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HealthChoices Provider FAQs

The latest Act 62 FAQs are available in our Act 62 resource section.

Acute and Non-Acute Levels of Care

1. What happens if a member has both Commercial Insurance and Medicare?
2. What is a pre-cert?
3. What is the pre-cert process?
4. Can a crisis worker complete a pre-cert?
5. What is Medical Necessity Criteria (MNC)?
6. What if the member does not meet medical necessity criteria for admission?
7. When will I obtain the authorization number?
8. What is the length of an authorization period for pre-cert and continued stay?
9. How do I complete a continued stay review?
10. What is the process for obtaining authorization for Partial Hospitalization and Case Management (including Intensive Case Management (ICM), Resource Coordination (RC), and Blended Case Management)?
11. What is the length of an authorization period for both Partial Hospitalizationand Case Management?
12. What if I need more units?
13. What happens if the Eligibility Verification System (EVS) shows the member is not eligible with Community Care or the member looses eligibility while receiving an authorized service?
14. What if I have a complaint?

Child and Adolescent Services

1. What is a transition of care authorization?
2. When can providers send transition of care authorizations to Community Care?
3. If our contract with Community Care is not yet finalized, should we wait to send the transition of care information?
4. What children’s services must be pre-authorized?
5. Can services begin without a pre-authorization?
6. Are there any services within Behavioral Health Rehabilitation Services (BHRS) in which providers can obtain an authorization after the service has been delivered?
7. We have already developed packets for services to begin or continue on January 1, 2007, using the Fee-for-Service paperwork and timelines, what should we do?
8. How do I know whether to submit continued-stay packets to the state or Community Care?
9. Will Community Care accept services that have been previously authorized by the state?
10. Where do I locate Community Care forms?
11. How/where do providers send transition-of-care information as well as upcoming initial and continued-stay packets?
12. Must we submit one Behavioral Health Rehabilitation Services (BHRS) or Residential Treatment Facility (RTF) packet per envelope?
13. What is the Community Care Review process for Behavioral Health Rehabilitation Services (BHRS), Residential Treatment Facility (RTF) and Family Based Mental Health Services (FBMHS)?
14. What is the length of time for authorizations?
15. How do we contact Community Care?

Quality Management

1. What is a Significant Member Incident?
2. What are the reporting timelines?
3. What form do I use to report?
4. Does this replace having to report incidents to my county?
5. Where can I find more information on this topic of Significant Member Incident’s (SMI)?
6. Will you come to my office and perform chart audits/record reviews?
7. How quickly do I have to give an appointment for consumers requesting services?
8. Do I have to cooperate with Consumer/Family Satisfaction Teams (C/FST)?
9. How do I know how I am doing as a Community Care provider?
10. What activities are being measured in the Quality Department?

Network Management

1. When will I receive my provider contract?
2. If the credentialing and contracting process is not yet completed, will I be able to see members?
3. Who do I call with questions regarding credentialing or contracting status?
4. How often will I be notified of authorizations?
5. Can the Authorization reports be sent to more than one location for large organizations?
6. What do I do if I have a waiting list and can not see a member within the required access standards?
7. How do I register to complete Outpatient Registrations on the website?
8. How much time will I have to enter Outpatient Registrations for consumers already in treatment?
9. What happens when the member is in treatment with another provider?
10. What is a Serious Emotional Disturbance (SED) plan?
11. What happens if I forgot to check Eligibility Verification System (EVS)?
12. How will I know which other providers are within the network?