Adult Brain Injury Program Provider Manual

All participants must be enrolled with the ABI Program before services can be authorized. All services must have prior authorization before provision of service. Services are authorized on a monthly basis up to thirteen months from one month past SCA date.

All Prior Authorization requests must be submitted on the most current ABI Program Prior Authorization form. Prior authorization requests may be sent to the ABI Service Coordinator via mail, fax or e-mail.

A treatment plan is required for all services and must be submitted with the Prior Authorization request. The treatment plan must address goals that match the participant’s functional level for the time of the Prior Authorization request. Participant/family participation in development of the plan should be documented.

Providers will not be reimbursed for any services delivered before approval.

Neither the ABI Program nor the participant/family shall be responsible for payment for a service when the Provider fails to complete the prior authorization process.

Approval of services is contingent upon the services being necessary to achievement of the participant’s goal(s) and the availability of funding.

Services will be approved for a definite period as indicated on the Prior Authorization form.

Written notification of approval or denial will be sent to the Provider.

Prior Authorization Procedures

Prior Authorization forms are due to the Service Coordinator within 10 days from the completion of a treatment plan for all services except for Adjustment Counseling which will need to be submitted within 30 days from completion of treatment plan.

The individualized treatment plan for the current authorized period must be attached to the Prior Authorization that is sent to the ABI Service Coordinator (with the exception of neuropsychological evaluation). The treatment plan and goals must be developed by a Qualified Head Injury Professional, and be on the most current treatment plan form which addresses the following:

• Reflect input from the participant’s planning team;
• Reflect services essential to the expected participant outcome;
• Specify the frequency, expected duration of treatment;
• Specify the expected function the participant will achieve if service is approved;
• Specify the methods to be used or strategies to be taught to address the participant’s unique barriers to independence;
• Incorporate information from previous services received; and
• Document participant/family participation in the plan.

Note: Refer to Treatment Plan and Progress Report section for specific requirements.

Prior authorization requests for participants that have ongoing treatment plans in place requiring services for an expected duration of a twelve-month period are submitted on an annual basis.

Services will be approved for participants if funds are projected to be available after funding has been allocated for participants;

• whose rehabilitation programs are in progress or
• who have had a rehabilitation service paid in the last six months, or last paid claim services

When the demand for services exceeds available funds, a waiting list will be maintained.

When services requested are also covered by MO HealthNet or another third party payer, a copy of the denial for coverage of the service must be attached to each Prior Authorization that is sent to the ABI Service Coordinator. The original denial or a fax copy of the denial is acceptable. If the third-party payer refuses to issue a written decision, a written statement dated and signed by the Provider documenting the third-party payer’s verbal decision will be acceptable as evidence of no coverage for the requested service.

Upon receipt of the Prior Authorization, the participant’s ABI Service Coordinator will:

• Review the request;
• Ensure medical and financial eligibility are met;
• Ensure that all other payment resources have been utilized;
• Ensure units authorized are achievable at time of Service Coordination approval;
• Review the Treatment Plan and Monthly Progress Report (as applicable);
• Review the participant’s long-term goals; and
• Advocate for the participant’s needs as funding decisions are made by the ABI Program.

The Prior Authorization Form and Treatment Plan are to be submitted to the ABI Program Manager. The ABI Program Manager is responsible for final approval. A copy of the approved Prior Authorization will be sent to the Provider by the ABI Program. Services should not be rendered until this authorization is received by the Provider.

Prior Authorization Request

The ABI Program Prior Authorization Form must be submitted to obtain prior approval to provide any rehabilitation service. No payment will be made for services rendered without prior approval. The form must be completed according to the instructions listed on the back of the form. Prior authorization requests for participants in services are due to the ABI Service Coordinator by the 10th of the month prior to services being delivered. The ABI Service Coordinator will coordinate due dates for authorization requests for participants coming off the waiting list. For example, authorizations for services beginning in January 2020, will be submitted by December 10, 2019 for the months of January 2020 through February 2021.