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Assessing Eligibility for the North Carolina Medicaid Personal Care Services

Frequently Asked Questions on the Personal Care Services Process

ALSO READ > What To Expect When You Apply For Services.

Q. What is the referral process for PCS?

A. In order for a beneficiary to receive PCS services, the referring physician must completely fill out the DMA referral form and fax it to Liberty Healthcare of NC at 484-434-1571. You will find this form, along with a list of instructions on the Liberty Healthcare of NC website. Click on the "Medicaid PCS" tab and then click on "Medicaid PCS Forms."

Q. Who can make referrals?

A. In most cases, the beneficiary's primary care physician (PCP) should make the referral. If the beneficiary is being discharged from an inpatient facility (hospital, nursing home, rehab facility), the attending physician, hospitalist, nurse practitioner, or physician's assistant may make the referral. In these cases, the case manager or discharge planner should be listed as the contact person on the referral form. If the beneficiary does not have a PCP, he/she should get the referral from the doctor who is treating the health problem that is causing disability.

Q. Can practitioners request a PCS provider/agency?

A. The beneficiary, not the physician, chooses the PCS agency. When a practitioner requests a particular PCS provider on the referral, Liberty will only honor the request if it matches the beneficiary's choice of provider.

Q. Does Liberty Healthcare of NC verify Medicaid eligibility for beneficiaries before sending referrals to PCS providers?

A. Prior to performing an independent assessment, Liberty Healthcare of NC verifies the beneficiary's eligibility for Medicaid programs that cover PCS. Liberty Healthcare of NC does not verify Medicaid eligibility prior to performing an assessment for existing PCS beneficiaries (i.e., beneficiaries who have been receiving PCS and require a Change of Provider, Change of Status, or Annual Review assessment).

It is possible for a beneficiary's Medicaid coverage to lapse in the period of time between when the assessment is completed and when the provider receives a referral to begin PCS. Therefore, Liberty Healthcare of NC and DMA recommend that providers check Medicaid eligibility before beginning services for a newly referred client. Additionally, since a beneficiary's eligibility may change from month to month, providers should consistently check eligibility for existing clients. This will help to avoid billing issues related to lapsed Medicaid eligibility. Beneficiaries who no longer have valid Medicaid coverage for PCS will need to contact their local Department of Social Services (DSS) office for assistance. You can read more information about verifying beneficiary Medicaid eligibility in Section 10, page 47 of the Provider Claims and Billing Guide on the NC Tracks website.

Q. Who do I contact if I want to check a beneficiary's eligibility?

A. To check beneficiary eligibility, please contact Provider Services AVRS system (option 1/ option 1) at 1-800-723-4337. You may also use the NC Tracks Provider Portal; you will locate more information on how to use the portal in Section 10.2 of the Provider Claims and Billing Guide on the NC Tracks website. To check eligibility for claims over 1 year old call 919-855-4045.

Q. What does the eligibility assessment include?

A. Functional Eligibility assessments will be conducted using a standardized process and assessment tool provided and approved by DMA. The assessment will incorporate observation, interview, and beneficiary demonstration of ADLs and associated IADLs, interviews with caregivers, family members or agency/facility staff and review of available records. The assessor may review some or all of the following records:

  • Patient/beneficiary confidentiality statement or agreement
  • Emergency medical release, or HIPAA form
  • Guardianship documents, if applicable
  • Resident admission records
  • FL-2 or MR-2
  • Medications, medication lists or Medication Administration Record (MAR)
  • Physician's orders or medical records provided by the beneficiary
  • Person Centered Plan
  • Service Plan
  • Aide Task List
  • Supervision Notes
  • Any relevant documentation provided by the beneficiary
Instructions are available at: http://www.ncdhhs.gov/dma/pcs/pcs_medical_attestation_Instructions.pdf

When To Start Services

Q. How do PCS providers know when to start services for a client?

A. Liberty Healthcare of NC will send a referral letter to the client's chosen provider after the IA has been completed and processed. The referral letter will inform providers of the effective date of the authorized hours. This information can be found near the bottom of the page. The provider has two business days to either accept or decline the referral. Providers who are using the Provider Interface of QiReport should accept the referral electronically, instead of by fax.

Providers accepting clients who have been authorized for PCS services will also receive a "Notice of Decision on Initial Request for Medicaid Services" (for new referrals), a "Notice of Decision on a Continuing Request for Medicaid Services" (for clients who previously received PCS services), or a "Notice of Change in Services" (for clients who previously received PCS services and are authorized for a reduced number of hours after the most recent assessment). The letter will indicate the final number of authorized hours for a particular client. Providers should begin services for a client based on the effective date noted in this letter, not in the referral letter.

Q. The agency acceptance letter from Liberty indicates "The effective date of this beneficiary's PCS authorization will be 10 days from the date of the notice of service authorization." Does this mean 10 business days or 10 calendar days?

A. Ten (10) calendar days.

Q. When will my client begin receiving hours after a complete assessment?

A. If a beneficiary selects your agency as their provider, you will receive a "referral notice", which contains the beneficiary's name and MID number, as well as the service level authorized. Your agency may accept or reject this referral. Please note that the "referral notice" is not an authorization to begin services for a beneficiary.

If your agency accepts the referral, you will then receive a "decision notice" which includes the authorized service level and identifies the date when the agency should begin providing services for the beneficiary.

Q. How many hours will my client receive?

A. Prior to receiving services, an independent assessment will be conducted by an Assessor using a standardized process and assessment tool approved by DMA. This assessment will determine and authorize hours of service and level of care for new referrals, annual renewals, and change of status requests.

Q. How do I confirm the number of hours my client should receive?

A. Beneficiary hours may be confirmed by reviewing the "decision notice", the beneficiary's record on the QiReport Provider Interface, or by calling the Liberty Healthcare of NC Call Center at 855-740-1400.

Q. At the time of the assessment, does the Liberty Healthcare of NC Assessor tell the beneficiary how many PCS hours he or she will get?

A. No. Authorized hours are calculated after the independent assessment is uploaded to our software system and are based on the beneficiary's IA. The Assessor does not determine approval/denial or the number of hours.

Q. Do PCS providers have to use all of the approved hours if the beneficiary says they do not need/want them?

A. If the beneficiary declines PCS hours during a particular week (e.g., does not need services on Thursday this week because family member is available to help) but will resume the regular number of hours after that, no change is needed to the initial assessment or to the RN plan of care. Also, if a beneficiary wants to change the days they are provided services, the provider will need to document the deviation and update the POC.

If the beneficiary wants to reduce the total number of days of service per week, the agency will need to submit a Change of Status request so an assessment may be completed for a reduction in service hours.

Choosing A Provider

Q. How do beneficiaries choose a PCS provider?

A. Individuals approved for PCS may select any eligible Medicaid PCS provider licensed to provide care in the beneficiary's area. The following steps are used to determine the beneficiary's provider and/or provider county preferences to facilitate beneficiaries' selection of three preferred providers:

  • Ask the individual to name any preferred PCS provider(s), which may include the current PCS provider, if applicable. If fewer than three preferences, go to next step.
  • Inform the individual which counties have licensed, eligible PCS providers that may serve his/her area. Ask the individual which county provider lists he/she would like to see. Present randomized lists of providers in those counties. If no county preferences, go to next step.
  • Present randomized list of licensed, eligible PCS providers in the beneficiary's county. If fewer than three preferred providers in total, go to next step.
  • Present randomized lists of providers from contiguous counties, beginning with the contiguous county nearest the beneficiary's residence. If fewer than three preferred providers in total, go to next step.
  • Present randomized lists of providers from non-contiguous counties within 90 minutes driving time of the individual's residence.

Q. How do I switch a beneficiary to a sister agency?

A. Switching a beneficiary to a sister agency can be completed through the QiReport Provider Interface . After selecting the intended beneficiary, select the "Provider Change Number" tab; then enter the required information, including effective date, to complete the request. For additional assistance call the Liberty Healthcare of NC Call Center at 855-740-1400.

Q. What is a Change of Provider (COP) Request?

A. A beneficiary has the right to change his/her provider at any time. A Change of Provider request is the means by which a beneficiary can request that his/her services be provided by a different provider.

To submit a Change of Provider request a beneficiary or individual who has Power of Attorney for the beneficiary may call the Liberty Healthcare of NC Call center at 1-855-740-1400 or submit a Provider Change Request Form available on the Liberty Independent Assessment Information Center Website.

Please note that a Change of Provider request may only be submitted by the beneficiary or a caregiver who has Power of Attorney for the beneficiary. Providers, physicians, and non-designated family members may not submit a Change of Provider request on behalf of a beneficiary.

Q. How does a beneficiary request a change of provider?

A. Beneficiaries may change their PCS providers by contacting the Liberty Healthcare of NC Call Center at 1-855-740-1400 to request the change or by filling out the Change of Provider Request form and faxing the completed form to Liberty at 484-434-1571.

Home Care Agencies and Licensed Residential Facilities should have beneficiaries or the recipient's legal representatives to call the Liberty Healthcare Corporation-NC Call Center for Change of Provider (COP) requests. Home Care Agencies and Licensed Residential Facilities may assist the beneficiary or legal representative in placing the call, but may not make a change without the permission of the beneficiary or legal representative.

Change In Status

Q. When should I submit a Change of Status (COS) Request?

A. A Change of Status request should be submitted for an existing client when he/she:

  • Needs more or fewer service hours because of a significant change in his/her ability to perform self-care tasks.
  • Now has more or less informal caregiver assistance than was documented on the independent assessment.
Please note that a Change of Status request may be submitted by the provider; the beneficiary; the beneficiary's family; guardian; or person with Power of Attorney; or by the beneficiary's' physician. The beneficiary's physician may request a COS on the QiReport Physician Interface.

Q. What if the beneficiary has been hospitalized?

A. A "Change of Status" form is only needed if there has been a significant change in function. Otherwise, PCS services may resume under the previous plan of care for the authorization period.

If you have requested a Change of Status assessment, you may resume PCS services for the previously authorized hours while the beneficiary waits for the assessment to be completed.

Q. Will the provider be required to submit a change of status form, when a beneficiary has a change in provider and the new provider believes that the PCC is inaccurate based on the beneficiary's needs?

A. Yes

Q. What is considered a significant change in medical status?

A. A change that affects the beneficiary's ability to self-perform qualifying ADLs.

Q. Will all beneficiary decision notices be sent by traceable mail or does this requirement pertain only to denial/reduction notifications?

A. Only adverse (denial/reduction) notifications will be sent traceable mail.

Q. What should happen when an agency receives a 10-day letter?

A. If a provider receives an old provider notification to discharge a beneficiary within 10 days, the beneficiary should be discharged no later than 10 calendar days from the date of the notification.

If an agency receives a 10-day start notification the agency should not start servicing the beneficiary until 10 calendar days from the date of the notice. For example: If a notification is dated January 1, 2013 - the start date would be January 11, 2013. This allows the previous providers adequate time to properly discharge the beneficiary and prevents interruption of service and overlapping dates of service.

Q. When do PCS services stop for beneficiaries who receive a denial?

A. Within 10 days of the date on the letter beneficiaries receive from Liberty Healthcare of NC.

Plan of Care

Q. Do PCS providers need to submit plans of care to Liberty Healthcare of NC?

A. Not at this time. DMA will notify providers before this is required.

Annual Reassessments

Q. What is an "Annual Review"?

A. To remain eligible for services, all beneficiaries must undergo an independent assessment on an annual basis. An independent assessment should be scheduled within 12 months of the beneficiary's most recent independent assessment.

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