PAC Waiver

eQHealth Solutions

PAC Waiver Authorization Process

January 2015

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Upon completion of the webinar, participants will be able to:

1. Prepare and submit PAC Waiver Requests for Exception to eQHealth Solutions

2. List the documents that are required to be submitted with PAC Waiver Requests for Exception

3. Interpret the message in the outcome letter that is sent in response to the Request for Exception to determine if the request was approved, denied or if additional documentation must be submitted

4. Identify resources that can be accessed if questions about PAC Waiver Requests arise

Purpose of Presentation

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Introduction to

eQHealth Solutions

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The Florida Agency for Health Care Administration

awarded eQHealth Solutions the contract to provide

comprehensive Medicaid Utilization Management

Services (CMUMP) for services such as inpatient

hospitalization, outpatient therapy services, DME,

home health, and PAC Waiver.

eQHealth Solutions is accredited by the Utilization

Review Accreditation Commission (URAC)

Partnership: AHCA and eQHealth

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Local office/operations address:

5802 Benjamin Center Drive, Suite 105

Tampa, FL 33634

Office Hours: Monday-Friday from 8 am – 5 pm, EST

How to Contact eQHealth Solutions

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Preparing to Submit a

Request for Exception

for PAC Waiver Services

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Case managers must coordinate access to services

through all available funding sources prior to accessing

PAC waiver services. Services cannot be provided

under the PAC waiver if they are available from another

funding source. Other funding sources must be

accessed in this order:

1. Third Party Payers including Medicaid Managed Care

2. Medicare

3. Other Medicaid Programs

4. PAC waiver

Preparing to Submit a Request

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Source: Page 3-2 of the Project AIDS Care Waiver Services Coverage and Limitations Handbook.

Other funding sources may cover such services as:

personal care services (through home health)

restorative massage (through outpatient physical

therapy)

skilled nursing -RN or LPN (through home health)

specialized medical equipment and supplies

(through DME)

management of substance of substance abuse

(through behavioral health)

Preparing to Submit a Request

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Required Documentation for

Request for Exception

for PAC Waiver Services

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Each time a Request for Exception is submitted, the

following documents are required:

1. Request for Exception Form

2. Physician’s prescription

3. Current level of care documentation (Notification of

Level of Care, DOEA-CARES Form 607)

4. Most current social needs assessment

Required Documents

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Source: Page 2-14 of the Project AIDS Care Waiver Services Coverage and Limitations Handbook.

Each time a Request for Exception is submitted, the

following documents are required:

5. Plan of care for the month in which the request is

submitted

6. Itemized cost list and work orders for environmental

accessibility adaptation or specialized medical

equipment and supplies

7. Narrative justification for the request

8. Length of time for which the exception is requested

Required Documents, Continued

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Source: Page 2-14 of the Project AIDS Care Waiver Services Coverage and Limitations Handbook.

1. Request for Exception Form

Required Documents

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2. Physician’s prescription:

Amount (number of units)

Frequency (how many times per week or month)

Duration (number of weeks or months)

The prescription must be signed and dated, and must

be current. Expired prescriptions are not

accepted.

Required Documents

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3. Current level of care documentation (Notification of

Level of Care, DOEA-CARES Form 607)

Required Documents

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Notification of Level of Care DOEA-CARES Form 607

Required Documents

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4. Current Social Needs Assessment

5. Plan of care for the month in which the request is

submitted

Required Documents

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6. Itemized cost list and work orders for environmental

accessibility adaptation or specialized medical

equipment and supplies

Required Documents

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7. Narrative justification for the request

Required Documents

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8. Length of time for which the exception is requested

Required Documents

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How to Submit

a Request for Exception

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1. All required documents must be submitted in PDF

format

2. Submit the request via encrypted email to:

pacwaiver@eqhs.org

3. Put PAC Request (Initials) (Last 4 Digits of the

Medicaid Beneficiary ID number) (Date) in the

Subject line

4. Submit only one request per email

How to Submit a Request

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Interpreting the Outcome

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There are 4 possible outcomes for the Request for

Exception:

1. Approved

2. Partially approved

3. Denied

4. Returned

Outcomes

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1. Approved

All required documentation was submitted

The request matched the prescription

Outcomes

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2. Partially Approved

All required documentation was submitted

There was a discrepancy in the documents.

Examples:

A prescription that expires prior to the “Thru

Date”

A request for services that exceeds 6

months

Outcomes

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3. Denied

All required documents were submitted

The request did not meet the requirements of the

PAC Waiver Handbook

Outcomes

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4. Returned

The request was not reviewed because of

incomplete or insufficient documentation.

Examples:

Expired Notification of Level of Care

Expired prescription

Plan of Care was not submitted

DOEA CARES Form 607 was not submitted

Outcomes

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Returned requests can be resubmitted

when all required documentation is available.

How to Streamline

the Request Process

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1. Submit all required documents with each request.

2. If a request is for continued services, submit all

required documents with the continued service

request, even if they were sent previously.

3. Place all required documents in a single PDF file per

recipient.

4. Submit only one request per email

Streamlining the Request Process

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5. Submit all required documents in a single email

6. Submit the request once; do not send duplicate

requests.

7. Use the pacwaiver@eqhs.org only to submit

requests.

Streamlining the Request Process

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How to Access Assistance

with a Request

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1. Outcomes are typically emailed to case managers

within 5 business days.

2. If you need to obtain the status of a request for

which you have not received an outcome after 5

business days, please contact eQHealth Solutions

Customer Service at our toll free number:

855-444-3747

M-F (except state recognized holidays)

8 a.m. – 5 p.m., Eastern Time

Assistance for Requests

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Questions and Answers

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Thank-you for attending. Your opinion is important to us. Please

complete the survey which will appear on your computer when the webinar ends.

Questions and Answers

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