MCCY/MCAW Prior Authorizations

Prior Authorization (PA) of MCCY/MCAW services by SHCN staff is required before services can be initiated and delivered to participants by a MO HealthNet (MHN) enrolled provider. PAs are typically renewed every six (6) months, with changes made as needed (see the ‘Request for Change’ process). Please reference the MHN Provider Manuals and the MCCY & MCAW Guidebooks for additional information on PA requirements. 

General Information

MCCY/MCAW Regions and Coverage

  • MCCY/MCAW is divided into the East and West Regions, as well as Central Office staff
  • Each MCCY/MCAW Regions consist of:
    • 1 Regional Coordinator (RC)
    • 10 Service Coordinators (SC)
    • 3 Facilitators
    • 2 Lead Administrative Support Assistants (LASA)
  • Central Office MCCY/MCAW staff consists of:
    • 1 Program Manager (PM)
    • 1 Senior Public Health Program Specialist (SPHPS)
  • Caseload coverage will be determined and overseen by the East/West RC

Caseload Tracking Spreadsheets

  • Regional caseload tracking spreadsheets will be saved in the ‘Facilitator’ folder
  • Facilitator will maintain the caseload spreadsheet for their region, including information for active MCCY/MCAW participants and new referrals
  • Facilitators will email links to monthly reports during the first week of each month to the SCs, copying the RCs, to compare to their own caseload tracking spreadsheet and/or to follow up on discrepancies 
  • Caseload reports will be saved in the ‘Caseload Reports’ folder in the ‘Facilitator’ folder

Shared Drives and Folder Organization

  • MCCY/MCAW participant records and PA processing information will be saved in the ‘MCCY/MCAW Participants’ folders and the ‘Prior Authorization’ folder of the corresponding Regional Office folders in the MCCY-MCAW Statewide folder, with utilization of folders dependent on your role
    • Regional Offices can choose to maintain MCCY records electronically, while MCAW records MUST be saved electronically in the participant folders for the PM to access for record reviews
    • ‘PA’ folders are working documents and are NOT considered the official record—FINAL documents should be saved in the ‘For Print & File’ folder for the LASAs to save in the participant’s record
  • Regional Office ‘Prior Authorization’ folders will be divided the following four subfolders
    • Facilitator (‘Caseload & Tracking Sheet,’ ‘Caseload Reports,’ ‘Email Templates,’ & ‘For Processing’)
    • Service Coordinator (one folder for each SC with ‘Calculation Sheets,’ ‘PAs’ and ‘POC (485), IOC, etc.’)
    • Signed PAs
    • VCs (‘Email Templates’ and ‘Signed VCs’) 1 August 2025
  • Regional Office ‘MCCY/MCAW Participant’ folders will be divided into the following subfolders for each active and inactive participant:
    • Annual Forms 
    • Assessments (MCCY PDN & PCA Assessments, MCAW Level of Care & Client Assessment)
    • *MCCY Record (only for MCAW participants who transitioned from MCCY)
    • Letters
    • Other
    • PAs, VCs, POC (485), etc.

Maintenance of Participant Records in the Regional Offices

  • All MCCY/MCAW participant records must be maintained in the Regional Offices, according to the Records Management policy
  • Participant records are maintained primarily by the LASAs in the Raytown, Springfield, Jefferson City, Cape Girardeau and St. Louis offices
    • If staff need to print/save documents temporarily as a working process, those documents will be treated as a copy and are NOT considered part of the official participant record
    • Once the working process is completed with the physical documents, they should be shredded and NOT retained as files to ensure there is no confusion on the official record vs. working copies
  • MCCY/MCAW staff are responsible for transferring the participant files to the LASA for printing/filing, either by physical or electronic transfer
  • If staff are unable to physically transfer documents for the participant record in the designated office (i.e. the SC, Facilitator and/or LASA are not located in the same office), staff will use the electronic ‘For Print & File’ folders to transfer documents

    • SCs and/or Facilitators will temporarily save a copy of the participant forms, PAs, assessment tools, legal custody documents, etc. in the ‘For Print & File’ folder of the designated Regional Office

    • LASAs will access the ‘For Print & File’ folder to print and save documents in the participant record, deleting the file from the ‘For Print & File’ folder after completion

East/West Reporting Email Organization

  • MCCY/MCAW East and West Regions each have a reporting email that all LASAs, Facilitators, RCs, SPHPS and PM have access to
  • East/West Reporting emails will be used for provider correspondence and incoming referrals
  • For coverage purposes, staff should redirect providers to email documentation to the East/West Reporting emails if they are receiving information directly to their personal email
  • The following folders should be included in the East/West Reporting emails: VCs, Monitoring Logs and one folder for each office in the Region Wipro
  • MCCY/MCAW PAs will be emailed to Wipro at PriorAuthorization@momed.com for entry into the MHN system (eMOMED/eMMIS) for providers to access and bill for services
  • Only ONE (1) PA can be included in an email to Wipro—if a participant has multiple services, each PA will be emailed separately

Prior Authorization Process

For steps 1-2, please see the ‘VC Template, Instructions & Examples’, ‘Calculation Spreadsheet Instructions & Examples’ & ‘SHCN Date Stamp Template & Adobe Instructions’ resources for details on how to complete a VC, write/calculate specific authorizations and electronically date stamp documents.

  1. Service Coordinator
    1. Determine the participant’s MCCY/MCAW authorization, based on their annual assessment and/or with any justified change to the participant’s authorization noted during ongoing assessment of the participant/family needs during face-to-face home visits and/or via phone if changes arise between scheduled home visits
    2. Calculate the authorization(s) using the current fiscal year (FY) ‘MCCY/MCAW Calculation Spreadsheet’ to determine monthly units, factoring in the number of days per month (FY is from July 1 – June 30 and the calculation sheet is updated according to rate changes that take place annually with the change in FY. The rate changes will only impact the unit calculation for MCAW PCA/APC/WAC services. Adjustments to PAs will be made by Facilitators accordingly after notification of the rate change.)
    3. Name the calculation spreadsheet(s) using the following template and example (provider name and specific effective dates should be clearly outlined in the calculation sheet fields)
      1. Template: ‘Participant last name, participant first name – service type(s) authorized, effective dates of authorization’
      2. Example 1: DOE, Jane – PDN 2.15.2024-6.30.2024
      3. Example 2: DOE, John – PDN, PCA & Supplies 7.1.2024-12.31.2024
      4. Example 3: DOE, Jane – PCA, APC & ARN 1.1.2024-12.31.2024
    4. Save the completed calculation sheet in the ‘Calculation Sheets’ folder of your SC folder

Please see steps 6C. and 6D. for variances in the calculation sheet and VC completion for MCAW supplies and MCCY skilled nurse visit (SNV) PAS.

  1. Service Coordinator 
    1. Complete the ‘MCCY/MCAW Confirmation of Verbal Service Authorization Form’ (VC) initially, annually and/or with any change to the participant’s authorization
    2. Email the VC(s) to the provider agency(ies) using the contact information listed in the MCCY/MCAW Provider Database and the ‘VC Email Template,’ copying the East/West Reporting email and East/West RC
    3. Name the VC using the following template and example
      1. Template: ‘Participant last name, participant first name – type of VC (new enrollment, annual renewal, change, temporary, travel, etc.), provider name, service type(s) authorized, effective date(s) of authorization’
      2. Example 1: DOE, John – Annual VC ABC Homecare PCA, effective 1.1.2024-12.31.2024
      3. Example 2: DOE, John – Change VC XYZ Nursing PDN, effective 2.15.2024
      4. Example 3: DOE, John – Temporary VC ABC Home Care PCA, effective 3.1.2024-3.15.2024
      5. Example 4: DOE, John – Travel VC XYZ Nursing PDN, effective 4.1.2024-4.7.2024
      6. Example 5: DOE, John – New VC ABC Homecare PCA, effective 1.17.2024
    4. Save the completed VC in the ‘VC’ folder of your corresponding RO folder
    5. Enter the VC into MOHSAIC in the ‘Forms/Letters’ screen and include the following information:
      1. Date sent
      2. Provider name 
      3. Authorization
      4. Effective date(s)
        1. For permanent/long-term changes, there will only be a ‘begin’ date
        2. For temporary/short term changes (up to 60 days) that are for a specific period of time, there will be both a ‘begin’ and ‘end’ date

If required documentation is received in your personal email, complete the following steps:  

  1. Forward the email to the East/West Reporting email for proper processing and coverage purposes

And/Or;

  1. IF you are the intended receiver of the required documentation, please process accordingly and redirect the provider agency to send any documents to the East/West Reporting email moving forward using the following language:

‘Thank you for emailing the [required documentation name]. For future submissions, please send any required documentation for MCCY/MCAW participants to the [East/West Reporting email address] to ensure it is processed accordingly and there are no delays due to staff absence.’

Facilitators are responsible for tracking receipt of provider agency’s signed VCs, 485/Plan of Care (POC), invoice of cost (IOC), interim order, PCA PAs, etc. and following up with the provider agency(ies), as needed, to obtain required documentation necessary to complete PAs in a timely manner. Each contact should be documented in MOHSAIC using a ‘Provider Contact’ note to ensure good faith effort (at least three documented attempts) is occurring. If a Facilitator follows up with the provider agency(ies) regarding delayed receipt of information, they should copy the East/West Reporting email.

If the facilitator has received required PA documentation and it is not ready for SC review/approval and/or for the LASA to print/file, the document should be saved in the 'for processing' folder in their respective facilitator folder for their region. Once it has been properly reviewed/processed by the facilitator, it will then be saved in the appropriate folders outlined in the following steps.

  1. LASA
    1. Receive signed VC from the East/West Reporting email
    2. Review the VC to ensure it is signed and dated by provider agency staff
    3. Date stamp the documentation electronically with the date received by the provider agency
    4. Save the VC in the ‘Signed VCs’ subfolder in the ‘VC’ folder of your corresponding Regional Office, renaming the VC using the template and examples above, if necessary
    5. Delete the unsigned version from the folder once the signed copy is saved
    6. If additional supporting documentation is received with the signed VC add a comment (i.e. VC name – interim order included, POC/485 included, etc.) at the end of the document name, as a note to the Facilitator
      1. Facilitator is then responsible for checking the ‘Signed VCs’ folder and processing the additional supporting documents, as well as the signed VC
    7. Mark the VC as ‘Received’ and ‘Signed’ in MOHSAIC in the ‘Forms/Letters’ tab
  2. Facilitator (For step 4, please see the 'Prior Authorization Checklist & POC Examples' resource)
    1. Obtain the signed VC and any other additional supporting documentation saved by the LASA in Step 3. from the ‘Signed VCs’ folder and/or receive the provider agency’s 485/POC, IOC, interim order, PCA PA, calendar, SNV referrals, etc. from the East/West Reporting email
    2. Review the supporting documentation for accuracy and completion, requesting any necessary corrections from the provider (If the documentation is an annual VC and no further action is needed, save the VC in the ‘For Print & File’ folder for the LASA to print and save in the participant’s record)
    3. Date stamp the documentation electronically with the date received by the provider agency, if not already date stamped by the LASA
    4. Name the received supporting documentation using the following template and example
      1. Template: ‘Participant last name, participant first name – type of document, provider name, service type(s) authorized, effective date(s)
      2. Example 1: DOE, John – Interim Order ABC Homecare PCA 2.7.2024
      3. Example 2: DOE, Jane – IOC 123 Supplies 1.1.2024
      4. Example 3: DOE, Jane – POC (485) XYZ Nursing PDN 4.1.2024-5.31.2024
      5. Example 4: DOE, John – SNV Referral XYZ Nursing SNV 1.1.2024-2.29.2024
    5. Save the supporting documentation in the ‘POC (485), IOC, etc.’ folder for the corresponding SC to review and in the ‘For Print & File’ folder for the LASA to print and save in the participant’s record
    6. Enter a ‘Provider Contact’ Progress Note in MOHSAIC stating that the supporting documentation was received and reviewed, using the following template and example
      1. Template: ‘I received and reviewed the [supporting documentation] from [provider agency name] dated [dates of service]. I saved the [supporting documentation] for [SC name], SC, for review and for the LASA to file in the participant’s record.’
      2. Example 1: I received and reviewed the POC/485 from XYZ Nursing dated 1/1/2024 2/29/2024. I saved the POC/485 for Sally Smith, SC, for review and for the LASA to file in the participant’s record.
      3. Example 2: I received and reviewed the IOC from 123 Supplies dated 1/1/2024. I saved the IOC for Sally Smith, SC, for review and for the LASA to file in the participant’s record.
      4. Example 3: I received and reviewed the calendar from ABC Homecare dated 1/1/2024 1/31/2024. I saved the calendar for Sally Smith, SC, for review and for the LASA to file in the participant’s record.
      5. Example 4: I received and reviewed the SNV referral from XYZ Nursing dated 1/1/2024. I saved the SNV referral for Sally Smith, SC, for review and for the LASA to file in the participant’s record.
  3. Service Coordinator
    1. Review the documented medical needs and skilled tasks on the saved 485/POC within ten (10) business days of receipt and saving of the document(s) from the provider agency(ies), as part of the ongoing assessment of the participant’s medical eligibility
    2. Follow up on any discrepancies with the participant/family to further assess the skilled needs and adjust the authorization accordingly, if needed
    3. Enter a ‘Provider Contact’ progress note in MOHSAIC using the following template and example
      1. Template: ‘I received and reviewed the [supporting documentation] from [provider agency name] dated [dates of service].’
      2. Example: I received and reviewed the POC/485 from XYZ Nursing dated 1/1/2024 2/29/2024.
    4. Once reviewed and documented accordingly, the 485/POC(s) can be deleted from the SC folder, as they will be saved in the participant’s record by the LASA
  4. Facilitator
    1. If a PA is due (the start date of the PA should be within the certification period of the 485/POC), use the calculation sheet previously completed and saved by the SC and the supporting documentation from the provider agency to complete and generate the PA from MOHSAIC (see details on processing the various types of PAs for specific services in steps 6A-6D)
    2. If there is not a current calculation sheet that corresponds with the VCs saved, follow up with the SC to request completion and clarification of the authorization(s) before proceeding with completing the PA

(6A) PDN and PPEC Prior Authorization 

  1. Enter the service plans in the ‘Service Plan’ screen in MOHSAIC for each month included in the PA
    1. Only information pertaining to the current authorization should be noted in the ‘Comments’
    2. Do NOT include historical information
  2. Once the service plans are entered, open the last service plan of the PA period and select ‘Prior Authorization Request’
  3. Enter the required information on the ‘PA Request’
    1. For PDN, if there are multiple providers in the home, include the following language in the ‘Detailed Explanation of Medical Necessity’ section: There are multiple providers in the home. The total authorization of [hours/week] should not be exceeded between providers and services should be coordinated accordingly between the agencies.
  4. Select the months included in the period of PA next to the ‘Services’ column and verify that the ‘Approved’ column is selected
  5. Select ‘Print’ once all required fields are completed to generate a PA PDF
  6. Review the PA PDF for accuracy and, if correct, save it in the ‘PA’ subfolder of the assigned SC’s folder for their review and approval, using the following template and example
    1. Template: ‘Participant last name, participant first name – PA, provider name, service type(s) authorized, effective date(s)’
    2. Example: DOE, John – PA XYZ Nursing PDN 1.1.2024-6.30.2024

(6B) MCCY PCA, APC and ARN Prior Authorizations

  1. Review the provider completed PCA, APC and/or ARN PA(s) for accuracy, correcting any information that does not correspond to the calculation sheet, 485 or Physician’s Certification of Need and/or Care Plan
  2. Enter the service plans in the ‘Service Plan’ screen in MOHSAIC for the months included in the PA c) Save the reviewed PA in the ‘PA’ subfolder of the assigned SC’s folder using the following template and example for their review and approval
  3. Template: ‘Participant last name, participant first name – PA, provider name, service type(s) authorized, effective date(s)
  4. Example: DOE, John – PA ABC Home Care PCA 1.1.2024-6.30.2024

(6C) MCAW Supply Authorization

Facilitator

  1. Review the IOC from the provider agency for completion, requesting corrections as needed
  2. Save the IOC in the ‘POC (485), IOC, etc.’ folder for the SC and in the ‘For Print & File’ folder for the LASA, as outlined in Step 4.
  3. Document receipt of the IOC in MOHSAIC, as outlined in Step 4.

Service Coordinator

  1. Review the IOC for accuracy, requesting corrections through the Facilitator, if needed
  2. Update the calculation sheet using the most recent cost of supplies
  3. Save the calculation sheet according to Step 1.

Facilitator

  1. Enter the service plans in the ‘Service Plan’ screen in MOHSAIC for the months included in the PA
  2. Once the service plans are entered, open the last service plan of the PA period and select ‘Prior Authorization Request’ i)
  3. Enter the required information on the ‘PA Request’
  4. Select the months included in the period of PA next to the ‘Services’ column and verify that the ‘Approved’ column is selected
  5. Select ‘Print’ once all required fields are completed to generate a PA PDF
  6. Review the PA PDF for accuracy and, if correct, save it in the ‘PA’ subfolder of the assigned SC’s folder for their review and approval, using the following template and example
    1. Template: ‘Participant last name, participant first name – PA, provider name, service type(s) authorized, effective date(s)’
    2. Example: DOE, John – PA 123 Supplies DME 1.1.2024-6.30.2024

(6D) MCCY Skilled Nurse Visit (SNV)

Facilitator

  1. Receive the SNV referral from the provider agency with Demographics/Face Sheet and doctor’s orders from the East/West Reporting email
  2. Document receipt in MOHSAIC, as outlined in Step 4.
  3. Email the SNV referral information to the SC as a ‘new referral’ (SNV referrals should be included on the caseload tracking spreadsheet in the same manner as PDN/PCA participants, including tracking duration of SNV enrollment to review for necessity of long term SNV. If SNV enrollment exceeds six months, a SCA will need to be completed prior to approval of continued SNV PAs.) 
  4. Enroll the participant in MCCY ‘Service Coordination’ in MOHSAIC

Service Coordinator 

  1. Review the SNV request and approve/deny
  2. Enroll participant in MCCY ‘Paid Services’ in MOHSAIC
  3. Email a VC to the provider agency with the approved SNV(s) authorized, as outlined in Step 2.
  4. Email the Facilitator and LASA notification of approval

LASA

  1. Mail a SNV referral letter and packet including;
    1. Two copies of the Rights and Responsibilities form
      1. 1 must be signed and returned to MCCY by the participant/responsible party
      2. 1 will be stamped with ‘For your information only’ that the participant/responsible party will retain
    2. Two copies of the Expectations for In-Home Services form
      1. 1 must be signed and returned to MCCY by the participant/responsible party
      2. 1 will be stamped with ‘For your information only’ that the participant/responsible party will retain o Addressed SHCN return envelope
    3. SHCN brochure
    4. NEMT brochure 8 August 2025
    5. Enter the forms and letter as ‘sent’ into the ‘Forms/Letters’ screen in MOHSAIC
    6. Once the forms have been signed and returned, enter the ‘Received’ and ‘Reviewed’ dates in MOHSAIC and mark the forms as ‘signed’
    7. File the forms and letters in the participant record

Facilitator 

  1. Receive the agency’s POC/485 and SNV PA from the East/West Reporting email
  2. Review the POC/485 and SNV PA for accuracy and completion, requesting corrections as needed
  3. Document receipt of the POC/485 and SNV PA in MOHSAIC, as outlined in Step 4.
  4. Enter the service plans in MOHSAIC
  5. Save the POC/485 and SNV PA in the ‘PA’ folder for the SC using the below template and example
    1. Template: ‘Participant last name, participant first name –PA, provider name, service type(s) authorized, effective date(s)’
    2. Example 1: DOE, John – PA XYZ Nursing SNV 1.1.2024-2.25.2024

Service Coordinator 

  1. Review the POC/485 and SNV PA, requesting corrections as needed
  2. Approve the SNV PA and save in the ‘Signed PAs’ folder, as outlined in Step 7.
  3. Document approval in MOHSAIC, as outlined in Step 7.

Facilitator 

  1. Review the approved PA and email to Wipro for entry into eMOMED, as outlined in Step 8.
  2. Save in the ‘For Print & File’ folder for the LASA to print and save in the participant’s record
  3. Close the enrollment in MOHSAIC 30 days after that last date of service (delay in closure is to ensure additional visits are not requested and no closure letter is sent to the participant/family, as there is with other services)

7. Service Coordinator 

  1. Review the PA and supporting documentation, completing any corrections and/or following up with the Facilitator, depending on the needed correction
  2. Once the PA is accurate, sign the PA using the electronic signature with your full name and RN credentials in the ‘Reviewed by Signature’ field of the PA and date it the day of approval below your RN signature
  3. Save the approved PA in the ‘Signed PAs’ folder of the corresponding Regional Office, without renaming the document to continue to follow the template for naming PAs, as outlined in Step 6.
  4. Enter a ‘Prior Authorization’ Progress Note in MOHSAIC using the following template and example
    1. Template: ‘I reviewed the [supporting documentation] from [provider agency] dated [date] and approved the PA for [service], effective [PA date range]. I saved the approved PA for [Facilitator name], Facilitator, for processing.’
    2. Example 1: I reviewed the POC/485 from XYZ Nursing dated 1/1/2024-2/29/2024 and approved the PA for PDN, effective 1/1/2024-6/30/2024. I saved the approved PA for John Smith, Facilitator, for processing.
    3. Example 2: I reviewed the POC and Physician’s Certification of need from ABC Homecare dated 1/1/2024-6/30/2024 and approved the PA for PCA, effective 1/1/2024-6/30/2024. I saved the approved PA for John Smith, Facilitator, for processing. 9 August 2025
    4. Example 3: I reviewed the IOC from 123 Supplies dated 1/1/2024-6/30/2024 and approved the PA for supplies, effective 1/1/2024-6/30/2024. I saved the approved PA for John Smith, Facilitator, for processing.
    5. Example 4: I reviewed the POC/485 from XYZ Nursing dated 1/1/2024-2/29/2024 and approved the PA for SNV, effective 1/1/2024-2/29/2024. I saved the approved PA for John Smith, Facilitator, for processing.

8. Facilitator 

  1. Review the approved PA from the SC
  2. Email PAs to Wipro for entry, using the PA email templates
  3. Save the PA(s) in the ‘For Print & File’ folder for the LASA to print and file in the participant’s record
  4. Enter a ‘Prior Authorization’ Progress Note in MOHSAIC using the following template(s) and example(s)

Template 1 (individual PA processed): ‘I emailed the approved PA for [service] provided through [provider name] dated [dates of service] to Wipro and saved for the LASA to file in the participant’s record.’

  • Example 1: I emailed the approved PA for PDN provided through XYZ Nursing dated 1/1/2024 6/30/2024 to Wipro and saved for the LASA to file in the participant’s record.
  • Example 2: I emailed the approved PA for PCA provided through ABC Homecare dated 7/1/2024 12/31/2024 to Wipro and saved for the LASA to file in the participant’s record.
  • Example 3: I emailed the approved PA for supplies provided through 123 Supplies dated 1/1/2024-6/30/2024 to Wipro and saved for the LASA to file the participant’s record.

Template 2 (multiple PAs processed): I emailed the following approved PAs to Wipro, dated [dates of service], and saved for the LASA to file in the participant’s record:

  • Service: [service name(s)]
  • Provider: [provider name]
  • *Repeat the services and providers accordingly*

Example (multiple PAs processed): I emailed the following approved PAs to Wipro, dated 1/1/2024-6/30/2024, and saved for the LASA to file in the participant’s record:

  • Service: PDN 
  • Provider: XYZ Nursing 
  • Service: PCA, APC, WAC and ARN 
  • Provider: ABC Homecare 
  • Service: DME supplies 
  • Provider: 123 Supplies

Facilitator 

  1. Monitor eMOMED for timely entry of PAs
  2. If PA is not entered within 10 business days and/or there is an error noted that is causing the provider to be unable to bill for services, notify the MCCY/MCAW SPHPS via email of the issue for follow up with MHN or Wipro staff.