MCCY/MCAW RFC Process

1. Service Coordinator

   1. Identify a change needed to a participant’s MCCY/MCAW authorization (i.e. discontinuation, temporary increase, change in authorized services, change in providers, etc.), based on changes in the participant’s skilled needs and/or caregiver availability
   2. Document all pertinent information related to the reason for the change in the authorization by entering a ‘Participant Contact’ and/or ‘Provider Contact’ progress note in MOHSAIC 

   Please see steps 1A. - 1C. for variances in the RFC processing that are identified and/or initiated by sources other than the participant/family and/or SC.

1A. Provider Agency Calendar Review

Facilitator

1. Receive the calendar review request from the provider agency from the East/West Reporting email
2. Enter a ‘Provider Contact’ Progress Note in MOHSAIC, as outlined in Step 5f.
3. Review the calendar for accuracy and completion
4. Generate a RFC as outlined in Step 5g-l.
5. Save the calendar and RFC in the assigned SC’s ‘PA’ folder for review, as outlined in Step 5m.

Service Coordinator

6. Review the hours and units served by the provider agency on the calendar to assess if the authorization has been utilized appropriately
7. Approve/deny the request and adjust the authorized units/month using the current MCCY/MCAW Calculation Spreadsheet, based on the weekly hours authorized, if the authorization has been utilized appropriately
8. Complete the RFC for the approved units, as outlined in Step 5n.
9. Sign, date and save the RFC, as outlined in Step 6.

Facilitator

10. Update the units or dollars in the service plans in the ‘Service Plan’ screen in MOHSAIC for each month included in the RFC, as outlined in Step 5o.

1B. Wipro Entry Errors

Facilitator

1. When an entry error is noted by MCCY/MCAW and/or provider agency staff, notify the SPHPS via email of the error

Senior Public Health Program Specialist

2. Email the identified MHN contact with the entry error and outline the requested correction, including an attached RFC, if applicable

1C. New Fiscal Year MCAW WAC Adjustments

Facilitator

1. When notification is received via email from the PM and/or SPHPS that the rates have been updated on the MCCY/MCAW calculation spreadsheet for the new FY, review all MCAW PCA/APC/ARN/WAC authorizations, as the state plan PCA maximum will be adjusted each year, based on the nursing home cost cap, and impact the authorized units
2. Recalculate the MCAW PCA/APC/ARN units using the updated spreadsheet
3. Save the calculation spreadsheet in the ‘Calculation Spreadsheet’ folder for the assigned SC
4. Complete a RFC to adjust the PCA/APC/ARN/WAC and/or a new WAC PA, as outlined in the RFC Process & PA Process
5. Service Coordinator 
   1. Update the participant’s calculation sheet for the authorization(s) using the current fiscal year (FY) ‘MCCY/MCAW Calculation Spreadsheet,’ based on the effective date of the change or last DOS
   2. Save the updated calculation sheet in the ‘Calculation Sheets’ folder of your SC folder, continuing to follow the naming template outlined in the PA Process
6. Service Coordinator
   1. If the RFC is being completed due to a change in the participant’s authorized services and/or selected provider agencies, complete the MCCY/MCAW Confirmation of Verbal Service Authorization Form’ (VC) for all changes to a participant’s authorized services 
      (RFCs in steps 1A. – 1C. do NOT require completion of a VC)
   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
      • If services are being discontinued, request the last date of service (DOS) in the VC email, as this will be the date used to adjust the authorization
      • If the discontinuation of services is due to the participant’s closure from the MCCY/MCAW Program, the participant’s enrollment will need to be closed in MOHSAIC according to the guidelines outlined in the PDN and PCA policies and a closure letter will be mailed to the participant/responsible party
   3. Name the VC using the following template and example
      • Template: ‘Participant last name, participant first name – type of VC (change, temporary, discontinuation, etc.), provider name, service type(s) authorized, effective date(s) of authorization’
      • Example 1: DOE, John – Change VC XYZ Nursing PDN, effective 2.15.2024
      • Example 2: DOE, John – Temporary VC ABC Home Care PCA, effective 3.1.2024-3.15.2024
      • Example 3: DOE, John – Discontinue VC ABC Home Care PCA, effective 3.17.2024
   4. Save the completed VC in the ‘VC’ folder of your corresponding RO folder
7. Enter the VC into MOHSAIC in the ‘Forms/Letters’ screen and include the following information:
   • Date sent
     • Provider name
     • Authorization
     • Effective date(s)
       • For permanent/long-term changes, there will only be a ‘begin’ date
       • 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
8. 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. If additional supporting documentation is received with the signed VC add a note (i.e. VC name – interim order included, POC/485 included, etc.) at the end of the document name, as a note to the Facilitator
      • Facilitator is then responsible for checking the ‘Signed VCs’ folder and processing the additional supporting documents, as well as the signed VC
   6. Mark the VC as ‘Received’ and ‘Signed’ in MOHSAIC in the ‘Forms/Letters’ tab
9. Facilitator
   1. Obtain the signed VC and any other additional supporting documentation saved by the LASA in Step 4. 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
   3. Date stamp the documentation electronically with the date received by the provider agency, if not already date stamped by the LASA
   4. 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 
   5. Name the received supporting documentation using the following template and example
      • Template: ‘Participant last name, participant first name – type of document, provider name, service type(s) authorized, effective date(s)’ 
      • Example 1: DOE, John – Interim Order ABC Homecare PCA 2.7.2024
   6. Enter a ‘Provider Contact’ Progress Note in MOHSAIC stating that the supporting documentation was received and reviewed, using the following template and example
      • 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.’
      • Example 1: I received and reviewed the interim order 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. 
      • Example 2: 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.
   7. Log into eMOMED
   8. Select ‘eMMIS’ then ‘eMMIS Gateway’
10. Select ‘Prior Authorization’
11. Select ‘Inquiry’ under ‘Action Code,’ enter the PA number and/or the Participant DCN then select ‘Submit’ to search for the PA
12. Select the PA number for the corresponding PA being changed 
13. Once the PA is generated, right click and select ‘Print’ the change the ‘destination’ to ‘Save as PDF’
14. Save the printed PA in the ‘For Processing’ subfolder of the Facilitator folder using the following template and example 
    • Template: ‘Participant last name, participant first name – RFC, provider name, service type(s) authorized, effective date(s)’ 
      • Example: DOE, John – RFC XYZ Nursing PDN 1.1.2024-2.15.2024

All steps can be completed electronically using Adobe tools & there is no need to print/scan documents to complete RFCs. Please see Adobe Resources for more information & training on how to use these tools. 

7. Complete the RFC by noting the corrected months and units or dollars on the printed PA, by following the below steps

   • Start at the month of the change and circle each affected line (each month will typically be listed as Line 1-6) 
     • Cross out ‘units requested’ and ‘units authorized’ then enter the updated units to the right of the previous units for PDN, PCA, APC, WAC & ARN PAs
     • Cross out ‘dollars requested’ and ‘dollars authorized’ then enter the updated dollar amount to the right of the previous units for MCAW supply authorizations
     • Cross out and update ‘authorized thru’ date in the same manner as the units, if applicable—the date entered should be the day AFTER the change was complete to ensure the provider can bill for the last DOS (i.e. services ended 1/1/2024, the ‘thru’ date will be 1/2/2024)
   • Save the printed PA in the ‘PA’ subfolder of the assigned SC’s folder without renaming the document to continue to follow the template for naming RFCs, as outlined in Step 5m.
   1. Update the units or dollars in the service plans in the ‘Service Plan’ screen in MOHSAIC for each month included in the RFC, including a note with the effective date of the change 

   (i.e. Effective 1/1/2024, discontinue authorized PDN. AB.) 

8. Service Coordinator
   1. Review the RFC and supporting documentation, completing any corrections and/or following up with the Facilitator, depending on the needed correction
   2. Once the RFC is accurate, sign the RFC using the electronic signature with your full name and RN credentials in the upper right corner of Page 1 of the RFC and date it the day of approval below your RN signature
9. Save the approved RFC in the ‘Signed PA’s folder of the corresponding Regional Office, without renaming the document to continue to follow the template for naming PAs, as outlined in Step 5.
10. Enter a ‘Prior Authorization’ Progress Note in MOHSAIC using the following template and example
    • Template: ‘I reviewed the [supporting documentation] from [provider agency] dated [date] and approved the RFC for [service] to [changes made to authorization], effective [RFC effective date/date range]. I saved the approved RFC for [Facilitator name], Facilitator, for processing.’
    • Example 1: I reviewed the interim order dated 2/15/2024 and approved the RFC for PDN to increase the authorization from 50 hours/week to 75 hours/week, effective 2/15/2024. I saved the approved RFC for John Smith, Facilitator, for processing. 
    • Example 2: I reviewed the signed VC from ABC Homecare dated 1/23/2024 and approved the RFC to discontinue PCA, effective 1/22/2024. I saved the approved RFC for John Smith, Facilitator, for processing.
    • Example 3: I reviewed the IOC from 123 Supplies dated 1/1/2024-6/30/2024 and approved the RFC for supplies to increase the authorization from 1 box of gloves/month to 2 boxes of gloves/month, effective 3/1/2024. I saved the approved RFC for John Smith, Facilitator, for processing.
11. Facilitator
    1. Review the approved RFC from the SC
    2. Email RFCs to Wipro for entry, using the PA email templates
    3. Save the RFC(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 RFC processed): ‘I emailed the approved RFC 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 RFC 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 RFC 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 RFC 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 RFCs processed): 

  I emailed the following approved RFCs 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 RFCs processed): 

  I emailed the following approved RFCs 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 

8. Facilitator
   1. Monitor eMOMED for timely entry of RFCs
   2. If RFC 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.