How Managing Prior Authorizations Can Reduce Claim Denials When Billing Georgia Medicaid Waiver Services

When billing for personal support services (PSS) provided to clients who participate in Georgia Medicaid Waiver programs such as SOURCE, CCSP, ICWP, COMP, or NOW, two components must be in place to ensure claim payment.

First, the client must be eligible to receive the services on the billed dates of service. In other words, the client’s Medicaid Benefit Plan must be active, and the client must also have active eligibility for Service Type “Home Health Care” (Service Type Code 42). Any billed dates of service must fall within the effective and end dates listed on the client’s eligibility verification request.

Second, the client must also have an active and accurate Prior Authorization (PA) on file. The billed dates of service must fall within the Prior Authorization beginning and end dates. Also, the PA must have enough units allotted to cover the frequency of service the client is receiving. In some cases, there is a monthly or daily maximum set—if that number is set too low, it can result in denials and underpayments. Finally, the PA must reference the correct procedure code and modifier(s). If your client’s Care Plan and Service Order calls for extended personal support units, the PA units should use the procedure code and modifier that corresponds to extended personal support units.

When there is a discrepancy between the Prior Authorization units and service type and the frequency you’re providing, the first thing you should do is review (again) the latest Care Plan and Service Order and check for any changes. Always remember that the Care Plan / Service Order dictates what should be on the PA, not the other way around.  For example, if the renewed Prior Authorization looks the same, but the Service Order is saying something different–perhaps a lower frequency than before, you have to get that straightened out with the case management agency as soon as possible because you are only authorized to provide (and bill) the service type and frequency stated in the client’s current Service Order. In the case of an audit, any additional hours of service provided to the client or any hours provided and billed using the wrong service type could be recouped by Medicaid.

For most waiver programs, the Prior Authorization is renewed annually; but CCSP issues authorizations (referred to as SAFs) monthly. Regardless of the waiver program, it is important that the PA is checked for accuracy regularly, especially after an increase or decrease in service frequency. Sometimes a Prior Authorization is entered correctly initially, but then it’s altered or even ended way ahead of the scheduled end date.

So, to recap, the current Prior Authorization must have the correct dates, units, unit maximums (if applicable), and procedure codes. In most cases, PAs are entered into the MMIS Portal by staff from the client’s case management agency; however, ICWP authorizations are completed by the Provider (you). It’s not uncommon for a PA to have inaccurate information due to mistakes or miscommunications. However, it is the provider’s responsibility to make sure all PAs have the correct procedure code (service type) and enough units to cover the duration stated in the PA.

One final thing to note is that a current and accurate Prior Authorization won’t matter if the client’s Medicaid plan is not active and eligible for Home Health Care, as stated earlier.

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