Fall

REQUIREMENTS: - Immediately: Billing and clinical staff must familiarize themselves with updated access/availability standards (PCP routine within 30 calendar days, behavioral health urgent within 24 hours, prenatal first trimester within 7 calendar days). Ensure scheduling systems enforce these timeframes to avoid member access complaints and potential compliance violations. - Before end of Q4 2025: Providers offering home and community-based services must verify that all Personal Care Aides (PCAs) have completed DMAS-compliant 40-hour training programs conducted by an RN. Obtain and file certificates of completion with RN instructor signature, printed name, and date. Non-compliance may result in service denials and reimbursement recapture. - By end of 2025: Ensure all billing staff are aware of Utilization Management (UM) criteria hierarchy used for prior authorization decisions (state/federal requirements → MCG guidelines → Aetna Medicaid Pharmacy Guidelines → LOCUS → ASAM → Aetna CPBs). When requesting prior authorization exceptions, reference the appropriate criteria level. Claims denied without proper UM justification per this hierarchy will not be successfully appealed. - Ongoing: Front desk and scheduling staff should direct members to call Member Services (1-800-279-1878) for community resource referrals, and ensure providers are aware of the Community Resource Directory (CRD) in Availity for creating social determinant of health referrals. Document all referrals appropriately for care coordination tracking.