Prior Authorizations (PAs) for Section 21, 28, 29 Providers

July 7, 2011

When providers under sections 21, 29, and 28 submit claims for services that have duplicate Prior Authorizations (PA) for the same member, date, location, and time period, you must include the Prior Authorization number on the claim. Duplicate prior authorizations can occur when: • Office of Adults with Cognitive and Physical Disability Services (OACPDS) or Children’s Behavioral Health Services (CBHS) updates an existing authorization (for example adding additional units) that already has a claim billed against it. • Office of Child and Family Services (OCFS) creates duplicate authorizations because two similar services can have the same procedure codes. For example, requesting two different evaluations for the same member can create a duplicate PA when they are issued at the same time. You do not need to use a PA number on the claim if the authorizations have a different service location, but are the same in every other way (for ex. same member, date, and time period). In the past, claims with these types of authorizations may have been denied for one of these reasons: • “Benefit requires authorization” • “Contract requires authorization” • “Provider group does not match authorization” Claims denied for one of the above reasons will be reprocessed. You do not have to rebill these claims. In order to determine if the authorizations are identical, you can now view the service location name of each authorization instead of the pay-to provider name when viewing your PAs on the portal.
For questions, please contact Provider Services at 1-866-690-5585.