MFAW Guidebook


Authorization of Services

Authorization of services by SHCN staff signifies that the service is medically necessary but is not a guarantee of payment. Requests for services requiring prior authorization must be accompanied by documentation demonstrating medical necessity (e.g., physician orders or certification of need). Based on the information obtained during the SHCN assessment of the participant, the frequency, amount, and duration of services are determined and indicated on the PA document. SHCN only prior authorizes those services that are required to educate the participant, parent(s), and/or responsible party(ies) in the medically necessary care of the participant or to provide the needed care to stabilize/maintain the participant’s condition. Reimbursement of authorized services requires the submission of the PA document signifying the SHCN authorization for the delivery of all MFAW services. A PA request form must be submitted to MO HealthNet Division Fiscal Agent for data entry.   

SHCN SC has the responsibility to determine medical necessity and prior authorize the following services:

  • Private Duty Nursing (PDN)
  • Personal Care Aide (PCA)
  • Advanced Personal Care Aide (APCA)
  • Waiver Attendant Care (WAC)
  • Authorized Registered Nurse Visit (ARN) if PC Aide/APC Aide services are authorized with a different service provider than the one authorized for PDN service delivery.
  • Durable Medical Equipment (DME) Supplies

Initial of Prior Authorization

All the PA forms are created and completed in the SHCN Regional Office. Upon receipt of the required forms from the service provider, the Facilitator and SC will review for accuracy and appropriate content. The Facilitator shall complete the PA Request Form for the authorized services. Upon completion, the SC will review for accuracy, then sign and date the PA indicating approval. PDN services may not be authorized for longer than a six month period. The service provider agencies are responsible for submitting the paperwork identified below to the SHCN Regional Office for the PA to be created by the SC and/or Facilitator.   

  • PDN Services (including those with both PDN and PCA services in the home) – the provider agency submits the Plan of Care (i.e., 485) with the correct Start of Care and certification dates.
  • PCA, APCA, WAC, and ARN Services (If authorized by a different provider agency than the one providing PDN services) – the provider agency submits the Plan of Care and Physician Orders/Certification of Need documentation for processing.
  • DME Supplies – The service provider submits a copy of the invoice of supplies with the wholesale cost of the product clearly identified.    
  • On the PA, there are different procedure codes/modifiers (sections 17 and 18) for each type of service being authorized and it is imperative that the correct code and modifier are entered on the PA. The codes and modifiers are as follows:
    • PDN – T1000 with modifier U5
    • PCA – T1019 with modifier EP
    • APCA – T1019 with two modifiers TF/EP
    • WAC – S5125 with modifier U5
    • ARN – T1001 with modifier EP
    • DME Supplies – T2028 with modifier U5NU
  • The From and Through dates on the PA (sections 19 and 20) represent the days of each month being covered by the authorization. Each Line is to be designated for a separate month and the authorization cannot be more than six months.
  • There are two places in which the types of services being authorized are indicated on the PA. In section 21, a general description of the services authorized such as “Private Duty Nursing” will be entered. In section 24, a detailed explanation of the services authorized is indicated such as 20 hours/week. The detailed description should match what is written on the VC.
  • The quantity of approved units is indicated in section 22 of the PA.
    • PDN, PCA, APCA and WAC services are authorized in 15-minute units, and calculated by multiplying the total number of hours/week x the number of weeks in the month x 4.
    • ARN services are authorized in visits/month and are calculated by adding the total number of approved visits per month
    • DME supplies are authorized as a dollar amount per month and are calculated by multiplying the cost of each supply x the authorized amount of the supply/month then adding the total of all calculated supplies and multiplying by 1.2% to obtain the total dollars per month
  • Part IV “Provider” section on the PA indicates which service agency has been authorized to provide the services for the participant. Please note that all provider agencies have a NPI number that must be included and at times there is a Taxonomy number that must also be included. The Facilitator is responsible for maintaining an up to date list of this information.
  • Part V “Prescribing/Performing Practitioner” section of the PA indicated that Physician’s name and address. Lines #32 - #35 may be left blank in this section. The physician’s signature is not required on this form.
  • At the bottom of the PA, in the section stating “If approved: services authorized to begin”, the date written in must be the same as the initial “From” date indicated on Line #1 section 19.
  • The SC demonstrates approval by placing a check mark in the ‘Approved’ column corresponding to each service line item in column 16. The PA must be signed by the SC with their credentials written behind their signature along with the date that it is signed. The SC’s dated signature indicates that the PA has been reviewed/approved for accuracy regarding the authorization of services to
  • be provided and total number of service units allowable for the designed timeframe.
  • At the top of the PA form, the code “PT 10” should be written to indicate that it is a MFAW PA.
  • The Facilitator completes a final review of all PA related documentation for accuracy to ensure all requirements are met and emails the PA the Department of Social Services, MO HealthNet Division Fiscal Agent to assure accurate provider reimbursement. A copy of the PA is kept in the participant’s file.

Program Manager (PM) Change Requests

A PM change request is completed for a variety of reasons which include, but are not limited to:

  • Any change in authorized PDN, PCA, APC, WAC and/or ARN services
  • The authorization for services exceeds 112 hours/week, including PRN hours
    • PM Change Requests are not required for the addition of PRN hours that are authorized solely to be shared between multiple providers for shift coverage purposes and worded as such that the overall authorization should not be exceeded between the providers
    • If a participant’s authorization exceeds 112 hours/week, a PM Change Request must be approved annually at the time of the participant’s SCA
  • Increases in supply authorizations
    • Decreases in supplies, provider and/or packaging changes, general cost increases and supply size, brand and/or type changes that are not a result of a change in the SC authorized supplies do not require a PM Change Request
  • DME item is requested aside from gloves, diapers, and chuxs.

The SC completes all the sections of the PM Change Request form and submits it to the RC. The RC assigns it to another SC for peer review, as needed. The PM Change Request is then returned to the RC for review and recommendations. The RC will send the PM change request to the MFAW PM and copy the Associate Bureau Chief for review and approval.  When applicable, the original PM Change Request form will be used to complete required updates for re-approval. Re-approval to continue the current authorization should only be submitted annually at the time of the SCA visit. The information on the new addendum will be designated by documenting in a different color corresponding to the date of the new request. Every addendum submitted must address each section of the document.

Continuation of Prior Authorizations

The re-certification of prior authorized services is done at least six months (or more frequently if needed) and is completed using the same steps indicated above. The provider agency must submit a new Plan of Care/485 with applicable interim physician orders up to four weeks in advance of expiration of the previous PA Request to ensure continuity of care for the participant provided the following criteria are met:

  • The start date of the next PA must be encompassed within the certification dates on the Plan of Care/485
  • The Plan of Care/485 must be updated to document continued medical necessity

If, at any time, the SC requires further information to determine a continuation of a PA, the SC is allowed to request any of the following documents from the provider agency: Participant's progress, prognosis, or summary, a verbal report of known facts by the provider, or a 30/60 day summary.

Services are Changed, Reduced, Terminated or Denied

Changes in authorizations may occur for a variety of reasons including, but not limited to:

  • A change in the level of care required for the participant,
  • Not utilizing hours previously authorized,
  • Family requests a change in services authorized,
  • Not following program requirements, responding to contact attempts by the SC, or attending home visits as scheduled,
  • The participant moves out of state,
  • The participant no longer qualifies for MFAW services,
  • Services are requested but the participant does not qualify due to lack of medical eligibility, or
  • No present need for SHCN services due to availability of a caregiver.

When a change to the active authorization is needed, the participant, parent(s), and/or responsible party(ies)must be fully informed by the SC prior to any action taken. Any planned change in services should be documented by the SC in the SHCN Information System. Documentation should reflect the participant, parent(s), and/or responsible party(ies)understanding of planned services. A face-to-face assessment is required when any SHCN action adversely affects the request for, or amount of, authorized services unless this action is initiated by the family.

Written Notification of 10 Calendar Days

SHCN shall provide notice at least 10 calendar days prior to the expected change in service even if the participant, parent(s), and/or responsible party(ies)is in agreement by sending a letter using the Denial/Reduction/Change letter template and identifying the appropriate reason for the authorization change. The 10 calendar day period begins the day after the date on the letter and does not include weekends or state holidays. The effective date of the change occurs on the 11th calendar day.

Exceptions to the 10 Calendar Day Rule

The 10 day calendar rule is not in effect when any of the following circumstances occur:

  • SHCN has factual information confirming the death of a participant,
  • SHCN receives a clear written statement signed by a participant, parent(s), and/or responsible party(ies)stating that they no longer want services,
  • The participant has been admitted to an institution where they are eligible under the plan for further services,
  • The participant’s whereabouts are unknown and the post office returns SHCN mail directed to the participant indicating no forwarding address is known,
  • SHCN establishes the fact that the participant has been accepted for Managed Care MO HealthNet coverage.

Cancellation of Authorized Services by a Provider Agency

Service providers are required to give a minimum of 21 days written notice to the participant, parent(s), and/or responsible party(ies), and SHCN prior to the discontinuation services, except in the case of an unsafe environment for the provider staff. The existing provider agency shall continue to provide care in accordance with the plan of care for these 21 days, or until alternate arrangements can be made by SHCN and/or the participant, parent(s), and/or responsible party(ies). The SC will assist the participant, parent(s), and/or responsible party(ies)in making appropriate arrangements to locate and transfer care (if possible and necessary) to a new provider. Reasons the provider may decide to discontinue services may include, but are not limited to:

  • Noncompliance by the participant, parent(s), and/or responsible party(ies)to the agreed upon plan of care,
  • The provider is no longer able to meet the service needs of the participant, or
  • The participant, parent(s), and/or responsible party(ies)requests a change.

The provider shall notify the SHCN within 72 hours of closure of a case due to the following circumstances:

  • Death of the participant,
  • Participant’s admission to a health care facility,
  • If the participant is no longer in need of care, or
  • The environment has become unsafe for the provider staff.

Changing Prior Authorizations

When a change from the initial authorization occurs, a change PA must be completed.  The appropriate number of units requested and authorized are indicated with the corresponding “Requested From and Thru Date” and the “Authorized From and Thru Date” on the Professional Prior Authorization document obtained through eMOMED.  Upon completion of this form, the SC reviews, signs, and dates the change PA indicating approval. The SC is required to document the nature of the change in the SHCN Information System. A changed or corrected PA Request Form (i.e., MO HealthNet Service Screen print from eMOMED) is required when:

  • The amount of authorized units increases or decreases,
  • The participant is discharged from services prior to the end date on the approved PA,
  • The type of service or procedure code is changed,
  • The service dates are changed, or
  • Provider information is changed or corrected.

Upon completion of these steps, the SC assembles a PA change packet that includes the following items:

  • The signed and dated change PA,
  • A copy of the progress note describing the circumstances of the change,
  • A copy of the MFAW calculation spreadsheet to demonstrate how the new values on the change PA were derived,
  • Calendars and/or staffing records/telephony records (as indicated),
  • Interim physician orders regarding the change (as indicated),
  • An updated DME invoice if there is a requested change for supplies, and
  • A copy of the change letter sent to the family (as indicated).

The Facilitator completes a final review of all change PA related documentation for accuracy to ensure all requirements are met and  emails the change PA to the Department of Social Services, MO HealthNet Division Fiscal Agent to assure accurate provider reimbursement. A copy of the change PA is kept in the participant’s file.

Table of Contents

On this page