(electronic Prior Authorization) User Manual
Contents
1. If you have an Emergency PA Request please follow your normal procedures For Reconsiderations Reconsiderations can NOW be submitted electronically for the following scenarios 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 PA 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 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 Effective July 16 2010 the PA 02 Form is no longer required The PA Request link located in the PA Options menu on the left offers you a path to the application You can also search for and view the status of e PA Transactions you have submitted using e PA Request System Additional capabilites are being added so check back frequently for new enhancements Fax Number 225 927 6536 Technical Support 8772. Date Revised 04 30 2012 Copyright 2010 Molina Medicaid Solutions All Rights Reserved 12 Electronic Prior Authorization e PA Web Application User Manual 4 0 AREQUEST 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 Select the View PA Requests link on the left side of the Home Page MITTEN Medicaid Department of Health and Hospitals PA Options PA Request PA Reconsideration View PA Requests Help My Profile e PA Home Logout Home Warming Unauthorized use of this site or of the information contained herein is prohibited by the Louisiana Department of Health amp Hospitals Prior Authorization Home Page Welcome Providers to the LA MEDICAID e PA 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 Requests DME Physician Services Personal Care Services PCS for EPSDT Outpatient Surgery Performed Inpatient Hospital Multiple and Extended Home Health Services Rehabilitation Air Ambulance Pediatric Day Health Care Facilities For ePA Requests with HCPCs that require NDCs 2010 12 22 Units are specific to NDC not HCPC One unit may be equal to 100 calories one packet one can on
3. Denied Requires Review Requires Review Requires Review Requires Review Recon 09 DME Requires 09 DME Denied Page jJof 1 16 Electronic Prior Authorization e PA Web Application User Manual e ER fain riper The PA Request Review eg TU S rior Autnorization neques screen Will appear PA Request cud ns i al i IN NA Lb IMPORTAHT IMFORMATIOH Flaase prit tr s page with the barcode uting E Pr phis Page buon or Print Frsrdiy bation Then use 9 a5 Pe cover page when fixing amp upportesg documentation for mis Prior Aufi ezabon request Falle bo do 0 may resut en delays in processing your request Fiaasa tax ap supportmg documaentason to one ot me folowing mrumbers irsied below THIS FAX COMBINICATION MAY CONTAIN CONFIDENTIAL MATERIAL And is thie for use only by The intended recipient H yu ecebeed vis lax Im euer please contac the sender and secinely discaid all pages ef this fax Lines Prinr Aytricemabon Fas Humbers 225 927 5536 Gb rrt mis Pues FA humher 62015555 PA Type 159 DME l Request Dale 7 20 2008 9 41 28 AN E andn ei REQUESTOR DATA beten vier 10 B o ees Contec res WEN Ir no SUBSCRIBER PATA wT ssi Last Hame BW eat Name mm CN sex DOB DTAGN SES d Desenpbon Primary Secondary SERVICE DATES From 10 24 2005 Thru PRESCRIBING PROVIDER DATA Physician Meng O hes tumber Prescription Date jimbor SERVICE LEVEL
4. The PA Request Review page will be displayed with a header at the top that includes a bar code This bar code will allow Molina to match the faxed supporting documentation back to the original electronic PA request Once a PA Request has been approved then the PA Number on this review screer will show Not assigned until it has been worked by the PA Unit 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 supporting documentation to the fax number indicated in the response header Date Revised 04 30 2012 Louisiana 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 Warming Unauthorized use of this site or of the information contained herein is prohibited by the Louisiana Department of Heg amp Hospitals Fo Print Friendly Prior Authorization PA Request Review I I i I UN 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 result in delays in processing your request Please fax all supporting documentation to one ofthe following numbers listed below
5. Web Application User Manual 3 2 PA Request Entry On the PA Request Louisiana Entry page enter the Medicaid Pran Authorzahin appropriate information gene Gen as You would for any PA Options PA Number Not assigned PA Type 09 DME Request Date 11 4 2010 12 36 36 PM standard PA request If S UM you have failed to fill In View PA Requests NPI mmm m Phone No M i all the required fields My Profile SUBSCRIBER DATA Medicaid 1D SSN the application will iue Last Name BS Jes name wt 7 E present a user friendly Home Ses SENE E S eturn to Search Results DIAGNOSIS Code Description pop up box listing the I Primary C Cid rod fi Secondary p 3 req ul red fields that m ust pes spear ta or SERVICE DATES From Imeoul mmoomw still be ente red The PEE PRESCRIBING PROVIDER DATA JURE e Louisiana Physician Name Ir 1 Physician NPI or Medicaid gt REIS entry consists Department or Hea Prescription Date wwbb vvvy of a Primary Diagnosis SERVICE LEVEL DATA Line Procedure Requested Requested Code From Date of Code Modifiers Description Amount Service and at least one PA Service line with a Procedure Code and Requested Units or Requested Amount Once you have completed all the required fields select the Submit button at the bottom of the page A confirmation page will then be displayed Place of Treatment v PROVIDER CONTACT INFORMATION NOTE For Hospic
6. e PA Web Application User Manual 1 0 OVERVIEW The Electronic Prior Authorization e PA Web Application provides a secure web based tool for providers to submit a prior authorization PA request 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 Molina 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 Molina 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 establish 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
7. 10 Once the documentation has been faxed to Molina 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 Molina 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 Molina 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 Date Revised 04 30 2012 2 Electronic Prior Authorization e PA Web Application User Manual 2 0 ACCESSING THE APPLICATION This section of the User Manual provides information on how to access the e PA application including how to establish an online account with Louisiana Medicaid complete with a valid login and password and how to comp
8. 2012 8 Electronic Prior Authorization e PA Web Application User Manual 3 3 Confirmation Screen amp Print Friendly Louisiana 2 Aa Medicaid Prior Authorization Department of PA Request Entry Health and Hospitals PA Options PLEASE CHOOSE ONE GF THE FOLLOWING OPTIONS The following PA Requesthas been entered Please choose one ofthe options to continue PA Request PA Reconsideration View PA Requests Cancel this request and return to the home g Help Lancel this request and return to the nome pate Submit the request All of the information is correct Go Back and modify the request PA Number Not assigned PA Type 06 Home Health Services Request Date 6 1 2009 8 56 25 AM My Profile PA Status 208 Submission Process Not Complete Expires 07 01 2009 e PA Home REQUESTER DATA Lo gout NPI Phone No 1 SUBSCRIBER DATA Warning Medicaid gt i SSN O O ts ee 8 Choose one of the three links in blue underlined type e Submit the request All of the information is correct Click this link to submit the request and proceed e Go Back and modify the request Click this link if you notice that the information on the request requires a modification e Cancel this request and return to the home page Click this link to cancel the request and start over Date Revised 04 30 2012 9 Electronic Prior Authorization e PA Web Application User Manual 3 4 PA Request Review
9. 9 DEPARTMENT OF HEALTH AND HOSPITALS Medicaid MOLINA Medicaid Solutions Louisiana Medicaid Management Information System LMMIS Electronic Prior Authorization e PA Web Application User Manual Date Created 03 11 2007 Date Revised 04 30 2012 Prepared By Technical Communications Group Electronic Prior Authorization e PA Web Application User Manual Molina Medicaid Solutions and the Louisiana Department of Health and Hospitals Proprietary Data Notice The information contained in this document is proprietary to Molina Medicaid Solutions and the Louisiana Department of Health and Hospitals The information in this document shall not be reproduced shown or disclosed outside Molina Medicaid Solutions or Louisiana DHH BHSF without written permission Information contained in this document is highly sensitive and of a competitive nature NO WARRANTIES OF ANY NATURE ARE EXTENDED BY THIS DOCUMENT Any product and related material disclosed herein are only furnished pursuant and subject to the terms and conditions of a duly executed license or agreement to purchase services or equipment The only warranties made by Molina Medicaid Solutions if any with respect to the products programs or services described in this document are set forth in such license or agreement Molina Medicaid Solutions cannot accept any financial or other responsibility that may be the result of your use of the information in this document including b
10. Authorization Request Home Page is displayed Select the PA Request link located in the upper left side of the main application page Louisiana Medicaid Department of Health and Hospitals PA Options PA Request 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 amp Hospitals Prior Authorization Home Page Welcome Providers to the LA MEDICAID e PA 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 Requests DME Physician Services Personal Care Services PCS for EPSDT Outpatient Surgery Performed Inpatient Hospital Multiple and Extended Home Health Services Rehabilitation Air Ambulance Pediatric Day Health Care Facilities For ePA Requests with HCPCs that require NDCs 2010 12 22 Units are specific to NDC not HCPC One unit may be equal to 100 calories one packet one can one brik or one bottle New Confirmation Process 2009 06 19 The Electronic Prior Authorization ePA application has been enhanced with a new confirmation process to facilitate editing requests before submitting for review Once a user submits a request a confirmation message will be displayed that will allow the following actions e Submit Complete the request This will finalize the request and send it for revi
11. have submitted through the e PA 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 PA Request will be reviewed You will be notified whether the PA Request has been accepted denied or if further review or other information is required adl adi odi um View Previously Submitted Prior Authorization Requests You can view PA Requests that had been previously submitted through the e PA web system by clicking on the View PA Requests menu option Please note that PA Requests that were not submitted through the e PA web system will not be available through the e PA web system Using the View PA Requests page you may enter one or more of the following e PA Number e Recipient Medicaid ID or CCN e eh Transaction Number Or bring up a list of PA Requests submitted using the e PA web system in the current week previous week or current month A list of PA 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 PA Requests page click on the Return to Search Results option that is now available on the left side menu beneath the PA Options box Profile The PA Profile allows you to customize the PA Types that will appear in the PA Type selection list when entering a PA Request
12. text in 3 2 added 3 3 added not assigned detail in 3 4 replaced screenshot in 4 0 replaced one screenshot and added another in 5 0 replaced screenshot in 6 0 replaced screenshot in 7 0 7 12 10 New logos Unisys Molina 7106 R Sheehan 7 22 10 Company update to the copyright information in the 7017 R Sheehan screenshots 11 04 10 NDC information and updated screen shots 2263 01 19 12 Updated screenshots and edited for new provider type 8248 J Lavigne access of 16 Pediatric Day Health Care 04 30 12 Updated for new provider type access of 88 Hospice 8416 3 10 09 Edited for new Type 097 Air Ambulance 5661 P Griffin By Date Revised 04 30 2012 ii Electronic Prior Authorization e PA Web Application User Manual TABLE OF CONTENTS T0 SOE VE EH 1 2 0 ACCESSING THE APPLICATION eere nnne nnn nnn nennen nn nnns 3 3 0 USING THE APPLICATION ME 5 3 1 Kee ee a o Mors de PL 6 3 2 BR zl M RIA e T 3 0 COnmlMatlOn SCCM EE 9 3 4 Bee EE 10 3 5 PA Redguestisecolnsiderallorssuo un rra e ER ENS ERR MEER eU EDS aunque et tue abe is 11 40 AREQUEST SEAR GP EE 13 5 0 PA RECONSIDERATION TRANSACTION HISTORY enn 16 5 1 Maxim m ReconsideratONS aasa EE 20 6 0 CONFIGURING THE E PA APPLICATION eene 22 7 0 VIEWING THE ON LINE HELP PAGE c ccccecceceeeeecssceeceeseeseeeeeeeeeeeeees 24 Date Revised 04 30 2012 iii Electronic Prior Authorization
13. three 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 link from the PA Options menu and do a search for requests Below are all of the Transactions that were submitted by you through the e P4 System To view the complete Transaction click on the PA 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 PA Request ee eee PA Type ARTE Reject ePA em Request Date Program status Code Transaction Recon 7 20 2006 NENNEN N i an 09 DME Requires Review 1 Recon mm Wm CT 09 OME Requires Review d 05 ENENE ENEEEENEENE tiS Rehabilitation Requires 1 23 AM T Re 1155 view herapy 1 07 53 PM 05 sy 7 24 2506 Rehabilitation Denied T herapy Recon 05 es Rehabilitation Requires Su iud Therapy Review 05 Recon EN eg e Rehabilitation Requires Therapy Review e 05 yg WR 772777205 Rehabilitation Recon Usch Thecaue Denied Records 1 7 of 7 Page 1 of 1 Select a PA to view Date Revised 04 30 2012 20 Electronic Prior Authorization e PA Web Application User Manual A PA
14. 100 calories information contained i uuum one packet one can one brik or one bottle the Louisiana Department of Health s New Confirmation Process 2009 06 19 The Electronic Prior Authorization ePA application has been enhanced with a new confirmation process to facilitate editing requests before submitting for review Once a user submits a request a confirmation message will be displayed that will allow the following actions The Profile page will open The scrolling list box in lower SS Print Friendly E L e E portion of the page labeled Your oeren Prior Authorization PA Types shows which PA types Department of Profile will be displayed in the select list PA Options The e PA Profile allows you to customize the PA Types that will appear in the PA Type selection list when entering a PA Request The default is that all PA Types for the e PA system will be in the PA Type list PA Request You can modify your choices at any time by returning to this page To add a P A Type to the pu down PA Reconsideration Be sure to click the Save Changes button to save your changes View PA Requests Available e PA System PA Types menu click once on the PA type you wish to add from the list in the El Home Heath serves upper portion of the page labeled oe Available e PA System PA Types and then select the Add To Your Your PA Types PA Types button The page will be Adult Denture refreshed to show your changes
15. 598 8753 Eligibility Information Support 800 473 2783 or 225 924 5040 Date Revised 04 30 2012 Copyright 2010 Molina Medicaid Solutions All Rights Reserved Electronic Prior Authorization e PA Web Application User Manual 3 1 Recipient amp PA Type Entry The Recipient amp PA Type Entry page will be displayed Louisiana i l Medicaid Prior Authorization Ce ee Reapient amp PA Type Entry Health and Hospitals PA Options Recipient s Medicaid ID Number or CCN PA Request Recipient s Date of Birth MM DD YYYY PA Reconsideration PA Type 05 Rehabilitation Therapy View PA Requests 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 amp Hospitals Technical Support 877 598 8753 Eligibility Information Support 800 473 2783 or 225 924 5040 Copyright 2010 Molina Medicaid Solutions 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 Date Revised 04 30 2012 6 Electronic Prior Authorization e PA
16. AM Enc No 48322 PA Options PA Request Dental PA Request PA Reconsideration View PA Requests Help My Profile amp PA Home Logout pmm Click on the Return to Search Results link on the PA Options menu Return to Search Results Below are all of the Transactions that were submitted by you through the e P4 System To view the complete Transaction click on the PA 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 vour records The column with the Indicates the number of attachments received for this PA Request LE MER Reject e6 PA Stats oe Program Code Transaction The status of aaa the PA 619885000 Pe ee EPSDT Denied 23984 e 3 03 25 PM Dental Request is now 7 17 2006 EHE quires spesa 3 07 50 PM Dental Review Gs Recon Ffl7 7 2006 EPSDT Requires Requires ELE 3 11 01 PM Dental Review 7 17 2006 EPSDT Requires Review eee 3 34 47 PM Dental Review KS 7 17 2006 EPSDT Requires Notifying the 4 06 40 PM Dental Review provider that 7 20 2006 Recon their et HH 0 15 32 AM 09 DME Requires Review reconsideration RETO has been CHE 09 DM Requires entered and is Review awaiting review Records 1 7 of 7 Page 1 Jof 1 Date Revised 04 30 2012 19 Electronic Prior Authorization e PA Web Application User Manual 5 1 Maximum Reconsiderations A provider may not submit more than
17. DATA Ashi keg EI Bios em IC CH C3 C3 fie ellene C m le mm ca po33e a oot caleaaarL L imu c oe S eS E23 C3 ca3 jii m u E EC C3 i SJ E93 3 ca ooo Ca coc e eebe ellene F3 c3 C3 ooo cM 3 C ca ooo EG C3 Place FE DUDAS ecipiemt s Hanne Amie Demi oes ue Click on the Submit ioa mam con ren Reconsideration button sideration Tun This Page ed 7 20 200 amp 9 41 20 AM Enc Ng 40222 echeicH Support E77 59B ETS3 Ehbzbiktg nfprmmetion Support 800 d73 27B3 or 225 824 50 Date Revised 04 30 2012 17 Electronic Prior Authorization e PA Web Application User Manual 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 Print This Page z 20 2006 9 41 28 AM Enc No 42322 Save Reconsideration ePA Trans ID 24000 Submittec After you click the Save Reconsideration button a screen similar to the one shown below is displayed ES _ Print Friendly Louisiana Medicaid Department of Health and Hospitals PA Options PA Request PA Reconsideration View PA Requests Help My Profile amp PA Home Home Return to Search Results Warning Unauthorized use of this site or of the information contained herein is prohibited by the Louisiana Prior Authorization PA Reconsideration Entry PLEASE CHO
18. OSE ONE OF THE FOLLOWING OPTIONS The following FA Request has been entered Please choose one of the options to continue 916755000 PA Type 05 Rehabilitation Therapy 208 Submission Process Not Complete Expires 07 16 2009 PA Number PA Status Request Date 6 16 2009 10 55 45 AM REQUESTER DATA SUBSCRIBER DATA Medicaid IO SSH I a E DOE Last Name Department of Health amp Hospitals Sex DIAGNOSIS Primary Code Description Secondary SERVICE DATES From PRESCRIBING PROVIDER DATA Physician Name EA Physician NPT or Medicaid IC d Prescription Date MM Db vvr Choose one of the three links in blue underlined type e Submit the request All of the information is correct Click this link to submit the request and proceed e Go Back and modify the request Click this link if you notice that the information on the request requires a modification e Cancel this request and return to the home page Click this link to cancel the request and start over Date Revised 04 30 2012 18 Electronic Prior Authorization e PA Web Application User Manual Once saved a Reconsideration History block will be available on the PA Request Review screen Click the PA Reconsideration ID Number link to view the previously entered information Reconsideration History PA Reconsideration ID Audit Date Comments Submit Another Request Print This Page ePA Trans ID 24000 Submitted 7 20 2006 9 41 28
19. Request Review screen will Prior Authorization Request appear SEH IMPORTANT INFORMATION Pigi pet Pri Bb gab uen Fol D Cn ind Pg Ped bed ES Loge o Poss eene Demon Thee gis 8 ab Pr L scht Ggs man Pass go E p pur Ie oer mee ior Ke Rer Prec Anime apo gee T haa lo Ep man i iban ei Leconte Pr dT Fera ln ai DupporBez coire i ae o ban Phere buted bare TAPS FAX COM Se MAC COA A MUERLAL and bx ras dac usa cody bey s Ele Pa pee nr gen date fen les ba sind pe a el Hs rsndrt ed ee hy ee all pepe al tiu Las ieee Pard Arto F xr hurries 225 927 8538 JE Prep mc Tam ER ie tii ioc FA Typs 25 Bahabdxabon Tres aqua Bequest Date Pali bao Fe E SEQUESTER DATA Medced Provider GC Phora Ha RES es OOOO esl 7 MCR Ee DATA ooo ch _ ii ee MENNEN jesse c O K ies eos Zwee DIAGNOSIS Coda Description Pme SERVICE DATES Freen 10 24 f 2085 Thes 1652372003 PRESCRIBING PROVIDER DATA Phrsican Marne Physician tember Prescrptwe Date MYDD SERVICE LEVEL DATA ar Hi a nil Sol E eC p e e e n o a aa C C Sess SS aS L3 ODD Ce eee SSS SSS Sooo SSS P o ccd amA cac M a c3 c3 Heare Se C3 E E C3 CIS eee io 1 Place of LIE PROVIDER CONTACT TF 084aATION E H ee Dag fe 1 Fes Addstiznal Comments Heed suce units far so rHI Feder ae T The message will be displayed at the bottom of the screen Rracenaideratisn History Maxim
20. THIS FAX COMMUNICATION 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 Molina Prior Authorization Fax Numbe 225 927 6536 e PA Fax Number ES PA Type Reque Date PA Status PA Number ePA Trans ID REQUESTER DATA NPI mmm m PhoneNo T9 2 S Contact Person CMS 8 raxo Td SUBSCRIBER DATA Medicaid 1D ay SSN Le a LastName First Name mes BI Sex e DOS rum mES DIAGNOSIS Code Primary Description Secondary SERVICE DATES From JEN vu ee PRESCRIBING PROVIDER DATA Physician Name Physician NPI or Medicaid ID 1 Prescription Date wwbb vvvv SERVICE LEVEL DATA Requested Requested Units Amount Line Procedure SE Description Modifiers Place of Treatment PROVIDER CONTACT INFORMATION Address City State Telephone LY Fax Additional Comments None Name LJ ze LC Submit Another Request Submitted ePA Trans ID Enc No Technical Support 877 598 8753 Eligibility Information Support 800 473 2783 or 225 924 5040 Copyright 2010 Molina Medicaid Solutions All Rights Reserved 10 Electronic Prior Authorization e PA Web Application User Manual 3 5 PA Request Reconsideration Use the PA Reconsideration link on the PA Options Menu to access the PA Request Reconsideration Initial Entr
21. The default is that all PA Types for the e PA system will be in the PA Type list Use the following buttons to customize your PA Type list e To Add a PA Type to your PA Type list select the PA Type from the Availalbe list then click the Add to Your PA Types button e Toremove a PA Type from your list select the PA Type and then click the Remove from Your PA 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 e PA system only those PA Types that you have chosen will appear in the PA 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 Date Revised 04 30 2012 Copyright 2010 Molina Medicaid Solutions All Rights Reserved 25
22. ained herein is prohibited by the Louisiana Department of Health amp Hospitals Technical Support 877 598 8753 Eligibility Information Support 800 473 2783 or 225 924 5040 Copyright 2010 Molina Medicaid Solutions All Rights Reserved Date Revised 04 30 2012 23 Electronic Prior Authorization e PA Web Application User Manual 7 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 i Medicaid Prior Authorization Department of Home Page Health and Hospitals PA Options Welcome Providers to the LA MEDICAID e PA 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 PA Requests PA Reconsideration DME Physician Services Personal Care Services PCS for EPSDT Outpatient Surgery Performed Inpatient Hospital Multiple and Extended Home Health Services Rehabilitation Air Ambulance Pediatric Day Health Care Facilities View PA Requests e PA Home Logout Warning For ePA Requests with HCPCs that require NDCs 2010 12 22 EEN Units are specific to NDC not HCPC One unit may be equal to 100 calor
23. e PA E SS Type 88 the SSN field City SSES State Zip has been replaced with Telephone SS E the Medica re ID Additional Comments Air Ambulance Proced u re Codes ePA Trans ID Submitted 11 4 2010 12 36 36 PM Enc No Technical Support 877 598 8753 Eligibility Information Support 800 473 2783 or 225 924 5040 A0430 Fixed WI ng Copyright 2010 Molina Medicaid Solutions All Rights Reserved Transport A0431 Rotary Wing Transport A0435 Fixed Wing Air Mileage A0436 Helicopter Air Mileage Date Revised 04 30 2012 T Electronic Prior Authorization e PA Web Application User Manual NOTE The ePA Request Screen also determines if a procedure code entered requires a NDC code If a NDC code is required the application prompts the user to enter the NDC before the submission can be finalized The NDC is edited to determine if the code is valid based on the current list of formulary NDCs with a type of service of 09 If the NDC is valid then the submission can be finalized if not an error message is displayed to let the user know that NDC code entered is not valid Once validated the name of the NDC will be displayed on the detail line beside the NDC code For example see below After you click on the Submit button a confirmation screen similar to the one shown below is displayed NOTE For Hospice PA Type 88 the Service Level Data section of the PA Request Entry screen is omitted Date Revised 04 30
24. e brik or one bottle New Confirmation Process 2009 06 19 The Electronic Prior Authorization ePA application has been enhanced with a new confirmation process to facilitate editing requests before submitting for review Once a user submits a request a confirmation message will be displayed that will allow the following actions The PA Request Transactions page will be displayed From the PA Request Transactions page you can search for a PA request by PA Number Recipient ID CCN or e PA Transaction Number Enter the appropriate information in any of these four fields and then select the Search button Located directly below the CCN input field EGEL Medicaid Department of Health and Hospitals PA Options PA Request PA Reconsideration View PA Requests Warning Unauthorized use of this site or of the information contained herein is prohibited by the Louisiana Department of Health amp Hospitals Prior Authorization PA Request Transactions oa enter at least one of the e PA ePA Transaction J Recipient ils Or conf Quick Search Quick Search 9 within Past 7 days OPast7 14days OPast 30 days Technical Support 877 598 8753 Eligibility Information Support 800 473 2783 or 225 924 5040 Copyright 2010 Molina Medicaid Solutions All Rights Reserved A Quick Search is also available that will search for PA requests entered in the curre
25. eceived Expires 06 14 2009 6 11 2009 05 10 59 13 Rehabilitation AM Therapy Not Assigned Not Assigned Records 1 2 of 2 Page dot Click on the PA or the e PA Transaction to see details of the request on the PA Request Review screen The following is a list of the status codes and their definitions oubmission Process Not Complete Expires 30 days from create date Cancelled by User A New Request is Required Submitted Attachments Not Received Expires 3 days from create date Cancelled by Molina Attachments Not Received Within 72 Hours A New Request Cancelled by Molina Attachments Received After 72 hours A New Request is 002 Approved 003 Denied 004 Requires Review 208 209 210 211 is Required 212 Attachments Received 213 Required 214 Date Revised 04 30 2012 Request Has Expired A New Request is Required 14 Electronic Prior Authorization e PA Web Application User Manual To return to your search select the Return to Search Results link on the left side of the page Print Friend Louisiana f i Medicaid Prior Authorization Department of PA Request Review Health and Hospitals PA Options I PA Request I i PA Reconsideration View PA Requests i I d Help My Profile IMPORTANT INFORMATION e PA Home 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 wh
26. ectronic Prior Authorization e PA Web Application User Manual Ca EZ Print Friendly MITTIT ESTE Prior Authorization Medicaid ide Request Reconsideration Initial Entry 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 Unauthorized use of this site or of the information contained herein is prohibited by the Louisiana Department of Health amp Hospitals PA Number PA Type 09 DME Request Date 11 4 2010 12 36 36 PM L Continuation of Services REQUESTER DATA NPI m Phone No MERE Contact Person WEE NE ue E Iessen SUBSCRIBER DATA Medicaid 10 SSN LastName First Name HE El Sex We DOB EL Description DIAGNOSIS Primary ay Es rom rwu Jwwob mvo PRESCRIBING PROVIDER DATA Physician Name O Physician NPI or Medicaid ID e Prescription Date E MM DD YYYY SERVICE LEVEL DATA Secondary SERVICE DATES Requested Requested Amount Line Procedure Modifiers Description Place of Treatment 0 PROVIDER CONTACT INFORMATION Name muc Ee Address E City Po Se ze 4 Telephone 1 Fax E Additional Comments ePA Trans ID Submitted 11 4 2010 12 36 36 PM Enc No Technical Support 877 598 8753 Eligibility Information Support 800 473 2783 or 225 924 5040
27. en faxing supporting documentation for this Prior Authorization request Failure to do so may resultin delays in processing your request Logout Please fax all supporting documentation to one of the following numbers listed below Home v AILO CONFIDENTIAL MATERIAL and is thus for use only by the intended Retum to Search Results Pet ip Search Resuite lease contact the sender and securely discard all pages of this fax Prior Authorization Fax Numbers Warming 225 927 6536 Gi print this Page Unauthorized use of this site or of the PA Number PA Type Request Date information contained ePA Trans ID PA Status herein is prohibited by the Louisiana Department of Health REQUESTER DATA amp Hospitals NPI gum Phone No FS ContactPerson MER mem mmm m me FaxNo sd SUBSCRIBER DATA Medicaid 1D BNNENNEENEE SSN Last Nome EE Jer eme oi 7 E DIAGNOSIS Description Primary bm 1 Secondary SERVICE DATES From sm Thru Rcs PRESCRIBING PROVIDER DATA Physician Name Ir OE Physician NPI or Medicaid ID IS j Prescription Date wwbb vvvv SERVICE LEVEL DATA Requested Requested Units Amount Line Procedure Code Modifiers NDC Description p Em Ce E C P C3 ccc C9 cj P c Jobe CC C3 ccc Ce LECH Place of Treatment PROVIDER CONTACT INFORMATION Name Address City Telephone Additional Comments None Reconsideration History PA Reconsideratio
28. ew e Go back and modify the request This will allow users to correct any information on the request before submitting the request e Cancel the request This will finalize the request and no further action will be taken The following policies have been enacted e Users can modify a request as many times as they need to but will only have 30 days to submit or cancel a request After 30 days the request will expire e Once submitted users will have 3 days to send attachments If attachments have not been received within 3 days the request will be cancelled and a new request will be required e f attachments are received after 3 days the request will be cancelled by Molina and a new request will be required e A Prior Authorization number will not be assigned until attachments have been received The attachments must be received within 3 days of the submission of the request Additional statuses have been added to facilitate the confirmation process 208 Submission Process Not Complete Expires 30 days from initial request date 209 Cancelled by User A New Request is Required 210 Submitted Attachments Not Received Expires lt 3 days from submission date 211 Cancelled by Molina Attachments Not Received Within 72 Hours A New Request is Required 212 Attachments Received 213 Cancelled by Molina Attachments Received After 72 hours A New Request is Required 214 Request Has Expired A New Request is Required
29. ies information contained j i aA one packet one can one brik or one bottle the Louisiana Department of Health EE New Confirmation Process 2009 06 19 The Electronic Prior Authorization ePA application has been enhanced with a new confirmation process to facilitate editing requests before submitting for review Once a user submits a request a confirmation message will be displayed that will allow the fallawing actions Date Revised 04 30 2012 24 Electronic Prior Authorization e PA Web Application User Manual The Help page provides general information on how to use the application as well as some basic reminders Print Friend Louisiana Medicaid Department of Health and Hospitals Prior Authorization Help 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 Using e PA Web System amp PA User Manual zi Submitting a PA Request Submitting a Prior Authorization Request through the e PA web application involves the following steps Log on to LAMEDICAID com with your username and password Select Electronic Prior Authorization from the secured menu options Select PA Request from the PA Options menu located on the left side of the page Enter the f
30. ior Authorization hyperlink LTE iaid du For Technical Support call toll free 1 877 598 8753 Provider Logout Click Here to Enter a Recovery Request New Medicaid Information HIPAA Information Center HIPAA Billing Instructions amp HIPAA Information Center HIPAA Billing Instructions amp Companion Guides EDI Information Training About Medicaid Provider Ownership Enroliment Provider Web Account Registration Instructions Provider Support Provider Manuals Billing Information Medical Equipment amp Supplies Fee Schedules Provider Update Remittance Advice Index Pharmacy Prescribing Date Revised 04 30 2012 Change Password Change Account Info Provider Logout Help E Provider Applications Area The application s listed below are for authorized use only Click on an application link to access the application Provider Applications LAMEDICAID COM Fact Sheet Restricted Provider Applications Administrative Tools Medicaid Eligibility Verification System NPI Claim Status Inquiry PCP Roster of Enrollees Electronic Clinical Data Inquiry Electronic Prior Authorization e PA Application Electronic Referral Authorizatio Electronic Referral Authorization P PA Requests for Case Managers Uncompensated Care Costs Document Provider Applications Area Date Modified 1 24 03 Electronic Prior Authorization e PA Web Application User Manual 3 0 USING THE APPLICATION The Louisiana Medicaid Prior
31. lete the login ID and password process Prior to initial use of the e PA web application the web browser setup must be configured Using a 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 lmmis 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 Molina 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 Date Revised 04 30 2012 3 Electronic Prior Authorization e PA Web Application User Manual 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 lmmis 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 Provider Applications Area screen is displayed Select the Electronic Pr
32. n ID Audit Date Comments Submit Another Request ePA Trans ID Submitted Enc No Technical Support 877 598 8753 Eligibility Information Support 800 473 2783 or 225 924 5040 Copyright 2010 Molina Medicaid Solutions All Rights Reserved Date Revised 04 30 2012 15 Electronic Prior Authorization e PA Web Application User Manual 5 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 an approved or denied PA Request using the View PA Requests link in the PA Options menu EGEL Medicaid Department of Health and Hospitals PA Options PA Request PA Reconsideration View PA Requests Help My Profile e PA Home Logout Home Waming Unauthorized use of this site or of the information contained herein is prohibited by the Louisiana Department of Health amp Hospitals Prior Authorization Home Page Welcome Providers to the LA MEDICAID e PA 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 Requests DME Physician Services Personal Care Services PCS for EPSDT Outpatient Surgery Performed Inpatient Hospital Multiple and Extended Home Health Services Rehabilitation Ai
33. nt week the previous week or the current month Select the appropriate time period you wish to search for and select the Quick Search button Date Revised 04 30 2012 13 Electronic Prior Authorization e PA Web Application User Manual Once a search has been submitted the page will be re displayed listing all of the PA requests that were found matching the search criteria Use this list to check the status of the PA request When a request has been submitted the default in the Status column will be 208 Submission Process Not Complete An expiration date is also provided Once the request has been approved this column will show Approve If the request is denied then the column will show Denied and the Reject Code column will indicate the PA reject reason code Below are all of the Transactions that were submitted by you through the e PA System To view the complete Transaction click on the PA 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 El indicates the number of attachments received for this PA Request a e PA Reject Transaction E we PA Type Program Request Date Recip ID CCN Status 208 Submission Process Not Complete Expires 07 11 2009 210 Submitted 6 11 2009 05 Attachments 2 11 40 Rehabilitation Not PM Therapy R
34. ollowing information O Recipient Medicaid ID or the Recipient s CCN Card Control Number Recipient s Date of Birth Please use slashes when entering the date for example 1 1 2000 O Select the type of PA Request that you wish to enter 5 The next page will be the PA Request entry page This is where you will enter the detailed information for the request just as you would if you were filing out a paper form 6 When you have completed entering information on the PA Request entry form click the Submit button 7 The information 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 PA Request is accepted 8 Ifthe PA Request is accepted you will be presented with a page that contains a bar code A bar code is simply a set vertical stripes or bars used to encode information A bar code is frequently referred to as a UPC symbol 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 will be used as the cover page when you fax in the supporting documentation for this PA Request 10 You must fax in supporting documentation using the printed page with the bar code There are two 2 reasons for this 1 Supporting documentation is required in order to properly review the PA Request 2 The bar code will link the supporting documentation to PA Request that you
35. r Ambulance Pediatric Day Health Care Facilities For ePA Requests with HCPCs that require NDCs 2010 12 22 Units are specific to NDC not HCPC One unit may be equal to 100 calories one packet one can one brik or one bottle New Confirmation Process 2009 06 19 The Electronic Prior Authorization ePA application has been enhanced with a new confirmation process to facilitate editing requests before submitting for review Once a user submits a request a confirmation message will be displayed that will allow the following actions Once the results appear locate an approved or denied PA Request and click on the PA Number to review the request pelow are all of the Transactions that were submitted by you through the e P4 System To view the somplete Transaction click an the PA Number of the request you wish ta see This will give you the complete information regarding the request as well as 4 print friendly version that you can print for your records The column with the Indicates the number of attachments received for this PA Request Recip ID CCN guy gem _ ee E Records 1 7 af 7 Date Revised 04 30 2012 Request Date 17 2006 3 03 25 PM 717 2006 3 07 50 PM 7 17 2006 3 11 01 PM l7 2006 3 3d d r PM ffl 2006 4 06 40 PM 7f20 2006 2 41 28 AM F Type Proaram EPSDT Dental EPSDT Dental EPSOT Dental EPSDT Dental EPSDT Dental Transaction Reject Status Code
36. this site or ofthe ge cupri iE Department of Health amp Hospitals Save Changes Save Changes Technical Support 877 598 8753 Eligibility Information Support 800 473 2783 or 225 924 5040 Copyright 2010 Molina Medicaid Solutions 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 Date Revised 04 30 2012 22 Electronic Prior Authorization e PA Web Application User Manual 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 WIESE TIE De Medicaid rior Authorization ee Reapient amp PA Type Entry Health and Hospitals PA Options Recipient s Medicaid ID Number or Po N OOOO woo PA Type Customized 05 Rehabilitation Therap Drop down List My Profile e PA Home Logout Home Return to Search Results Warning Unauthorized use of this site or of the information cont
37. um amount of Reconsiderations 3 has been reached EPA Trani BD 24553 Subenttted 1 Ii Dee RER Ph E r Pip ETE Teche Support 877 598 073 Ehg dulty Enformaton Gupeort 800 472 2783 or 225 924 5040 Date Revised 04 30 2012 21 Electronic Prior Authorization e PA Web Application User Manual 6 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 1 of this document To customize the PA Type select list Louisiana do the following Prior Authorization Department of Home Page Health and Hospitals PA Options Welcome Providers to the LA MEDICAID e PA 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 PA Requests PA Reconsideration e DME View PA Requests e Physician Services Click the My Profile link on the left Help e Personal Care Services PCS for EPSDT Outpatient Surgery Performed Inpatient Hospital D My Profile e Multiple and Extended Home Health Services side of the main page Ee SE Pediatric Day Health Care Facilities Logout Home For ePA Requests with HCPCs that require NDCs 2010 12 22 Warning Unauthorized use of this site or of the Units are specific to NDC not HCPC One unit may be equal to
38. ut not limited to direct indirect special or consequential damages Exercise caution to ensure the use of this information and or software material complies with the laws rules and regulations of the jurisdictions with the respect to which it is used The information contained herein is subject to change without notice upon DHH approval Revisions may be issued to advise of such changes and or additions Molina Medicaid Solutions is a registered trademark of Molina Healthcare Inc Copyright 2012 Molina Medicaid Solutions All rights reserved Date Revised 04 30 2012 i Electronic Prior Authorization e PA Web Application User Manual PROJECT INFORMATION Document Title Louisiana Medicaid Management Information System LMMIS Electronic Prior Authorization e PA Web Application User Manual Author 00 Technical Communications Group Molina Medicaid Solutions LMMIS QA Date Description of Change LIFT 6 1 05 Added bolded note to Section 1 0 page 1 that S Clark reconsiderations cannot be done through the e PA application 7 25 06 Updated manual and added Recon info 3372 C Stickney 8 11 06 Inserted new screens on pages 5 9 11 14 and 19 Kc C Stickney 9 26 06 Made corrections to pages 1 10 17 and 18 3372 C Stickney 11 17 06 Corrected spelling error page 9 amp TOC MEN C Stickney 6 19 09 Reformatted document in accordance with new user 0286 R Sheehan manual standards Replaced screenshot in 3 0 modified
39. 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 following provider types 01 Inpatient 05 Rehabilitation 06 Home Health 07 Air Ambulance 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 16 Pediatric Day Health Care 88 Hospice 99 Other Date Revised 04 30 2012 1 Electronic Prior Authorization e PA Web Application User Manual 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 recipient s 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 the PA Request Entry response page printout fax the request and the supporting documentation to the number indicated on the response page Molina e PA Fax Number 225 927 6536
40. y screen The Request Reconsideration Initial Entry screen is displayed Enter a valid PA Number and click on the Submit button Louisiana f l i Medicaid Prior Authorization T AE Request Reconsideration Initial Entry Health and Hospitals PA Options PA Request NOTE Prior Authorization Reconsiderations can be requested for the following reasons PA Reconsideration e Denied requests that have incomplete or missing documentation View PA Requests 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 Help My Profile e EE Pater P Number Enter Valid PA 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 Technical Support 877 598 8753 Eligibility Information Support 800 473 2783 or 225 924 5040 Copyright 2010 Molina Medicaid Solutions All Rights Reserved 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 Date Revised 04 30 2012 11 El
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