SCL Questions and Answers

Questions Related to Carewise Health
Q.
Why is it Carewise has not returned any SCL2 authorizations? Are there sufficient staff reviewing these documents and how many?
A.
A review of 200 SCL2 cases was conducted. Of these 200, 25 were submitted with complete documentation, met criteria, and were approved with the initial submission. The remainder of the submissions were placed in Lack of Information (LOI) status. Since 1/28/13, 39 LOIs have been approved with the submission of additional information. This brings the total approved cases of the sample to 64 of the 200.

The reasons for LOI were reviewed. The top five reasons for LOI are:
  • 1. Missing forms
  • 2. SIS-specific questions related to goals incomplete
  • 3. ICD-9 missing
  • 4. Signatures missing
  • 5. Incomplete forms
Haley Hammond (haley.hammond@ky.gov) and Mary Mann (mary.mann@ky.gov) are available for on-site technical assistance. Please contact them for help.
Q.
Case Management providers are still not receiving authorization from Carewise for all requested supports. Instead we are continuing to receive duplicate PA's for case management services. This has been a pervasive issue and will lead to increased difficulties in ensuring adequate service provision for waiver recipients.
A.
Please provide specific examples. The PAs reviewed for approved services have all been copied to the Case Management agency.

Please submit specific questions or member issues to Pam Smith (pamela.smith6@hp.com) for resolution.
Q.
For both SCL and SCL2, Case Managers are coming across instances where services are remaining unapproved for a glitch within the Carewise approval system where they are being flagged for review and no one has been able to adequately explain why or when they will be corrected. Specific examples can be provided but this is not an isolated occurrence and has been evident for a number of months.
A.
The root cause of this issue is when providers request a modification for a service but continue to bill the service. Since modifications are backdated 14 days unless a start date is specified, this results in claims continuing to be paid. The system will not allow a service to be end-dated to create the new approved service line with increased units. Carewise Health will review each of these on a case-by-case basis and adjust the dates based on paid claims data.

There are two simple ways to prevent this issue:
  • 1. If a modification is submitted, do not continue to bill the service until the updated PA is received; or

  • 2. Specify a start date for the new service or increased units and do not bill until the PA is received for the modification.
Please submit specific questions or member issues to Pam Smith (pamela.smith6@hp.com) for resolution.
Q.
RE: New to SCL2 Clients. When the client enters SCL2, the effective date is not near or around their date of birth. How do we get back on track for the LOC to be the date of birth?
A.
People receiving allocations and entering SCL for the first time after 1-1-14, will not have level of care (LOC) dates that match their birth dates. Their LOC will begin on the date of the initial submission of the documentation to Carewise Health. LOC birth dates are only for people transitioning from SCL1 to SCL2.
Q.
I submitted a MAP-95 for my client who is now under the SCL2 waiver. How do I resubmit his request for classes using Carewise Health?
A.
The MAP-95 is no longer used in SCL2. Requests for medically related items are requested through the MAP-530 service of Specialized Medical Equipment. Items that are not medical in nature are requested through the service of Goods and Services.

If the SCL2 plan has already been submitted, you would send in a modification to add the appropriate service.