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The purpose of this bulletin is to notify all providers that through a competitive procurement process, the Department of Medical Assistance Services (DMAS) has awarded the new Service Authorization and Specialty Services Contract for Medicaid fee-for-service (FFS) behavioral health and medical service authorization (SA) processing to Keystone Peer Review Organization, Inc. (Kepro).  The Service Authorization and Specialty Services contract includes processing for behavioral health and medical service authorizations and registrations, currently conducted through existing Magellan Behavioral Health Services Administrator (BHSA) and Kepro contracts.

Kepro will also implement and staff a crisis call center, a member and provider call center, and transition coordination for members moving back and forth between FFS and managed care plans and additional programs for medical and behavioral service authorization.    

Registrations and service authorizations for services managed by the Medicaid Managed Care Organizations (MCOs) for individuals in managed care will continue to be managed by the MCOs.

Kepro Introduction

Kepro was founded by physicians and has been providing an array of service authorizations and specialty services programs to State Medicaid agencies and their most vulnerable populations nationwide since 1992.

Kepro is accredited by the Utilization Review Accreditation Commission (URAC) for Health Utilization Management, Case Management, and Disease Management and as an Independent Review Organization - Internal & External. Kepro has maintained Health Utilization Management certification continuously for more than 15 years and will continue maintaining this accreditation going forward.

Kepro has supported Medicaid agencies nationally with clinical expertise and successful program operations for 30 years and has worked with DMAS since 2006. Kepro’s combination of national service authorization experience, deep clinical knowledge of both physical and behavioral health care, and proven program results will continue to benefit Virginia’s Medicaid members and providers well.

Keeping Current Vendors in Place During Implementation of the Service Authorization and Specialty Services Contract

DMAS is working with Kepro to implement the new Service Authorization (SA) and Specialty Services Contract on November 1, 2023. While DMAS is working with Kepro on the Service Authorization and Specialty Services contract, the existing contracts with Kepro and Magellan BHSA have been extended to October 31, 2023. When the SA and Specialty Services contract goes live November 1, 2023 the current Magellan BHSA and Kepro contracts will be terminated. Future memos and email blasts will be posted to prepare providers during this transition process.

Impacts of Contract Award for Behavioral Health Services

The new SA and Specialty Services Contract will realign the following processes for behavioral health services currently managed by Magellan BHSA.

Behavioral Health Claims Processing

DMAS is transitioning behavioral health claims processing from Magellan BHSA to DMAS’s Fiscal Agent Solution (FAS), Conduent, formerly known as Virginia Medicaid Management Information System (VAMMIS), for ongoing claims processing. Claims for behavioral health services will be submitted and processed at Conduent beginning November 1, 2023. Conduent will have the most recent three (3) years of claims on file in their system.  Behavioral health providers will receive additional instructions and training  on the process for submitting claims to Conduent. The overall process for claims processing will not change for FFS claims. Conduent will be the point of contact for all FFS claims-related questions starting on and after November 1, 2023.

Behavioral Health Service Authorization

Conduent will begin generating behavioral health service authorization notifications beginning November 1, 2023. The most recent three (3) years of service authorization approvals and denials will be on file in Conduent’s system on November 1, 2023. Behavioral health providers will receive the official authorization notification status letter and service authorization number from Conduent. Providers will have access through Medicaid Enterprise System (MES) to review authorizations in Conduent’s FAS system. Training will be provided on this process.

When the behavioral health service authorization end date is prior to November 1, 2023, providers are to submit the continued stay review request to Magellan BHSA.

When the behavioral health service authorization end date is on or after November 1, 2023, providers are to submit concurrent review requests to Kepro.

When the behavioral health service authorization initiated by Magellan BHSA ends on or after November 1, 2023, Kepro will honor the approved Magellan BHSA service authorization. No action is necessary from the provider unless a concurrent review is required. Within two (2) weeks of the authorization end date, providers are to submit their request to Kepro on or after November 1, 2023.

Behavioral Health Registration

Service registration is a means of notification to Kepro that a Medicaid member will be receiving behavioral health services. The purpose of registration is for avoiding duplication of services and ensuring informed care coordination. As a reminder, providers must submit a registration request prior to the start of any new service or within two (2) business days of the service start date.

Table 1 below represents Behavioral Health and ARTS services that require registration.  (This information is not new, but serves as a reminder of DMAS requirements.)

Table 1 – BH and ARTS services requiring registration

Kepro‘s Atrezzo Next Generation (ANG) system and its secure provider portal support automated web-based Service Registration and tracks all services that the member receives throughout the member’s continuum of care. The Service Registration request form will be easily configurable in Kepro’s system during implementation and available to providers prior to the start of the contract for provider training purposes.

When the behavioral health service registration end date is prior to November 1, 2023, providers are to submit the concurrent review request, if appropriate, to Magellan BHSA.

When the behavioral health service registration dates initiated by Magellan BHSA crosses over November 1, 2023, Kepro will honor the Magellan BHSA service registration. No action is necessary from the provider unless a concurrent review is required. Within two (2) weeks of the registration end date, providers are to submit their concurrent review request to Kepro.

When the behavioral health service registration end date is on or after November 1, 2023, providers are to submit the registration requests to Kepro.

Kepro will honor Magellan BHSA registrations and service authorizations.

Behavioral Health Provider Network

The Behavioral Health provider network will continue to be managed by Gainwell Technologies and providers will continue to utilize the Provider Services Solution Portal (PRSS) for all provider related transactions. 

New Medical Services Added

Kepro will begin accepting requests on November 1, 2023 for these newly added medical services:

• Baby Care Program
• Continuous Glucose Monitoring
• EPSDT Private Duty Nursing
• Out of State Imaging
• Genetic Testing
• Emergency Services for Non-Resident Aliens (NRA)

Information and instructions on how to request these new medical services starting November 1, 2023, will be presented by Kepro.

For all other medical services that Kepro reviews today, there are no changes.

Training Opportunities

Kepro will provide training for providers on how to register and access their secure Atrezzo Next Generation (ANG) portal to submit requests for SA and Registration. Training will also be provided for all programs included in the Service Authorization and Specialty Services contract. Please be on the look-out for these training sessions in upcoming bulletins and on Kepro’s website.  Some trainings will be live, and some will be recorded. Attendance is strongly encouraged for successful submission of SA requests and Registration services.

Provider Enrollment – for all providers

Newly enrolling providers should refer to the DMAS memorandum dated March 18, 2022 for enrollment instructions on the Provider Services Solution Portal, and various online provider enrollment resources.  

All providers are required by federal regulations to enroll in the MES Provider Services Solution (PRSS), DMAS’s Provider Enrollment Solution, before they are able to submit service requests to Kepro.  It is extremely important for behavioral health providers to enroll in PRSS. Kepro will import provider information from the PRSS into ANG. Providers not enrolled in PRSS will not have their provider information imported to Kepro which may cause a delay in gaining service authorization resulting in an interruption with continuity of care. 

Both existing and new providers can obtain information in the March 18, 2022 DMAS memorandum on how to register for portal access, enroll, and how to update existing enrollment profiles.