Developmentally Disabled Waiver Providers: When a PA gets updated mid-stream

May 24, 2011

Waiver providers under sections 21 and 29 can have two nearly identical Prior Authorizations, different only in one detail. The difference could be rates, units, or dates of service. This happens when something changes after a PA has been approved. As the waiver provider, you receive a revised Summary of Authorized Services, showing the most up to date approval.

You can also see two PAs on the MIHMS portal. (To learn more about the portal and how to use it, see the MIHMS HealthPAS Online User Guides.)

If you have billed the member’s services before the PA was updated, then the later claims need to show the Authorization ID or PA number. The Authorization/PA number needs to appear in box 23 of the CMS 1500 form. The Summary of Authorized Services lists the Authorization ID; when listing it on the claim, add “EIS” before and “A” after the ID number.

The MIHMS portal will show the PA number exactly as it should appear on the claim.

An example scenario: An authorization is created for service dates 4/1 to 6/30 for a rate of $100 per day. On 4/22, circumstances change and the rate must be $130 per day. The original authorization will be replaced by two authorizations: one will cover 4/1-4/21 at the $100 rate and a second authorization will cover 4/22-6/30 at the $130 rate. Any claims for 4/22 – 6/30 will need to list the PA number.

If you have not billed any services before the PA was updated, then the claims do not need to show the Authorization ID or PA number.

For questions, contact Provider Services at 1-866-690-5585.