where Family Care acts as the beneficiary’s Medicaid replacement plan.

Community Care, Inc. may still choose to send an authorization or communicate in other ways with providers of these services; however, this does not imply the service will be approved without submission to Medicare or other liable parties first unless that is explicitly stated on an authorization. Claims approved by another insurer will not require an authorization for payment of deductibles and co-insurances or cost shares, but will still be subject to other claim processing standards, and claims may be denied if the other insurance does not approve payment. Per 1902(a)(25) of the Social Security Act, Medicaid is the payer of last resort meaning that Medicaid will only pay for services after all liable insurers have met legal obligations to pay.

Providers must work directly with the member’s physician to obtain supporting documentation and prior authorization required by the member’s primary insurance. If it is not possible to obtain coverage from the primary payer, providers must provide an ABN (Advance Beneficiary Notification of Non-Coverage) or other suitable documentation that the beneficiary does not meet coverage criteria to IDTS (Interdisciplinary Team Staff) prior to the delivery of any equipment or service. Community Care will not pay primary for benefits covered by a member’s primary insurance when the denial reason is lack of sufficient paperwork or without prior authorization by IDTS. When a primary insurance denies coverage, Community Care, Inc. will not approve payment unless we have provided an authorization in advance to the provider indicating that we will pay as the primary insurer.

This new coverage policy applies only to Family Care members for benefits covered by Medicare or other primary insurance at the time of service beginning November 1^st 2018. There are no changes to the coverage policy for Medicaid only Family Care members or benefits not covered by Medicare or another primary insurer. These services will continue to require prior authorization as a condition of payment.

Forms (PACE and Partnership Only)

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