HealthChoices Provider FAQs
Acute and Non-Acute Levels of Care
What happens if a member has both Commercial Insurance and Medicare?
The member’s commercial insurance will be considered the primary payer, Medicare will be the secondary payer and Community Care would be the final payer. HealthChoices is always the payer of last resort.
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What is a pre-cert?
The pre-certification process is used to assess clinical information in order to
determine Medical Necessity Criteria (MNC) for admission to acute levels of care.
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What is the pre-cert process?
The pre-cert is conducted telephonically (1-888-251-2224) with a care
manager for all care that is non-ambulatory. Prior to calling to complete the pre-cert, the caller must have the clinical information, have completed a facility bed search (the location where the member will go) and have an MD medically clear the member and approve the admission. A pre-cert will not occur unless all information is presented to the care manager.
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Can a crisis worker complete a pre-cert?
A crisis worker can provide the clinical information for a pre-cert. However,
in order to get the authorization number, the admitting facility must call when the member arrives to confirm that a medical doctor has approved the admission for inpatient mental health.
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What is Medical Necessity Criteria (MNC)?
Medical Necessity Criteria is used to make consistent decisions to authorize
care and corresponds to the level and intensity of services.
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What if the member does not meet medical necessity criteria for admission?
Community Care care managers can not deny services, but will seek a
Physician Advisor who will then contact the assessor for additional
information/clarification.
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When will I obtain the authorization number?
Community Care will give an authorization number to the facility once the
member arrives. Community Care also sends authorization numbers to an identified person at each facility on a weekly basis.
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What is the length of an authorization period for pre-cert and continued stay?
The length of time for an authorization will be clinically determined as per
Medical Necessity Criteria for both mental health and drug and alcohol
services.
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How do I complete a continued stay review?
Continued stay reviews for acute levels of care will be conducted
telephonically with an assigned care manager.
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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)?
The provider will complete a notification form and fax to Community Care at 1-866-294-3935.
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What is the length of an authorization period for both Partial Hospitalization and Case Management?
Authorizations will be given for 6 months at a time.
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What if I need more units?
If additional units are needed at any time during the authorization period, the
provider needs to call the care manager to discuss the clinical rationale before
the requested units will be authorized.
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What happens if the Eligibility Verification System (EVS) shows the member is not eligible with Community Care or the member loses eligibility while receiving an authorized service?
Authorization does not guarantee payment. If this happens, the provider needs to follow its county protocol for noninsured individuals. It is important for providers to regularly check EVS for member eligibility status.
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What if I have a complaint?
Contact Community Care, who is obligated under Act 68 to investigate any
and all complaints. However, there are timelines for the process and a care
manager will assist members and providers throughout.
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