What is a pre-cert?
The pre-certification process is used to assess clinical information in order to determine Medical Necessity Guidelines (MNG) for admission to acute levels of care.
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.
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.
What are Medical Necessity Guidelines (MNG)?
Medical Necessity Guidelines are used to make consistent decisions to authorize care and corresponds to the level and intensity of services.
What if the member does not meet the Medical Necessity Guideline for admission?
Community Care care managers cannot deny services but will seek a Physician Advisor who will then contact the assessor for additional information/clarification.
When will I obtain the authorization number?
Community Care will give an authorization number to the facility once the member arrives. Providers can also check authorizations via the e-portal in report center.
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 Guidelines for both mental health and substance use services.
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.
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.
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.
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.