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This memorandum supersedes the previous February 4, 2020 memorandum entitled, “Revisions to CCC Plus Service Authorization Requirements.” Please use this REVISED version.

The purpose of this memorandum is to inform providers of changes being made to the Commonwealth Coordinated Care Plus (CCC Plus) Service Authorization (SA) processing timeframes.  Beginning February 1, 2020, unless otherwise specified in the CCC Plus Contract (i.e., ARTS or Pharmacy specific requirements), the SA processing timeframes for the CCC Plus will be revised to align with national standards established by the National Committee for Quality Assurance (NCQA) as well as the Medallion 4.0 program. 

This change does not preclude a provider from requesting an expedited review as described in 6.2.10.2 Expedited Authorization Decision Timeframe of the CCC Plus contract and 42 CFR  § 438.210(d)(2).    

Current NCQA service authorization timeliness standards are as follows (days are counted in calendar days):

Urgent requests are requests for medical care or services where application of the timeframe for making non-urgent or non-life threatening care determinations could:

• Seriously jeopardize the life or health of the member or the member’s ability to regain maximum function, based on a prudent layperson’s judgment; or
• Seriously jeopardize the life, health or safety of the member or others, due to the member’s psychological state; or
• In the opinion of a practitioner with knowledge of the member’s medical or behavioral condition, would subject the member to adverse health consequences without the care or treatment that is the subject of the request.

Physical/non-behavioral health and behavioral health care or services to accommodate transitions between inpatient or institutional setting to home/community shall be considered urgent preservice requests.

Non-urgent requests are requests for medical care or services for which application of the time periods for making a decision does not jeopardize the life or health of the member, or the member’s ability to regain maximum function and would not subject the member to severe pain.

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Medicaid Expansion Eligibility Verification

Medicaid coverage for the new expansion adult group began January 1, 2019.  Providers may use the Virginia Medicaid Web Portal and the Medicall audio response systems, as shown in the table below, to verify Medicaid eligibility and managed care enrollment, including for the new adult group.  In the Virginia Medicaid Web Portal, individuals eligible in the Medicaid expansion covered group are shown as “MEDICAID EXP.”  If the individual is enrolled in managed care, the “MEDICAID EXP” segment will be shown as well as the “MED4” (Medallion 4.0) or “CCCP” (CCC Plus) managed care enrollment segment.  Eligibility and managed care enrollment information is also available through the DMAS Medicall eligibility verification system. Additional Medicaid expansion resources for providers are available on the DMAS Medicaid Expansion webpage at:  http://www.dmas.virginia.gov/#/medex.