Providers submit medical, dental, durable medical equipment (DME), Home and Community-Based Services (HCBS) and other types of service authorization (SA) requests to ND MMIS to determine the necessity of services for members enrolled in the ND Medicaid program. You use the SA pages to search, add, and edit SA requests.
Providers can submit authorization requests a number of ways, including through the provider Web portal, X12 278 electronic transactions, and hardcopy by fax or mail. You enter hardcopy authorization requests, received by fax or mail, into ND MMIS manually using the appropriate Service Authorization page for the type of request.
Once an SA request enters ND MMIS, you manage it using the Service Authorization page. On the Service Authorization page, you can address exceptions, update header and line item status, override the location/user assigned to the SA request, and add and view attachments. Attachments can include images of SA letters sent to and received from providers or members, and supplemental documents received from the provider that are related to the SA request.
You can also set up alerts (or reminders) for future events such as an SA expiration. On the date you establish, ND MMIS posts an alert to the appropriate user's My Tasks panel that indicates the reason for the reminder.
During claim adjudication, ND MMIS analyzes each claim received to determine if the service requires an SA. If the claim requires an SA, ND MMIS analyzes the SA records to determine if an approved SA request for the claim exists. Once found, the claim is updated with the approved SA request information. The claim is applied to the SA and the units and dollars remaining on the SA are decreased. The SA request is updated to note each time a claim is applied to an SA line item.
Status codes indicate how ND MMIS is handling the SA request. ND MMIS may assign a status depending on whether or not exceptions are found and what type of exceptions are found.
ND MMIS posts exceptions to an SA request when edits, which are business rules defined by North Dakota to manage SA processing, evaluate the SA request and find discrepancies. These may include the absence of required information or the presence of invalid information. SA exception codes are established in Rules Management on the Service Authorization Exception page.
When an exception associated with a denied status is posted to an SA request, it is processed and the provider/member is notified of the denial. When an exception associated with a pended status is posted to an SA request, ND MMIS does not process the SA request further until you take action to address the exception. To facilitate this, each exception code in the exceptions box on the Service Authorization page links to the resolution text that describes how to address the exception. Once you address the exception, you change the pended status code to approved or denied, as appropriate.
Status codes are posted to the SA request header, which is the overall SA information, and to each line item, which are the individual services submitted on the SA request.
Exceptions that are associated with a pended status are also associated with a location code and in some cases, a specific user name and ID. The location code and the user name and ID represent the business unit and individual responsible for addressing the exception. If you have the appropriate user permissions, you can manually reassign or 'override' a default location or user.
SA Letters are sent to enrolled members and providers to notify them of service authorization status changes, changes to previously approved SA requests, and to request additional information from providers.
You can initiate a manual letter in the Letters & Responses panel on the Service Authorization page. ND MMIS initiates letter generation automatically when certain events occur, including the adjudication of an SA request or a status change to an existing request.
SA letters are generated based on the criteria in the SA Letter Assignment records established in Rules Management on the SA Letter Assignment pages. The SA Letter Assignment record contains the contact information, enclosures, letter template, and send to information used to generate an SA letter.
If the option is selected in the SA Letter Assignment, the additional addressees you add in the Automated Letters panel on the Service Authorization page will receive a copy of the letter.
You can view the images of letters, both automated and manually generated, in the Electronic Document Management System (EDMS). You access the EDMS from the Letters & Responses panel on the Service Authorization add or edit pages.
How to Search for a Service Authorization
How to Add or Edit a Service Authorization Request
Service Authorization Inquiry Page
Service Authorization Detail Page
About Service Authorization Transactions
What Is Service Authorization Exception?
Version as of 5/16/14.
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