Provide training in the use of the Enhanced Claims Editing 313. CRB59 function of the MEMS to CHFS, and its designee’s, personnel, initially and on an ongoing basis. CLAIMS ADJUDICATION (CA) Operate and maintain the Prior Authorization function of the 314. CAB1 MEMS, in accordance with Kentucky Medicaid policy. Process prior authorization for designated services, as 315. CAB2 required by the CHFS’s policy, and carry sufficient information to adjudicate all claims. Implement policy and procedures related to prior 316. CAB3 authorization/claims/encounter processing. Require prior authorization, as required by CHFS program 317. CAB4 policy. Submit prior authorization (PA), addendums to prior authorization and update requests to CHFS, for approval or 318. CAB5 denial, within 24 hours of receipt and perform appropriate processing of the requests, following approval or denial by CHFS. Accept and all PAs, addendums, and update requests 319. CAB6 from PA contractors. Disallow entry of PA requests for dates during which a 320. CAB7 member is ineligible for services. Purge old prior authorization records, according to CHFS, or 321. CAB8 its designee, specified criteria. Provide online inquiry and access to the authorization 322. CAB9 data set.
313. CRB59 Provide training in the use of the Enhanced Claims Editing function of the MEMS to CHFS, and its designee’s, personnel, initially and on an ongoing basis. CLAIMS ADJUDICATION (CA) 314. CAB1 Operate and maintain the Prior Authorization function of the MEMS, in accordance with Kentucky Medicaid policy. 315. CAB2 Process prior authorization for designated services, as required by the CHFS’s policy, and carry sufficient information to adjudicate all claims. 316. CAB3 Implement policy and procedures related to prior authorization/claims/encounter processing. 317. CAB4 Require prior authorization, as required by CHFS program policy. 318. CAB5 Submit prior authorization (PA), addendums to prior authorization and update requests to CHFS, for approval or denial, within 24 hours of receipt and perform appropriate processing of the requests, following approval or denial by CHFS. 319. CAB6 Accept and all PAs, addendums, and update requests from PA contractors. 320. CAB7 Disallow entry of PA requests for dates during which a member is ineligible for services. 321. CAB8 Purge old prior authorization records, according to CHFS, or its designee, specified criteria. 322. CAB9 Provide online inquiry and access to the authorization data set.
Attachment_I_-_MEMS_Fiscal_Agent_Requirements[1].docx