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:
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 [email protected] 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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