EPA Login Instructions
Contents
1. 14 7 0 MAXIMUM 65 17 8 0 CONFIGURING THE E PA 19 9 0 VIEWING THE ON LINE HELP PAGE 2 21 08 11 2006 e PA User Manual UNISYS 1 0 OVERVIEW The Electronic Prior Authorization e PA Web Application provides a secure web based tool for providers to submit prior authorization PA requests and to view the status of previously submitted requests This tool is intended to eliminate the need for hard copy paper PA requests as well as provide a more efficient and timely method of receiving PA request results Each day the Unisys Prior Authorization department will review and determine the approval denial status of PA requests The resulting decisions will be updated on a nightly basis back to the e PA web application This enables the provider to see the decision for a PA request the following business day after the status was determined The requirement to submit standard supporting documentation to the Unisys Prior Authorization department remains unchanged This user manual describes how both tasks are accomplished using the e PA web application The e PA application is accessible to all providers who have a computer with Internet access using a recent version of either Netscape Navigator or Internet Explorer browser software Providers must establ2. all the required fields iis s i DIAGNOSIS Code Description the application will diem LLL present a user friendly Secondary 1 1 pop up box listing the SERVICE DATES Thru PRESCRIBING PROVIDER DATA required fields that must still be entered Once O uMM DB YYW you have completed all SERVICE LEVEL DATA the required fields Toor Procedure PETO I Description Requested Requested select the Submit button eee Units Amount at the bottom of the L3 oco Lit The PAR t sic a L EHEEEEN EE be displayed Place of Treatment PROVIDER CONTACT INFORMATION fus Address City E e O CO Telephone j rx Additional Comments z ePA Trans ID Submitted 7 24 2006 4 16 25 PM Enc No Technical Support 877 598 8753 Eligibility Information Support 800 473 2783 or 225 924 5040 2004 Unisys Corp Unisys Lammis 610551 All Rights Reserved 08 11 2006 e PA User Manual 7 UNISYS The PA Request Review page will be displayed with a header at the top that includes a bar code This bar code will allow Unisys to match the faxed supporting documentation back to the original electronic PA request Print the page using the Print Friendly link at the top Using the printed version of the PA Request Review page as a cover sheet fax the request and the
3. 23884 the equest i i 619885001 9975385244886 17 17 2006 EPSDT Requires IS NOW ae 3 07 50 PM Dental Review 17 2006 EPSDT Requires Recon 619595002 9975395244886 3 11 01 PM mental ace 7 17 2006 EPSDT Requires 6195950053 9975385244886 3 34 47 PM CET 23987 eview T l7 20086 EPSDT Requires 619865004 X 9975385244885 4 06 40 PM Dental Boer 23998 notifying the Recon YING 620155000 9975385244886 09 DME Requires 23999 1 provider that o Review their Recon i 7 20 2006 reconsideration 620155001 9975385244886 9 41 28 AM 09 OM 24000 1 has been eo entered and is waiting review Records 1 7 of 7 Page jof 1 08 11 2006 e PA User Manual 16 UNISYS 7 0 MAXIMUM RECONSIDERATIONS A provider may not submit more than 3 reconsiderations for each prior authorization request A message will be displayed at the bottom of the screen when the provider reviews a PA Request that has reached the maximum number of reconsiderations allowed To view the message click the View PA Requests from the PA Options menu and do a search for requests Below are all of the Transactions that were submitted by you through the System To view the complete Transaction click on the P4 Number of the request you wish to see This will give you the complete information regarding the request as well as a print friendly version that you can print for your records The column with the indicates the number of
4. Last Name FirstName mmm 8j Sex m j DOB DIAGNOSIS Code Description Primary z Secondary SERVICE DATES From Th ENNNNNNNNI PRESCRIBING PROVIDER DATA Physician Name Physician Number Prescription Date 2 SERVICE LEVEL DATA Requested Requested Units Amount Description Place of Treatment z Name Address mm 2 City m state zo Telephone mm Fax Additional Comments this is the comment Submit Another Request Print This Page ePA Trans ID Submitted Enc No BENI Technical Support 877 598 8753 Eligibility Information Support 800 473 2783 or 225 924 5040 2004 Unisys Corp Unisys Lammis 610551 Rights Reserved e PA User Manual 8 UNISYS 4 0 PA RECONSIDERATION Use the PA Reconsideration link on the PA Options Menu to access the PA Request Reconsideration Initial Entry screen Print Friendly Louisiana Medicaid Department of Health and Hospitals PA Options PA Request PA Reconsideration View PA Requests Profile e PA Home Logout Home Warning Unauthorized use of this site or of the information contained herein is prohibited by the Louisiana Department of Health amp Hospitals Louisiana Medicaid Department of Health and Hospitals FA Request FA Reconsideration View Requests Help My Profile Home Log
5. Rights Reserved 08 11 2006 e PA User Manual 15 UNISYS A new PA Request Entry screen will appear Edit the information and submit the Reconsideration Request by clicking the Save Reconsideration button at the bottom of the screen Save Reconsideration Print This Page Trans ID 24000 i TP2O0 2006 9 41 28 Enc Wo 45252 Once saved a Reconsideration History block will be available on the PA Request Review screen Click the PA Reconsideration to view the previously entered information Reconsideration History Reconsideration ID Audit Date Comments Submit Another Request Print This Page Trans ID 24000 Submitted 7 20 2006 9 41 23 Enc 45352 Options PA Request Dental PA Request Reconsideration View PA Requests Help My Profile e PA Home Logout Return to Search Results Click on the Return to Search Results on the PA Options menu Below are all of the Transactions that were submitted by you through the e P4 System To view the complete Transaction click on the Number af the request you wish to see This will give you the complete information regarding the request as well as a print friendly version that you can print for your records he calumn with the Indicates the number of attachments received for this Request PA Recip ID Request Date Status ie n EA s T Lode ranzaction His tss of 819885000 9975385244886 P Pd
6. request by PA Number PA Request DES 21 ransaction Recipient ID CCN or Reconsideration fu ipli E PA Transaction View PA Requests Help Number My Profile Enter the appropriate cm j na ick Se rel 6 within Past 7 days Past 7 14 days Past 30 days information in any of Home these four fields and tee Unauthorized use of this site or then select the Search of the information contained herein is prohibited by the butto n Located d cee of Health below the CCN input field Technical Support 877 598 8753 Eligibility Information Support 800 473 2783 or 225 924 5040 2004 Unisys Corp Unisys Lammis 610551 All Rights Reserved A Quick Search is also available that will search for PA requests entered in the current week the previous week or the current month Select the appropriate time period you wish to search for and select the Quick Search button 08 11 2006 e PA User Manual 11 UNISYS C within Past 7 days Past 7 14 days Past 30 daws Once a search has been submitted the Below are all of the Transactions that were submitted by you thraugh the e P4 System To view the aae will be re complete Transaction click on the Number of the request you wish ta see This will give you the p g complete information regarding the request as well as a print friendly version that you can print for displayed listing all your records of the
7. supporting documentation to the fax number indicated in the response header 08 11 2006 Medicaid Department of Health and Hospitals PA Options PA Request PA Reconsideration View PA Requests Help My Profile e PA Home Logout Home Return to Search Results Warning Unauthorized use of this site or of the information contained herein is prohibited by the Louisiana Department of Health amp Hospitals PROVIDER CONTACT INFORMATION Print Friendly Prior Authorization Request PA Request Review IMPORTANT INFORMATION Please printthis page with the bar code using the Printthis Page button or Print Friendly button Then use it as the cover page when faxing supporting documentation for this Prior Authorization request Failure to do so may result in delays in processing your request Please fax all supporting documentation to one ofthe following numbers listed below THIS FAX COMMUNICATION MAY CONTAIN CONFIDENTIAL MATERIAL ayd is for use only by the intended recipient If you received this fax in error please contact the sender af Lsecute EE pages of this fax Unisys Prior Authorization Fax Num 225 927 6536 amp Print this Page Number x 3 Continuation of Services REQUESTER DATA Medicaid Provider ID Phone Contact Person lt lt SUBSCRIBER DATA Medicaid mm _ SSN
8. MAY CONTAIN CONFIDENTIAL MATERIAL and is thus for use only by the intended recipient If you received this fax in error please contact the sender and securely discard all pages of this fax Unisys Prior Authorization Fax Numbers 225 927 6536 S Print this Page PA Number 620155001 Type 09 DME Request Date 7 20 2006 9 41 28 AM Continuation of Services REQUESTER DATA Medicaid Provider 1D MN Phone No Contact Person CO lt SUBSCRIBER DATA Medicaid ID mmm SSN LastName FirstName cmm NJ Sex Em j DOB 5 8 2002 DIAGNOSIS Code Description ei PRESCRIBING PROVIDER DATA Physician Name PhysicanNumber Prescription Date MM DD YYYY SERVICE LEVEL DATA Procedure Code Rees OOO C1 p C Oa C3 Pp C 0062 ef Oa a 8 C 062 C DEL Lit p C C9 Pp C Ona Lt Requested Requested Line Units Amount Modifiers Description Place of Treatment Recipient s Home PROVIDER CONTACT INFORMATION Name Address City Telephone Click on the Submit Ye IU Reconsideration button ePA Trans offa Sy fhitted 7 20 2006 9 41 28 AM Enc No 49382 echnical Support 877 598 8753 Eligibility Information Support 800 473 2783 or 225 924 5040 2004 Unisys Corp Unisys Lammis 610551
9. PA Request and click on the PA Number to review the request are all af the Transactions that were submitted by you through the e P4 System To view the somplete Transaction click on the Number of the request you wish to see This will give you the complete information regarding the request as well as a print friendly version that you can print for your records The column with the Indicates the number of attachments received for this Request c m 2 5 status Transaction 7 17 2006 EPSDT pg 3 03 25 PM Dental Denied 7 17 2006 EPSDT Requires 3 07 50 PM Dental Review 1722006 EPSDT Requires ae 3 11 01 PM Dental Review P l1T 2006 EPSDT Requires 3i34d 47 PM D ental Review p 7 17 2006 EPSDT Requires 4 06 40 PM Dental Review Recon 09 OME Requires 7 20 2006 2 15 32 AM 09 OME Denied Records 1 7 of Page jJof 1 08 11 2006 e PA User Manual 14 UNISYS Print Friendly The PA Request Review Prior Authorization Request screen will appear PA Request Review IMPORTANT INFORMATION Please printthis page with the bar code using the Printthis Page button or Print Friendly button Then use it as the cover page when faxing supporting documentation for this Prior Authorization request Failure to do so may result in delays in processing your request Please fax all supporting documentation to one ofthe following numbers listed below THIS FAX COMMUNICATION
10. PA requests column with the indicates the number af attachments received for this Request matching the search ous Transactio tari e zi z0ne 09 Requires 2212008 Rehabilitation 2 Therapw 7 6 21 2006 E Bilitati Requires 1 3 31 20 PM ahaa Review Therapy 05 Rehabilitation Therapy 6 21 2006 3 41 00 PM Requires This list is where the Review status of the PA request can be checked When a Hs ur Require request has been ME 10220 Review al submitted the 05 muy Rehabilitation Requires EN 02 as 1 6217 2006 column will be vena ELE Requires pp Rehabilitation Requires Review 2 51 08 PM Therapy Review Once the request 6 28 2006 5 litat Requires has been approved a E Therapy Review this column will DECORUS m ETE BQUIFES show Approve If 10 50 12 i RUE Review the request is 053 denied then the 07200000 Rehabilitation Approve Th column will show erapy Denied and the Reject Code column will indicate the PA reject reason code Records 1 10 of 53 Page jJof 6 877 598 8753 Eligibility Information Support 800 473 2783 or 225 924 5040 POO4 Unisys Corp Unisys Lammis 610551 lt All Rights Reserved When either the PA Number in the far left column or the e PA Transaction ID on the far right column of the list is clicked the PA Request Review screen will be displayed This is the same pa
11. Support 800 473 2783 or 225 924 5040 2004 Unisys Corp Unisys Lammis 610551 All Rights Reserved e PA User Manual 18 UNISYS 8 0 CONFIGURING THE E PA APPLICATION The e PA web based application allows for the customization of the PA Type pull down menu that appears on the PA Recipient amp Type Entry screen described in Section 3 0 of this document To customize the Type select list do the following pisei Prior Authorization Request Department of Home Page Health and Hospitals PA Options Welcome Providers to the LA MEDICAID Request System The purpose of the e PA System is to provide a web alternative to faxing PA Request Forms for the following NON EMERGENCY types of PA Request Requests PA Reconsideration e DME View PA Requests e Physician Services Help e Personal Care Services PCS for EPSDT Click the My Profile link on the left Tor foreso side of the main page My Profile ended Hame Health Services e PA Home Logout If you have an Emergency Request please follow your normal procedures Home dv For Reconsiderations Unauthorized use of Reconsiderations can NOW be submitted electronically for the following scenarios this site or of the information contained Denied requests that have incomplete or missing documentation herein is prohibited by e Requests that require a change in the procedure codes units and or dollar amounts the Louisiana 5 Departm
12. System PA YourPATypes 4 cesor personal care Services Types and then select the Add Your PA Types button The page will be 1 refreshed to show your changes Your PA Types Technical Support 877 598 8753 Eligibility Information Support 800 473 2783 or 225 924 5040 2004 Unisys Corp Unisys Lammis 610551 All Rights Reserved To remove PA Types from the select list within the Your PA Types box click once on the PA Type you wish to remove and then select the Remove from Your PA Types button The page will be refreshed to show your changes Repeat until you have completed adding or removing PA Types Select the Save Changes button at the bottom of the page This will save all your changes If after you have made changes but have not yet selected the Save Changes button you may cancel the changes you made by selecting the Reset button 08 11 2006 e PA User Manual 19 UNISYS The changes made to the PA Types indicated on the My Profile page will be reflected in the Recipient amp PA Type Entry page that appears immediately after clicking the PA Request link on the PA Options menu A Print Friendly Louisiana ANNAM rior Authorization Reques Department of Recipient amp PA Type Entry Health and Hospitals PA Options Recipient s Medical Number ar CCN 0 8 DME PA Type Customized Drop Down List Warning Unauthorized use of this site or of the informat
13. this site or of the information contained herein is prohibited by the Louisiana Department of Health amp Hospitals Print Friendly Prior Authorization Request Recipient amp Type Entry 05 Rehabilitation Therapy Y Recipient s Medicaid ID Number or CCN Recipient s Date of Birth P Type Technical Support 877 598 8753 Eligibility Information Support 800 473 2783 or 225 924 5040 2004 Unisys Corp Unisys Lammis 610551 All Rights Reserved On the Recipient amp PA Type Entry page enter the Recipient s Medicaid ID number or CCN and the Recipient s Date of Birth in the appropriate boxes In the PA Type drop down list select the type of PA request then select the Submit button The PA Request Entry page will be displayed If you wish to discontinue the request click the Cancel button and you will be returned to the e PA home page 08 11 2006 e PA User Manual 6 UNISYS Print Friendly Prior Authorization Request PA Request Entry On the PA Request z Number PA Type 05 Rehabilitation Therapy Request Date 7 24 2006 4 16 25 PM Continuation of Services Entry page enter the REQUESTER DATA appropriate information Medicaid Provider 1D _ Phone No BERE as you would for any Contact Person TT I SUBSCRIBER DATA standard PA request If Medicaid i SSN you have failed to fill in LastName FirstName m1 NI ex
14. BER DATA Medicaid 1D SSN Last MEE Sex m DIAGNOSIS Code Description Primary EM mmm 35D9J Secondary d 1 SERVICE DATES From ENNENEEN 7 7 PRESCRIBING PROVIDER DATA Physician Name Physician Number Prescription Date MM DD YYYY SERVICE LEVEL DATA Requested Requested Units Amount Line Procedure Modifiers Description Code Place of Treatment Y PROVIDER CONTACT INFORMATION Name Address City Telephone Additional Comments this is the comment Submit Another Request Print This Page ePA Trans ID Submitted Enc No BEN Technical Support 877 598 8753 Eligibility Information Support 800 473 2783 or 225 924 5040 2004 Unisys Corp Unisys Lammis 610551 All Rights Reserved e PA User Manual 13 UNISYS 6 0 PA RECONSIDERATION TRANSACTION HISTORY When a PA Reconsideration has been entered additional information and functionality is available on the View PA Requests screen and PA Entry screen To modify and review Reconsideration information complete the following steps Search for Print Friendly approved or Louisiana mI denied PA Medicaid Prior eons Request Request using the View PA PA Options Welcome Providers to the L MEDICAID e P4 Request System The purpose of the e P4 System is Se to provide a web alternative to faxin
15. UNISYS Louisiana Medicaid Enhancement Project Electronic Prior Authorization Web Application User Manual May 11 2005 Revised August 11 2006 Document Number 3372 Prepared By Unisys Louisiana HIPAA Operations Team Baton Rouge LA 70809 Change Tracking Log Change Changed Change Source Name of Date By Description Type Source Doc 6 1 05 5 Clark Added bolded note to Section 1 0 page e mail RE Enh 11 90 e PA 1 that reconsiderations cannot be done Operations Reference through the e PA application Guide P Misner s last comment msg 7 25 06 C Stickney Updated manual and added Recon info Lift 3372 Test Plan 8 11 06 C Stickney Inserted new screens on pages 5 9 ePA ePA 11 14 and 19 Application 9 26 06 C Stickney Made corrections to pages 1 10 17 e mail RE Lift 3372 and 18 updated ePA User Manual 11 17 06 C Stickney Corrected spelling error page 9 amp TOC FW ePA User Manual UNISYS Table of Contents Section Number Title Page TO OVERVIEW 1 2 0 ACCESSING THE 3 20 PAHEQUEST ENEP 6 4 0 PA RECONSIDERATION 9 5 0 PA REQUEST OSEANHGT L 11 6 0 RECONSIDERATION TRANSACTION
16. attachments received for this Request IDX Request Date 7 20 2006 di15 32 7 20 2006 9 41 20 4 2006 11 55 23 AM 24 2006 24 2006 1 18 54 242006 zoe 242006 3 42 45 PM Records 1 7 af 7 Select a PA to view 08 11 2006 Prograrn 09 OME 09 OME 05 Rehabilitatian 05 Rehabilitation Therapy 05 Rehabilitation Therapy 05 Rehabilitatian Therapy 05 Rehabilitatian Therapy e PA User Manual Recon Requires Review Recon Requires Review Requires Review Denied Recon Requires Review Recon Requires Revie Recon Denied Transaction Page jof 1 17 UNISYS A PA Request Review screen will appear The message will be displayed at the bottom of the screen Maximum amount of Reconsiderations 3 has been reached 08 11 2006 Print Friend Prior Authorization Request PA Request Review IMPORTANT INFORMATION Please print this page with the bar code using the Print this Page button or Print Friendly button Then use it as the cover page when faxing supporting documentation for this Prior Authorization request Failure to do so may resultin delays in processing your request Please fax all supporting documentation to one of the following numbers listed below THIS FAX COMMUNICATION MAY CONTAIN CONFIDENTIAL MATERIAL and is thus for use only by the intende
17. d recipient If you received this fax in error please contact the sender and securely discard all pages of this fax Unisys Prior Authorization Fax Numbers 225 927 6536 GS print this Page Number 620555004 Type 05 Rehabilitation Therapy Request Date 7 24 2006 3 42 45 PM 3 Continuation of Services REQUESTER DATA Medicaid Provider 1D NN Phone No Contact Person MMMM 0 SUBSCRIBER DATA Medicaid Last Name MEMME First Name cm Sex DOB 5 8 2002 DIAGNOSIS Code Description Primary Secondary SERVICE DATES From Thru PRESCRIBING PROVIDER DATA Physician Name 21 Physician Number 1 Prescription Date MM DD YYYY SERVICE LEVEL DATA N Requested Requested Units Amount Procedure Code Line Modifiers Description o N ie Place of Treatment PROVIDER CONTACT INFORMATION Name Address Additional Comments Need more units for some reason another 2 Reconsideration History PA Reconsideration ID Audit Date Comments soe 7 24 2006 4 03 44 PM 7 24 2006 4 26 03 PM Need more units for some reason 50690 7 24 2006 4 27 41 PM Need more units for some reason anothe aximum Amount of Reconsiderations 3 has been reached Submit Another Request Print This Page E P PPP RP Mm Lantutieibb dbi temm ePA Trans ID 24005 Submitted 7 24 2006 3 42 45 PM Enc No 48387 echnical Support 877 598 8753 Eligibility Information
18. deration Initial Entry screen is displayed Enter a valid PA Number and click on the Submit button Prior Authorization Request Request Reconsideration Initial Entry NOTE Prior Authorization Reconsiderations can be requested for the following reasons Denied requests that have incomplete or missing documentation Requests that require change in the procedure codes units and or dollar amounts Requests that require change in the begin or end dates of service Enter P4 Number Enter valid PA Technical Support 877 598 8753 Eligibility Information Support 800 473 2783 or 225 924 5040 08 11 2006 2004 Unisys Corp Unisys Lammis 610551 All Rights Reserved e PA User Manual UNISYS Once the provider has entered a PA Number into the PA Reconsideration Initial Entry screen or has selected to submit a reconsideration from the PA Request Review screen the PA Reconsideration Entry screen will be displayed All the original information including deny codes and comments will be displayed on this screen Providers can update the information and submit the reconsideration Prior Authorization Request PA Reconsideration Entry Number 617355000 Type 05 Rehabilitation Therapy Request Date 6 22 2006 2 51 08 P Continuation of Services REQUESTER DATA Medicaid Provider 1D MN Phone No MEN Contact Person m SUBSCRIBER DATA Medicaid ERN SSN La
19. ding how to establish an online account with Louisiana Medicaid complete with a valid login and password and how to complete the login ID and password process Prior to initial use of the e PA web application the web browser setup must be configured Using web browser such as Internet Explorer v4 0 or higher ensures that the latest updates to the e PA application are displayed to the user The Louisiana Department of Health and Hospitals DHH determines who is an authorized user defining all user access capabilities Directions for establishing a valid online provider account are available on the Louisiana Medicaid website at www lamedicaid com or www mmis com The Provider Web Account Registration Instructions link located on the left side of the Louisiana Medicaid main menu contains the instructions for setting up an online account Providers who are experiencing difficulty in establishing an account may contact the Unisys Technical Support Desk at 1 877 598 8753 Monday Friday 8 00 a m 5 00 p m CT or request support by e mailing lasupport unisys com 08 11 2006 e PA User Manual 3 UNISYS To access the main menu and the e PA application open your web browser and enter the URL for the Louisiana Medicaid main menu www lamedicaid com or www Immis com Click on the Provider Login button and then log on to the Provider applications Area using your Louisiana Medicaid Provider ID and your registered login and password The Prov
20. dly Loulsiana Medicaid Prior Authorization Request Department of Home Page Health and Hospitals PA Options Welcome Providers to the L4 MEDICAID Request System The purpose of the e P4 System is to provide a web alternative to faxing Request Forms for the following NON EMERGENCY types of PA Request Requests PA Reconsideration Physician Services Personal Care Services PCS for EPSDT Outpatient Surgery Performed Inpatient Hospital Multiple and Extended Home Health Services Rehabilitation View PA Requests Help My Profile e PA Home Logout If you have an Emergency PA Request please follow your normal procedures Home For Reconsiderations Unauthorized use of Reconsiderations can NOW be submitted electronically for the following scenarios this site or of the information contained herein is prohibited by the Louisiana Department of Health amp Hospitals Denied requests that have incomplete ar missing documentation Requests that require a change in the procedure cades units and or dollar amounts Requests that require a change in the begin ar end dates of service IMPORTANT At the end of the Request System you will be presented with a web page that contains a barcode image Please print this page and use it as the cover page to fax in supporting documentation Failure to do so may result in delays in processing your request Each Request will have a uniq
21. e PA Request Entry response page printout fax the request and the supporting documentation to the number indicated on the response page Unisys e PA Fax Number 225 927 6536 10 Once the documentation has been faxed to Unisys it will be cross referenced back to the original electronic request so that the PA staff can view the supporting documentation on line while reviewing the PA request If the supporting documentation is not faxed to Unisys or the PA Request Entry response page is not used as a cover sheet or is un readable then the request will remain in a Pending Review status and will not be processed by the Unisys PA department To identify whether or not the supporting documentation was received and processed without error the provider can view the PA Entry Request response page presented in Section 3 0 of this document and review the Encounter field at the bottom of the page If this number is Zero 0 then the attachments have not been received or were not appropriately matched to the original request Reprint the PA Entry Request response page and re fax it and the supporting documentation again If the faxed documentation is received and processed correctly the encounter number field will reflect this change one business day after the documents were faxed 08 11 2006 e PA User Manual 2 UNISYS 2 0 ACCESSING THE APPLICATION This section of the User Manual provides information on how to access the e PA application inclu
22. ent of Health e Requests that require a change in the begin or end dates of service 8 Hospitals IMPORTANT At the end of the Request System you will be presented with a web page that contains a barcode image Please print this page and use it as the cover page to fax in supporting documentation Failure to do so may result in delays in processing your PA request Each e PA Request will have a unique barcode When faxing it is imperative that each set of supporting documentation be preceeded by its corresponding cover page that contains its own barcode The Profile page will open The scrolling list box in lower portion of the page labeled Medicaid Prior Authorization Request Your PA Types shows E which PA types Will be PA Options The Profile allows you to customize the Types that will appear in the Type selection list when entering a Request The default is that all Types for the system will be in the Type displayed in the select list modify your choices at any time by returning to this page to click the Save Changes button to save your changes Available PA To add a PA Type to the A TI sand ca pull down menu click once quum Dental EPSDT on the PA type you wish to Warning E EEE add from the list the upper Add to Your PA Types from Your PA Types Types portion of the page labeled etw WIL Available e PA
23. g PA Request Forms for the following NON EMERGENCY types of 1 PA Request Requests link in Requests PA Reconsideration the PA Options View PA Requests menu Personal Care Services PCS for EPSDT enu Help Outpatient Surgery Performed Inpatient Hospital My Profile Multiple and Extended Health Services Rehabilitation e PA Home Logout If you have an Emergency Request please follow your normal procedures Home VEI For Reconsiderations Unauthorized use of Reconsiderations can NOW be submitted electronically for the following scenarios this site or of the information contained Denied requests that have incomplete or missing documentation herein is prohibited by Requests that require a change in the procedure codes units and or dollar amounts the Louisiana 5 Department of Health Requests that require a change in the begin or end dates of service 8 Hospitals IMPORTANT At the end of the Request System you will be presented with a web page that contains a barcode image Please print this page and use it as the cover page to fax in supporting documentation Failure to do so may result in delays in processing your request Each Request will have a unique barcode When faxing it is imperative that each set of supporting documentation be preceeded by its corresponding cover page that contains its own barcode Once the results appear locate an approved or denied
24. ge that is presented when the original request was entered 08 11 2006 e PA User Manual 12 UNISYS To return to your search select the Return to Search Results link on the left side of the page 08 11 2006 EAEE Medicaid Department of Health and Hospitals PA Options PA Request PA Reconsideration View PA Requests Help My Profile Home Logout Home Return to Search Results Warning Unauthorized use of this site or of the information contained herein is prohibited by the Louisiana Department of Health amp Hospitals Print Friendly Prior Authorization Request Request Review I I IMPORTANT INFORMATION Please printthis page with the bar code using the Printthis Page button or Print Friendly button Then use it as the cover page when faxing supporting documentation for this Prior Authorization request Failure to do so may result in delays in processing your request Please fax all supporting documentation to one ofthe following numbers listed below J MAY CONTAIN CONFIDENTIAL MATERIAL and is thus for use only by the intended fax in error please contact the sender and securely discard all pages of this fax ix Results MURIS Unisys Prior Authorization Fax Numbers 225 927 6536 print this Page PANumber Request Date Bi Continuation of Services REQUESTER DATA Medicaid Provider 1D Phone Contact Person 00 i SUBSCRI
25. he page Logout 4 Enter the Following information Recipient Medicaid ID or the Recipient s CCN Card Control Number Werning Recipient s Date of Birth Please use slashes when entering the date For example 1 1 2000 Select the type of Request that you wish to enter Unauthorized use 5 Thenext page will be the PA Request entry page This is where you will enter the detailed inFormation For the of this site or of the request just as you would if you were filling out a paper Form information 6 When you have completed entering inFormation on the Request entry Form click the Submit button 7 Theinformation you have entered will be edited to ensure that it is complete and accurate If there any problems with the information you will see a list of errors that need to be corrected before the Request is accepted 8 If the P Request is accepted you will be presented with a page that contains a bar code bar code is simply set vertical stripes or bars used to encode information bar code is Frequently referred to as a UPC symbol contained herein is prohibited by the Louisiana Department of 9 The next step is to Print the page with the bar code This is very important as this printed page with the bar code Health amp Hospitals will be used as the cover page when you fax in the supporting documentation For this Request 10 You must Fax in supporting documentation using the printed page with
26. ider Applications Area screen is displayed Select the Electronic Prior Authorization hyperlink Louisiana ig 2 Change Password Change Account Info Provider Logout Help E Provider Applications Area For Technical Support call toll free 1 877 598 8753 Provider Logout Click Here to Enter The application s listed below are for authorized use only Click on an application link to access the application Recovery Request Hew Medicaid Information HIPAA Information Center Provider Applications LAMEDICAID COM Fact Sheet HIPAA Billing Instructions amp BAR Center Restricted Provider Applications HIPAA Billing Instructions amp Companion Guides EDI Information Training About Medicaid Provider Ownership Enrollment Provider Web Account Registration Instructions Provider Support Provider Manuals Billing Information Medical Equipment amp Supplies Fee Schedules Provider Update Remittance Advice Index Pharmacy Prescribing 08 11 2006 Administrative Tools Medicaid Eligibility Verification System NPI Claim Status Inquiry PCP Roster of Enrollees Electronic Clinical Data Inquiry Electronic Prior Authorization e PA Application PA Requests for Case Managers Uncompensated Care Costs Document Provider Applications Area Date Modified 1 24 03 e PA User Manual UNISYS The Louisiana Medicaid Prior Authorization Request Home Page is displayed Print Frien
27. ion contained herein is prohibited by the Louisiana Department of Health amp Hospitals Technical Support 877 598 8753 Eligibility Information Support 800 473 2783 ar 225 924 5040 2004 Unisys Corp Unisys Lammis 6104551 All Rights Reserved 08 11 2006 e PA User Manual 20 UNISYS 9 0 VIEWING THE ON LINE HELP PAGE In addition to this document the e PA application also provides a brief online help page offering basic instructions and tips on using the application To view this help page select the Help link on the left side of the main page Print Friendly Louisiana mE Medicaid Prior Authorization Request Department of Home Page Health and Hospitals PA Options Welcome Providers ta the L MEDICAID e P4 Request System The purpose of the e P4 System is to provide a web alternative to faxing Request Farms for the follawing NON EMERGENCY types of PA Request Requests PA Reconsideration DME Physician Services Ss are Services PCS far EPSDT Outpatient Surgery Performed Inpatient Hospital Multiple and Extended Hame Health Services Rehabilitation e PA Home Logout If you have an Emergency Request please follow your normal procedures Home Warning For Reconsiderations Unauthorized use of Reconsideratians can NOW be submitted electronically for the following scenarios this site or of the information contained Denied requests that have incomplete ar missing documentation herei
28. ish a valid online account with Louisiana Medicaid complete with a valid login ID and password in order to access the web based application Attachment A includes specific instructions for obtaining an online provider account Providers who do not have access to a computer and or fax machine will not be able to utilize the web application However prior authorization requests will continue to be accepted and processed using the current hard copy PA submission methods Access to the application is limited to the follow provider types 01 Inpatient 05 Rehabilitation 06 Home Health 09 DME 10 Adult Dental to be implemented at a later date 11 EPSDT Dental to be implemented at a later date 12 EPSPW Dental to be implemented at a later date 14 EPSDT PCS 20 Physician PT 99 Other 08 11 2006 e PA User Manual 1 UNISYS The steps below provide a basic high level overview of what is required to submit a PA request using the e PA application Detailed step by step instructions are listed in Section 3 0 of this document 1 Enter the secured provider area of the LAMedicaid com website 2 Select the Electronic Prior Authorization application link 3 Select PA Request 4 Enter the recipients 13 digit Medicaid ID number and date of birth 5 Select the type of PA request 6 Select the Submit button 7 Complete the PA Request Entry page amp select the Submit button 8 Print the PA Request Entry response page 9 Using th
29. n is prohibited by Requests that require a change in the procedure codes units and or dollar amounts the Louisiana Department of Health Requests that require a change in the begin or end dates of service amp Hospitals IMPORTANT the end of the Request System you will be presented with a web page that contains a barcode image Please print this page and use it as the cover page to fax supparting documentation Failure to do sa may result in delays in processing your request Each Request will have a unique barcode When faxing it 15 imperative that each set of supporting documentation be preceeded bw its corresponding cover page that contains its own barcode 08 11 2006 e PA User Manual 21 UNISYS The Help page provides general information on how to use the application as well as some basic reminders LJ 1 Print Friendhy Louisiana Medicaid Prior Authorization Request Department of Help Health and Hospitals Using Web System PA Options Request View Requests Help Submitting a Request Submitting a Prior Authorization Request through the web application involves the Following steps Profile 1 Logonto LAMEDICAID com with your username and password 2 Select Electronic Prior Authorization From the secured menu options c 3 Select PA Request from the Options menu located on the left side of t
30. nt Hospital Home Page My Profile Multiple and Extended Hame Health Services Rehabilitation Personal Care Services PCS for EPSDT e PA Home Logout If you have an Emergency Request please follow your normal procedures Home dice For Reconsiderations Unauthorized use of Reconsiderations can NOW be submitted electronically for the following scenarios this site or of the information contained e Denied requests that have incomplete or missing documentation herein is prohibited by e Requests that require a change in the procedure codes units and or dollar amounts the Louisiana 4 5 Department of Health e Requests that require a change in the begin or end dates of service 8 Hospitals IMPORTANT At the end of the Request System you will be presented with a web page that contains a barcode image Please print this page and use it as the cover page to fax in supporting documentation Failure to do so may result in delays in processing your request Each Request will have a unique barcode When faxing it is imperative that each set of supporting documentation be preceeded by its corresponding cover page that contains its own barcode The PA Request Transactions page will be displayed From the TEE PA Request EIE Prior Authorization Request Transactions page you Department of PA Request Transactions Health and Hospitals Can search for a PA PA Options Please enter at least one of the following
31. out Homie Unauthorized use of this site or of the information contained herein is prohibited by the Louisiana Department of Health amp Hospitals Prior Authorization Request Home Page Welcome Providers ta the L4 MEDICAID e P4 Request System The purpose of the e P4 System 15 to provide a web alternative to faxing Request Farms for the following NON EMERGENCY types of Requests OME Physician Services Personal Care Services PCS for EPSDT Outpatient Surgery Performed Inpatient Hospital Multiple and Extended Hame Health Services Rehabilitation If you have an Emergency Request please follow your normal procedures For Reconsiderations Reconsiderations can NOW be submitted electronically far the following scenarios Denied requests that have incomplete or missing documentation Requests that require a change in the procedure codes units andor dollar amounts Requests that require a change in the begin or end dates of service IMPORTANT At the end of the e P Request System you will be presented with a web page that contains a barcode image Please print this page and use it as the cover page to fax in supporting documentation Failure to do so may result in delays in processing your request Each Request will have a unique barcode When faxing It is imperative that each set of supporting documentation be preceeded by its corresponding cover page that contains its own barcode The Request Reconsi
32. rch Results option that is now available on the left side menu beneath the Options box Profile The Profile allows you to customize the Types that will appear in the Type selection list when entering a Request The default is that all Types For the system will be in the Type list Use the following buttons to customize your Type list e To Add a PA Type to your Type list select the Type From the Availalbe list then click the Add to Your Types button e Toremove a PA Type from your list select the Type and then click the Remove from Your Types button The Reset button will restore Your PA Types to the most recently Saved changes After saving your changes each time you visit the system only those Types that you have chosen will appear in the Type list You can modify your choices at any time by returning to the Profile page Technical Support 877 598 8753 Eligibility Information Support 800 473 2783 or 225 924 5040 2004 Unisys Corp Unisys Lammis 610551 All Rights Reserved 08 11 2006 e PA User Manual 22
33. st sx DIAGNOSIS Code Description Primary 1 Secondary Po SERVICE DATES From Thru 1072472005 MMw DD rrrv PRESCRIBING PROVIDER DATA Physician Name 21 Physician Number Prescription Date MM DD YYYY SERVICE LEVEL DATA Requested Requested Units Amount Line ideis ah Modifiers Description Place of Treatment PROVIDER CONTACT INFORMATION Additional Comments ePA Trans ID Submitted 7 24 2006 4 16 25 PM Enc No Technical Support 877 598 8753 Eligibility Information Support 800 473 2783 or 225 924 5040 2004 Unisys Corp Unisys Lammis 610551 All Rights Reserved 08 11 2006 e PA User Manual 10 UNISYS 5 0 PA REQUEST SEARCH The search screen allows a provider to search for a Prior Authorization Request Once a provider locates a PA they can review the PA information using the PA Request Review screen From the review screen they can also submit a reconsideration Print Friendly Louisiana Medicaid Prior Authorization Request Department of Home Page Health and Hospitals Select the PA Options Welcome Providers to the L MEDICAID Request System The purpose of the System is to provide a web alternative to faxing PA Request Forms for the following NON EMERGENCY types of View PA PA Request PA Requests PA Reconsideration Requests link on s the left side of the uep Outpatient Surgery Perfnrmed Inpatie
34. tem The purpose of the System is to provide a web alternative to faxing PA Request Forms for the following NON EMERGENCY types of Requests DME Physician Services Personal Care Services PCS for EPSDT Outpatient Surgery Perfnrmed Inpatient Hospital Multiple and Extended Health Services Rehabilitation If you have an Emergency Request please follow your normal procedures For Reconsiderations Reconsiderations can NOW be submitted electronically for the following scenarios e Denied requests that have incomplete or missing documentation e Requests that require a change in the procedure codes units and or dollar amounts e Requests that require a change in the begin or end dates of service IMPORTANT At the end of the e P Request System you will be presented with a web page that contains a barcode image Please print this page and use it as the cover page to fax in supporting documentation Failure to do so may result in delays in processing your request Each Request will have a unique barcode When faxing it is imperative that each set of supporting documentation be preceeded by its corresponding cover page that contains its own barcode The Recipient amp PA Type Entry page will be displayed Louisiana Medicaid Department of Health and Hospitals PA Options PA Request PA Reconsideration View PA Requests Help My Profile e PA Home Logout Home Warning Unauthorized use of
35. the bar code There are two 2 reasons For this 1 Supporting documentation is required in order to properly review the Request 2 The bar code will link the supporting documentation to PA Request that you have submitted through the e system 11 Please fax the supporting documentation using the bar coded cover page to one 1 of the two 2 fax numbers listed on the page 12 Once the supporting documentation has been received the Request will be reviewed You will be notified whether the Request has been accepted denied or if Further review or other information is required View Previously Submitted Prior Authorization Requests You can view Requests that had been previously submitted through the web system by clicking on the View Requests menu option Please note that Requests that were not submitted through the web system will not be available through the web system Using the View Requests page you may enter one or more of the following Number e Recipient Medicaid ID or CCN e e P Transaction Number Or bring up a list of PA Requests submitted using the web system in the current week previous week or current month list of Requests matching the criteria entered will be displayed To view the detailed information For a particular request simply click on the PA Number To return to the View Requests page click on the Return to Sea
36. ue barcode When faxing it is imperative that each set of supporting documentation be preceeded by its corresponding cover page that contains its own barcode You will still be required to fax supporting documentation Please note that the presence of a Prior Authorization Number does not indicate approval of the request Rehabilitation Prior Authorization Requests Type 05 must be accompanied by a 02 FORM Request link located in the Options menu on the left offers you a path to the application You can also search for and view the status of Transactions you have submitted using e P Request System Additional capabilites are being added so check back frequently for new enhancements Fax Humber 225 927 6536 Technical Support 877 598 8753 Eligibility Information Support 800 473 2783 or 225 924 5040 2004 Unisys Corp Unisys Lammis 610551 All Rights Reserved 08 11 2006 e PA User Manual 5 UNISYS 3 0 PA REQUEST ENTRY Select the PA Request link located in the upper left side of the main application page Louisiana Medicaid Department of Health and Hospitals My Profile e PA Home Logout Home Warning Unauthorized use of this site or of the information contained herein is prohibited by the Louisiana Department of Health 8 Hospitals Print Friendly Prior Authorization Request Home Page Welcome Providers to the L MEDICAID Request Sys
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