Caresource removing auths for PT/OT/SLP:
Auths are not required for CareSource claims anymore as of October 1st, 2024. It's very scary to think about, as we worry about limits, however after talking to the reps they stated it is true there are no limits on visits. However, this is also based on medical necessity. Which means, more medical reviews/audits are on the way. I suggest you go by Medicaid guidelines and visit limits set in your plan of care.
On Caresource's website the have links to their policies here:
That being said, I cannot push providers enough to make sure your notes and POCs are timely (notes must be written within 3 business days, POC/Evals must be written within 7 business days) and always stating medical necessity of each visit.
When I asked all three cmos what their standards are for medical documentation, all stated they follow the cms guidelines. (cms.gov)
I often have providers ask questions about documentation. I'm still researching this but please search the cms website to find out more as well. In a general sense you want to make sure for evaluations/pocs you document the need of the patient as much as possible. Make sure each evaluation/plan of care has standardized scores and yes you need to do this every 6 months for patients under 21, adults and rehab patients every 3 months. SOAP notes need to document time in and out with am/pm, S: describing the patient's temperament and parents' response to homework previously given the week before. A: should go over responses to tx that day as well as homework assigned (description, not just referring that you assigned it) to the parent for the next week. If a patient is struggling, address those issues with a positive underline statement to encourage as it would reflect that patient is good for state goals. Keep goals in mind that the patient can achieve. If they achieve several of their goals before the timeline of the 6 month plan of care would expire, you can write a new POC with new goals to continue services. In fact it's expected from the insurance companies that you do so.
Several AG provider reps are no longer with the company. The stated to request help from a rep, you must now email here:
PSHP will be transitioning to Availity and will discontinue their web portal in the near future. The transition date to begin with Availity will be 11/18/24
A lot of the cmos offer members benefits such as gift cards and resources for work/housing connections. Make sure they realize they have some of these benefits and can find these resources by creating a login at the cmo website for members. They can change their CMO insurance at their anniversary date each year and have 30 days to do so by calling GA Families.
Members were still encouraged to update their information via gateway. They can also create a login on gammis web portal to update demographic information.
A provider can look up on eligibility for a patient on gammis currently and see when the patient's redetermination is due.
Make sure the patient has a login for gateway.ga.us to submit any documents they might need for redetermination. Remind patients to add the cell phone and email addresses so they can receive alerts. Patients should not mark out anything on documents submitted as this will cause an application to be rejected.
Each CMO posts an updated newsletter at the beginning of each month. I try to always read through these, among other commercial insurance companies newsletters to make sure changes were not made. Please make sure you glance through these as well. Also there was no mention of any new CMOs coming onboard, but will keep everyone updated if that change happens.
