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The purpose of this memorandum is to notify DMAS enrolled hospital providers that Keystone Peer Review Organization (Kepro) will begin to review inpatient hospital requests when non-resident aliens (NRAs) are admitted to an inpatient status due to a medical emergency. This includes members enrolled in aid categories (AC) 112 and 113.

Emergency Medicaid and Service Authorization (SA)

Effective March 13, 2023, Kepro will begin reviewing inpatient hospital requests for non-resident alien emergency inpatient admissions when the member is in the following aid categories designated for non-resident aliens who require emergency services.

Aid Category 112 Expansion population/Modified adjusted gross income (MAGI) Adults

Aid Category 113 Non-MAGI/ABD/Children

Inpatient hospital providers are to submit their request through Kepro's secure portal, Atrezzo, using service type 0400. Kepro will review the request for emergency hospital admissions. Since inpatient hospital requests are only for emergency services for this population, qualifying admissions must be preceded by treatment and transfer from an Emergency Department (ED) with appropriate physician certification for inpatient services.

For admissions prior to July 1, 2022, providers are to reference the Physician/Practitioners Manual and the Hospital Manual, Chapters 4, in both manuals.

For admissions on and after July 1, 2022, providers must refer to the Emergency Medicaid Non-Resident Alien Supplement.

Hospital to Hospital Transfers

Documentation for transfers will include initial hospital ED records, inpatient admission certification, and discharge note/transfer summary to support that emergent care is still necessary.  Transfers are for treatment that the initial hospital cannot provide, usually a higher level of care.

Grace Period for Providers

From March 13, 2023, through April 30, 2023, Kepro will waive timeliness for the inpatient hospital admission when the aid category is 112 and 113.  This grace period will allow admission dates of service from July 1, 2022 – April 30, 2023 to be submitted without timeliness penalty, as long as the case is submitted by April 30, 2023 in Atrezzo. Kepro’s Atrezzo system is available 24/7 for submission of requests.

The SA grace period will also allow providers to submit SA requests for claims that have denied for edit 155 (procedure requires authorization) for dates of service July 1, 2022 – April 30, 2023 for this population.

Starting May 1, 2023, Kepro will apply timeliness for emergency admissions dated July 1, 2022 and forward. The timeliness rule for all inpatient providers is to submit requests for inpatient services within 24 hours of the admission or on the next business day after the admission, or the case is subject to be denied for timeliness.

Providers can also request SA to DMAS through April 30, 2023 for claims that deny for edit 155 and require authorization. Send a list that includes the provider’s NPI, the member ID number, the ICN, and the date of service to ProviderFocusGroup@dmas.virginia.gov. An authorization number will be issued and returned for providers to submit new claims for processing. DMAS will not accept SA requests for this population on and after May 1, 2023.

Service Authorization and Guarantee of Payment

Please note that service authorization does not guarantee payment for the service; payment is contingent upon passing all edits contained within the claims payment process, the individual’s continued Medicaid eligibility, the provider’s continued Medicaid eligibility, and ongoing medical necessity for the service.

Who to Contact for SA Follow Up

When Kepro reviews the request for SA, providers will contact Kepro for any follow up needed.

When the provider submits the SA request to DMAS on or before April 30, 2023, providers are to contact DMAS for assistance or follow up pertaining to the SA and claims processing.

Starting May 1, 2023 and forward, all requests for SA will be directed to Kepro.