medicaid-1915c-authorization-guidelines-for-innovations-20220101 by Vaya Health

Vaya Health

Medicaid 1915(c) Authorization Guidelines for Innovations Intellectual/Developmental Disability (I/DD) Services Medicaid 1915(b) Child/Adult Non‐Innovations IDD Services Authorization Guidelines Service

Innovations Waiver Services

Billing Code See Vaya Standard Rate Schedule for all codes

Auth Required?

Yes; all services

Home Modifications

S5165

Vehicle Modifications

T2039

Yes

Assistive Technology - Equipment & Supplies (ATES)

T2029

Yes

(b) codes (see rate schedule); if not listed use T2029MM

Yes

Nutritional Supplements and Monitoring/Connectivity (ATES)

Yes

Utilization Parameters

Documentation Submission Requirements

Initial request: LOC signed by MD, current psychological evaluation, Individual Support Plan that includes Member Care Plan, Crisis Plan, Risk Supports Needs Assessment (or Annual plan up to 12 months Health Risk Assessment), Freedom of Choice, and Budget as required in Clinical Coverage Policy 8P for the NC Innovations Waiver Submitted in annual plan or updated Individual Support Plan that includes Member Care Plan, plan, up to 12 months depending on Crisis Plan, Risk Supports Needs Assessment (or Health Risk birth month; Assessment); Freedom of Choice, and Budget; Subject to lifetime of the Innovations Wavier limit of $50,000 Two quotes, Prescription by MD or PD, recommendation by (shared total with ATES) appropriate professional Individual Support Plan which includes Member Care Plan, Submitted in Annual plan or Crisis Plan, Risk Supports Needs Assessment (or Health Risk updated plan, up to 12 months Assessment) Freedom of Choice, and Budget; depending on birth month; Subject to lifetime of the Innovations Wavier Two quotes, prescription by MD or PD, recommendation by limit of $20,000 appropriate professional, proof of ownership, proof of insurance, state of life expectancy of vehicle Submitted in annual plan or updated Individual Support Plan which includes Member Care Plan, plan, up to 12 months depending on Crisis Plan, Risk Supports Needs Assessment (or Health Risk birth month; Subject to lifetime of Assessment) Freedom of Choice, and Budget the Innovations Wavier limit of $50,000 (shared total with Home 2 quotes, prescription by MD or PD, recommendation by Modifications) appropriate professional Individual Support Plan that includes Member Care Plan, Submitted in annual plan or updated Crisis Plan, Risk Supports Needs Assessment (or Health Risk plan, up to 12 months depending on Assessment), Freedom of Choice, and Budget birth month One quote due to standard rate, prescription by MD or PD, or one quote if standalone provider Clinical Strategies | Effective 01.01.2022 Version 1.0

Employer Supplies – Startup costs

T2025U2U1

T2025U2 – not submitted into AlphaMCS

Employer Supplies

Yes

Submitted in annual plan or update at beginning of change to Employer of Record model – purchases to be made in 60 days, Fiscal Support Agency to submit invoice or receipts within 90 days of purchase (onetime event)

Yes

Submitted at any time during member’s plan year

Individual Support Plan that includes Member Care Plan, Crisis Plan, Risk Supports Needs Assessment (or Health Risk Assessment), Freedom of Choice, and Budget along with Employee Supplies Request Form

Individual Support Plan that includes Member Care Plan, Crisis Plan, Risk Supports Needs Assessment (or Health Risk Assessment), Freedom of Choice, and signatures along with Employee Supplies Request Form that is emailed to I/DD UM Approval letter is generated to Employer of Record and Fiscal Support Agency granting use of fund balance

These are the authorization guidelines for Medicaid 1915(c) Innovations Intellectual/Developmental Disabilities (I/DD) Services for child and adult residents of the Vaya Health (Vaya) catchment area. Providers may be reimbursed only for those specific services included in their contracts with Vaya. Some services for particular age or disability groups in selected counties may only be provided by designated providers. In order to be authorized, services in the authorization guidelines must be determined to be medically necessary at a specific intensity level for each individual member. The maximum number of units listed in the guidelines is not necessary for all members requiring the service—the necessary amount of service must be determined individually for each member. The service intensities listed in the guidelines are the maximum amounts that will be necessary and approved for most members at a given Level of Care. Services at a higher level of intensity than that listed in the guidelines may be requested and will be reviewed for approval by Vaya’s UM staff.

Effective date:

01.01.2022

REVISION INFORMATION: Date 01/01/2021

Change Created consolidation Innovations Waiver auth guidelines

Clinical Strategies | Effective 01.01.2022 Version 1.0