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Care & Service Coordination

Posted May 22, 20242 min Read

Payment & Reimbursement

FSSA statement clarifying the PathWays prior authorization policy for skilled nursing facility admissions:

PathWays NF Providers and MCEs–

Upon review of prior documentation issued by the state and in acknowledgement of the many changes and challenges providers and MCEs face with any new program launch, OMPP has made the decision to remove short-term prior authorization requirements from the PathWays scope of work for skilled nursing facility (NF) stays for the first year of the PathWays program.

The nursing facility level of care (LOC) will serve as the prior authorization to qualify a nursing facility stay. Skilled nursing services are ordered by a physician and are required to be provided on a daily basis, essentially seven (7) days a week. The primary objective of the LOC assessment is to determine if an individual meets NF LOC criteria as set forth in Indiana Administrative Code at 405 IAC 1-3-1 and 405 IAC 1-3-2. To qualify for skilled short-term LOC, documentation of medical necessity for increased intensity of skilled services must be noted in the physician’s orders, progress notes, and nurse’s notes. When this level of intensity for skilled services is no longer required, it is the responsibility of the nursing facility to re-assess member for long-term NF LOCC. Possible outcomes for a LOC assessment include the following:
• Approved for short-term NF stay (30, 60, 90, or 120 calendar days)
• Approved for long-term NF stay (more than 120 days)
• Denied NF stay
MCEs are still responsible for the ongoing management of a member’s care and discharge planning.

OMPP plans to continue to work in the coming months on future policy updates regarding prior authorization requests for skilled short-term stays. This policy update will apply to all managed Medicaid programs including Healthy Indiana Plan, Hoosier Healthwise, Hoosier Care Connect, PathWays, as well as for fee-for-service Medicaid. OMPP will share more information on NF policy revisions in the coming months. Considering the variance presented in the December 2023 Medicaid forecast, the agency, in partnership with the legislature, will work to ensure all enacted policies ensure the long-term sustainability of the Medicaid program. We look forward to working with MCEs and providers to ensure we execute on this shared goal.


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