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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 is a pre-cert?
  2. What is the pre-cert process?
  3. Can a crisis worker complete a pre-cert?
  4. What is Medical Necessity Criteria (MNC)?
  5. What if the member does not meet medical necessity criteria for admission?
  6. When will I obtain the authorization number?
  7. What is the length of an authorization period for pre-cert and continued stay?
  8. How do I complete a continued stay review?
  9. 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)?
  10. What is the length of an authorization period for both Partial Hospitalizationand Case Management?
  11. What if I need more units?
  12. 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?
  13. What if I have a complaint?

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 members 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. Where can I see my authorization reports?
  5. What do I do if I have a waiting list and can not see a member within the required access standards?
  6. How do I register to complete Outpatient Registrations on the website?
  7. How much time will I have to enter Outpatient Registrations for members already in treatment?
  8. What happens when the member is in treatment with another provider?
  9. What is a Serious Emotional Disturbance (SED) plan?
  10. What happens if I forgot to check Eligibility Verification System (EVS)?
  11. How will I know which other providers are within the network?

Fraud, Waste & Abuse (FWA) Program Integrity & Compliance Activities

  1. Is Community Care required to have a Fraud, Waste & Abuse (FWA) program?
  2. Where can I find information regarding Pennsylvania HealthChoices FWA requirements?
  3. Why does Community Care's Special Investigations Unit (SIU) conduct FWA audits?
  4. Are FWA audits the same as Quality audits?
  5. How does the FWA SIU determine which provider or level of care to audit?
  6. What is the difference among fraud, waste and abuse?
  7. Though my agency didn't commit fraud, why were we required to repay Community Care as a result of a FWA audit?
  8. What are proactive steps a provider can take to maintain compliance with FWA Policies & Procedures?
  9. Do Providers have to participate in the audit and with financial consequences identified through the audit?
  10. What is the difference between a retrospective claims review audit and a prospective payment claims audit?
  11. What is extrapolation?
  12. How can a Provider prepare for an upcoming FWA audit?
  13. What are some avoidable problems providers encounter during an audit?
  14. What can a Provider expect relative to communication regarding the audit?
  15. What documentation does a Provider need to produce and how can a Provider submit their documentation?
  16. What items is an auditor examining during the audit? Regulations?
  17. Why didn't the auditor accept additional documentation after the audit started?
  18. What are common findings that are considered to be FWA?
  19. Why do auditors contact consumers during an audit?
  20. What happens if there are deficiencies found in the audit of a Provider?
  21. Why might a Provider be asked to produce a Corrective Action Plan (CAP) in response to an audit? What should be included?
  22. Who is notified of the audit results in addition to the provider?
  23. What are some reasons that the SIU would file a BPI report?
  24. Can a Provider dispute the results of the audit? How?
  25. What happens if I discover FWA in my agency or practice?
  26. Are there penalties for submitting false claims? Is there protection for individuals who report fraud?
  27. How can I report suspected fraud, waste or abuse?
  28. Where can a Provider find more information about fraud, waste and abuse?

Other

  1. What procedures should be followed for member Exemptions for Supplemental Nutrition Assistance Program (SNAP) for Able Bodied Adults Without Dependents (ABAWD)?