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CCSP Level of Care and Placement Requirements Version 1.1
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Revision History
Version Date Description Editor
1.0 3/7/2014 Draft D. Barrett
1.1 4/3/2014 DCH requests incorporated
D. Barrett
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Review Process Overview
Alliant is assuming responsibility for reviewing initial placement and continued placement
(reassessments) level of care requests for enrollment in the Community Care Services Program (CCSP). The
CCSP provider must submit the Level of Care (LOC) and Placement request via the web portal. Providers must
also attach to the CCSP LOC request certain required documents as part of the ‘packet’ of information.
The Alliant nurse reviews the LOC request with attached information and renders a decision. The nurse may
render the following types of decisions:
Initial Tech Denial: This decision is rendered when no documents are attached to the LOC request
within 5 calendar days from the LOC request date; OR when required documentation is incomplete
within 5 calendar days from the LOC request date.
Final Tech Denial: Following an initial TD, a Final Tech Denial is rendered when no documents are
attached to the LOC request within 30 calendar days from the LOC request date; OR when required
documentation is incomplete within 30 calendar days from the LOC request date.
Initial Decision/Approved: This decision is rendered when the LOC is complete and meets level ofcare criteria upon initial nurse LOC review.
Initial Decision/Nurse Denied: This decision is rendered when the LOC is complete, but does not meet
the level of care/policy guidelines upon initial nurse LOC review. Member/Provider may request a
reconsideration of this decision by sending additional medical information to the CCSP office within
ten calendar (10) days of the date of the Notice of Denial/Termination of Level of Care.
Second Level Nurse Review/Approved: This decision is rendered when a reconsideration of the Initial
Nurse Denial has occurred, and based on the documentation submitted, the LOC now meets level of
care/policy guidelines.
Second Level Nurse Review/Denied: This decision is rendered when a reconsideration of the Initial
Nurse Denial has occurred, but the LOC still does not meet the level of care/policy guidelines.
Initial Decision/Withdrawn: Generally, this is used for duplicate requests.
When any decision is rendered, a No reply email is sent to the provider notifying them of the decision. In
addition, PA notifications and decision information display on the Provider Workspace. For Final Tech Denials,
Initial Nurse Denials and Second Level Nurse Denials, a Denial Notification letter is sent to the provider via
regular mail and the member via certified mail. The reviewer is responsible for triggering the letter. Letter
processing and distribution to be handled by SourceCorp using the same process established for SOURCE and
other waiver letters.
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LOC Submission via the Portal
1. The LOC requests will be entered by the CCSP Care Coordinators. These providers are not Medicaid
providers. In order to be able to submit CCSP requests via the portal, however, the Care Coordinators
will need to obtain provider IDs and portal credentials that will need to be associated with the CCSP
590 category of service.
2. The Care Coordinators will use the standard process for initiating a PA request:
Log into the portal
Click Prior Authorization tab and then Submit/View or select Provider Workspace. If they
select Provider Workspace, they then select - Enter a New Authorization Request.
Select the CCSP Level of Care and Placement Request link.
On the Authorization Request page, the provider ID is system populated based on login
credentials.
Applicants ID: Some CCSP applicants may not yet have a Member Medicaid ID. Provider will
need the option to enter the member’s Medicaid ID; OR, if the applicant does not yet have a
Medicaid ID, to enter the applicant’s Social Security Number, and/or the member’s AIMS
number (1-9 characters - all numeric).
Upon submission of the appropriate IDs, the CCSP LOC online form opens.
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CCSP Level of Care and Placement Request Template
(The screen shots below are from the SOURCE LOC request template)
Page Header: Change Source Level of Care and Placement –TO - CCSP Level of Care and Placement. Member Information: If the Medicaid ID is entered, system can populate member data. If SSN entered
and/or the AIMS number is entered, the system could also populate data based on demographic data received
from AIMS. Other option is manual entry.
1. Add address fields.
2. Add a field for the the applicant’s AIMS number.
Provider Information:
3. Change Service Provider Information heading- TO - CCSP Care Coordinator Agency.
_____________________________________________________________________________________
Physician Information:
4. Remove the following:
Checkboxes for ‘Primary Physician’ and ‘Site Medical Director’.
Date LOC signed by Physician
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Physician License Number
Address fields
5. Require ‘Physician Name’ and ‘Phone’ ONLY. Retain Fax field but do not require. ______________________________________________________________________________
Contact Information:
6. Change section header to: Care Coordinator/Assessment Nurse Contact Information.
6.7. Populate contact information based on the Care Coordinator Agency ID but allow editing.
7.8. Only Contact Name and Contact Email are required.
_________________________________________________________________________________
Request Information:
8.9. No changes - all fields are required.
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Above Sections:
9.10. Primary Diagnosis is required. Will include the same ICD-9/ICD-10 changes included for all
other PA types as that project is implemented.
10.11. Comments/Messages are optional.
11.12. Remove Retro Eligibility question.
12.13. Acute Care Hospital Dates, Diagnosis on Admission to Hospital, Medications and
Diagnostic/Treatment Procedures are OPTIONAL.
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Above Sections:
13.14. Services table: Retain but do not require.
14.15. Treatment Plan: Retain but do not require.
15.16. Remove ALL Yes and No Questions.
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Above Sections:
16.17. Remove: Evaluation of Nursing Care; Mental Behavioral Status; Nursing Care and Treatment; Hours out of bed per day; Frequency per week of therapy; Activities of Daily Living; and Level of Impairment.
17.18. Remove Name of RN and Date Signed.
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CCSP LOC Attachments
1. Providers are required to submit additional documentation by attaching the documents to the LOC PA
request. Providers should be able to attach documents according to these rules:
Attach when submitting a new LOC PA
Attach to an existing pending LOC PA
Attach to LOC PAs that have a decision of Initial Tech Denied/No Final Tech Denial/No Initial
Decision/and no more than 30 days has elapsed since the LOC request date
As part of a reconsideration request entered via the web portal, providers may also attach
documents supporting a request for reconsideration of an initial nurse LOC denial.
2. Under Create an Attachment, add checkboxes for the following required documents:
Initial Placements:
Appendix E- Level of Care and Placement Instrument Form
Crosswalk from AIMS
Minimum Data Set (MDS) for Home Care (MDS-HC) from AIMS
Demographic information from AIMS
Medication Record
Case notes from AIMS
DON-R
Continued Placements:
Appendix E- Level of Care and Placement Instrument Form
Crosswalk from AIMS
Appendix F - Minimum Data Set (MDS) for Home Care (MDS-HC) from AIMS
Demographic information from AIMS
Medication Record
Case notes from AIMS
Note: PCP Notes were removed since Tom indicated that it is not required and the above documents are the
REQUIRED documents which are needed to avoid a tech denial.
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Nurse Decisions and Decision Page The CCSP LOC Nurse Review and Decision Page will generally mirror the SOURCE LOC Decision Page in design
and functionality. However, some changes are requested to accommodate the CCSP review process.
1. Change the page header from Source Level of Care and Placement TO CCSP Level of Care and
Placement.
2. The reviewer will enter Initial Tech Denials, Final Tech Denials, and Initial Decision/Nurse Denied or
Initial Decision/Approved in this section:
Reconsiderations
3. Providers (for members) have the right to request a second review (reconsideration) of the Initial
Nurse Denial decision.
Providers are required to submit the requests for reconsideration using the existing Submit
Reconsideration Requests functionality on the provider workspace. This functionality will
need to be opened for CCSP LOCs.
Requests may only be submitted for this decision: Initial Decision/Nurse Denied; and when
there does not exist any Second Level Review decision.
Requests must be submitted within twenty (20) calendar days from the ‘NOTICE OF
DENIAL/TERMINATION OF LEVEL OF CARE’ letter sent date.
3.4. Providers submit the reconsideration request via the portal and attach supporting documentation to
the reconsideration request.
4.5. If a reconsideration of the initial nurse denial is requested, the original CCSP Review Nurse reviews the
case and makes a final nurse determination. Referral information and the rationale for the decision
are captured in the nurse comment box on the Nurse Decision page.
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5.6. To document decisions for reconsiderations, a new section will need to be added to the Nurse Decision
page for Second Level Reviews:
Second Level Reviews (header)
Second Level Review Decision: <drop list: Approved, Nurse Denied > The decision selected will
change the case status to Approved or Denied.
Second Level Decision Date: <date field>
Denial Reason: <drop list of denial reasons>
Second Review Denial Letter Sent Date:
If the second level nurse review is Approved or Nurse Denied, a decision date is required.
In addition, if the second level nurse review decision is Nurse Denied, a denial reason and
denial letter sent date is required.
6.7. If DCH overturns a second level nurse review decision, the decision is entered in this section:
Notifications Process
The following methods will be used for notifications depending on the decision type:
No reply email
Contact Us
Notifications on the Provider Workspace
Notification Letters
No Reply Email
ALL decisions (except pending) trigger a no-reply email to the provider associated with the LOC. For Initial and
Final Tech Denials, the no reply email indicates what documents are missing based on what is attached to the
LOC PA. Sample no reply email:
*** DO NOT RESPOND TO THIS E-MAIL ***
Dear Provider,
The CCSP Level of Care and Placement (PA#:********0012) PA submitted by you, has been Denied. The PA is missing some
document(s) : <<document names>>
You can visit Provider Workspace section of Georgia MMIS portal: https://www.mmis.georgia.gov to check the PA status
details.
Regards,
Nurse Reviewer Team
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*** Please note: This e-mail was sent from a notification-only address that cannot accept incoming e-mail. Please do not
reply to this message. ***
Contact Us
In addition to the no reply email, ‘Contact Us’ is used to notify providers of missing information for Initial Tech
Denials; and notify providers of ALL approvals - Initial Approvals and Second Level Approvals.
1. Add CCSP to the ‘Contact For’ list in the PA system. Will enter separate Task for this change.
Provider Workspace Notifications
PA Notifications
In addition to the no reply email, for ALL decisions including approvals, a PA notification is posted to the Level
of Care and Placement request on the portal/provider workspace and can be viewed by the provider
associated with the CCSP LOC PA. The PA notification includes the notification date and PA status. If the LOC
decision is an Initial Tech Denial or Final Tech Denial, the PA notification indicates what documents are missing
based on what was attached to the LOC PA.
Denial Notifications
The nurse’s review comments entered on the application letter page are posted to the LOC PA on the provider
workspace under Denial Notifications along with the ‘Denial Decision Date’ and the ‘Letter Type’. For CCSP,
the ‘Letter Type’ under denial notifications would be: Notice of Denial or Notice of Second Review Denial or
Notice of Final Tech Denial.
Workspace Decision Information The following decision information should also display on the provider workspace: Type of Recommendation,
Denial Reason, Decision Type, and Decision Date. This needs to be shown for all Initial and Second Level
Review denials and approvals.
The following screen shot shows how the PA Notifications, Denial Notifications, and Decision Information are displayed for a SOURCE LOC PA:
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Letter Notifications
1. Letters are sent for CCSP LOCs that are denied, excluding Initial Tech Denials and LOCs that are
withdrawn.
2. The reviewer is responsible for triggering the applicable letter based on the denial decision entered.
The three possible letters are:
NOTICE OF DENIAL/TERMINATION OF LEVEL OF CARE: This letter is triggered when the Initial Decision is Nurse Denied.
NOTICE OF SECOND REVIEW DENIAL/TERMINATION OF LEVEL OF CARE: This letter is triggered when the nurse conducts a second review upon reconsideration and the decision is denied. Hearing Rights are sent with this letter
NOTICE OF TECHNICAL DENIAL FOR LEVEL OF CARE: This letter is triggered for final tech denials when the LOC is missing required documentation. This letter will only be sent for Recommendation type – Continued Placement (Reassessments) and not Initial Placements. Hearing Rights are sent with this letter.
3. Denial letters are sent to the Member associated with the LOC via certified mail, and to the provider via regular mail.
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4. When a Final Tech Denial or Initial Decision/Nurse Denied or Second Level Nurse Review/Denied
(Nurse Final Denial) is entered, the reviewer is alerted to send the denial notification letter. This is
currently set up for SOURCE.
The alert will display until the letter is saved and the ‘Sending Letter’ indicator (on the letter page) equals Yes.
Letter Suppression
Allow staff to suppress a letter before the letter data is sent to Source Corp. This could be set up similar to the
suppression function currently available for the Standard Approval/Denial Letters.
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Application Denial Letter Pages
1. Three application letter pages are needed that correspond to the three denial letters
2. Add the following letter send buttons to the Nurse Decision page to be used by the reviewer to access
the application letter pages:
Send Final Tech Denial Letter
Send Notice of Initial Denial
Send Notice of Second Review Denial
3. Display the send letter buttons at all times. It is up to the reviewer to select the correct letter send
button.
4. The denial letter pages capture the denial reasons and reviewer’s rationale. The denial reasons and
reviewer comments are applied to the actual notification sent to the provider. Only the checked
denial reasons should be pulled into the actual letter.
An example of each application letter page follows:
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(Used with Initial Nurse Denials/Terminations)
COMMUNITY CARE SERVICES PROGRAM (CCSP) NOTICE OF DENIAL/TERMINATION OF LEVEL OF CARE
State and federal law require that if you receive care in the Community Care Services Program, your medical condition must be such that if you require the level of care provided in a nursing facility. Your participation in the CCSP Program has been given careful consideration. In accordance with the Code of Federal Regulation, 42 CFR 441.301(b)(i)(ii) and 441.302(c)(2), the following determination has been made that you are not eligible because you do not: Check all that apply: Check all that apply: Meet criteria for Intermediate Nursing Home Level of Care, pursuant to Section 605.1 of the CCSP General
Services Manual.
Meet the criteria for the target population for Georgia’s Elderly and Disabled Waiver due to a primary diagnosis of mental illness or intellectual disability.
Other:
The assessment forms are not consistent.
The documents submitted do not support or confirm the diagnosis.
The diagnosis is not consistent with the reported disability.
Other reason:
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(Used with Second Nurse Review/Terminations)
NOTICE OF SECOND REVIEW DENIAL/TERMINATION OF LEVEL OF CARE
State and federal law require that if you receive care in the Community Care Services Program, your medical condition
must be such that if you require the level of care provided in a nursing facility. Your participation in the CCSP Program has
been given careful consideration. In accordance with the Code of Federal Regulation, 42 CFR 441.301(b)(i)(ii) and
441.302(c)(2), the following determination has been made that you are not eligible because you do not:
Check all that apply:
Meet criteria for Intermediate Nursing Home Level of Care, pursuant to Section 605.1 of the CCSP General Services Manual. Meet the criteria for the target population for Georgia’s Elderly and Disabled Waiver due to a primary diagnosis of mental illness or intellectual disability. Other:
The assessment forms are not consistent.
The documents submitted do not support or confirm the diagnosis.
The diagnosis is not consistent with the reported disability.
Other reason:
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(Used with Final Technical Denials)
COMMUNITY CARE SERVICES PROGRAM (CCSP) NOTICE OF TECHNICAL DENIAL FOR LEVEL OF CARE
Type of Recommendation: Initial Reassessment
State and federal law require that if you receive care in the Community Care Services Program, your medical condition
must be such that if you require the level of care provided in a nursing facility. In accordance with the Code of Federal
Regulation, 42 CFR 441.301(b)(i)(ii) and 441.302(c)(2), the Alliant Health Solutions, on behalf of the Department of
Community Health (DCH), makes the level of care determination based on the information submitted. We were unable to
make a decision regarding level of care due to the following missing information:
Appendix E – Level of Care and Placement Instrument Form
Crosswalk from AIMS
Minimum Data Set (MDS) for Home Care from AIMS
Demographic information from AIMS
Medication Record
Case notes from AIMS
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Letter Page Requirements:
1. Member information and provider information is prepopulated on the page.
2. At least one of the first three checkboxes must be checked on the Notice of Denial and Notice of
Second Review Denial letters.
3. At least one checkbox must be selected on the Notice of Technical Denial Letter.
4. If ‘Other is checked on the Notice of Denial or Notice of Second Review Denial, then at least one denial
reason under other must be selected.
5. ‘Reviewer Comments’ are required.
6. Save must be clicked and the ‘Sending Letter’ indicator = Yes - in order to generate the letter.
7. When the letter is saved, the denial letter displays in the PA Interface Letter Information table as
Letter Types: Notice of Denial, Notice of Second Review Denial, or Notice of Technical Denial.
8. After the letters are mailed and returned by SourceCorp, a copy of the Member and Provider letters
are attached to the PA in the Source Letter Information table.
9. The letters attached to the PA will be available to the provider on the Provider Workspace.
