Requirements for authorization requests
Starting January 1, 2025
For dates of service on/after Jan.1, 2025, the prior authorization requirements for 1915(i) services for home and community services will no longer be required.
1915(i) providers will follow the1915(i) DHHS plan “Home and Community-based Services administration of operation guide located at https://www.hhs.nd.gov/sites/www/files/documents/1915i/ND-24-0017%20Approval.pdf.
Plan of Care and SMART goal requirements
Plan of Care and SMART goal requirement documentation will continue into 2025, to align with the standards outlined by DHHS.
DHHS offer training opportunities to learn about these requirements. Their website https://www.hhs.nd.gov/1915i/trainings keeps a list of recordings and trainings. A few that may be beneficial to you under the “Technical Assistance Calls” section:
- Quality Assurance- Needs, SMART Goals and Services (recording)
- Quality Assurance- Needs, SMART Goals and Services (slides)
Services delivered outside of the administrative guidelines need review for medical necessity prior to administration of services.
Process for January 1, 2024 to December 31, 2024
Once a 1915(i) provider is enrolled with both the DHHS and BCBSND Medicaid Expansion, they will want to ensure they follow the proper steps to submit an authorization/precertification for the service they plan to provide.
This can be done by contacting the BCBSND Medicaid Expansion Customer Contact Center (CCC) for initial instructions on how the authorization process works or referring to the information below.
All 1915(i) services require authorization. This step-by-step process guide will assist providers with how to check if authorization is required, as well as how to submit an authorization for review.
Things to note for precertification/authorization requests:
a. The request should be submitted prior to seeing the member. Retro authorizations are not accepted.
b. Authorizations can only start the date the request is submitted.
- Back dating may occur on an initial plan of care and only for the Care Coordination service, when he initial contact, plan of care completion and authorization submission are within 30 calendar days.
c. The provider’s name on the request should be the agency name, not the individual rendering the service.
d. If the authorization is incomplete and missing information necessary to complete the request, a fax will be sent back to obtain the information to the number listed on the initial authorization request.
e. If you have a question on your request or need the status of your request, call the Utilization Management department by calling 1-800-952-8462.
Plan of Care and SMART goal requirements
Service authorization/precertification requests will not be approved if the plans and goals did not meet the standards outlined by DHHS.
DHHS had offered training opportunities to learn about these changes. Their website https://www.hhs.nd.gov/1915i/trainings keeps a list of recordings and trainings. A few that may be beneficial to you under the “Technical Assistance Calls” section:
- Quality Assurance- Needs, SMART Goals and Services (recording)
- Quality Assurance- Needs, SMART Goals and Services (slides)
Two main items to include in authorizations are:
- An updated plan of care with SMART goals with each new service request. New requests will not be approved without a Plan of Care attached that fully meets the established standard.
- For example, if a new request is submitted for another service provider, a plan of care identifying the current need and goal for that member is required. Please ensure all questions in the SMART goal section are completed for each separate goal identified.
- The Care Coordinator is responsible for the plan of care and will need to work with the accepting agency to provide the plan of care for the request.
- Request for the acknowledgment form and the meeting attendees signature page. These forms need to be submitted with the Plan of Care.
The BCBSND Utilization Management (UM) team will request this information and if it is not received, the case will be canceled, and the provider can resubmit the request when the documentation is acquired. This may mean the start date of care changes.