PCPA has learned that budget limit exceptions requests can be made through the Prior Authorization Request Line in the Department of Public Welfare (DPW) Office of Medical Assistance Programs (OMAP). These exceptions are requested for care and services that are needed beyond the limitations that were established in the 2005/06 Governor’s Executive Budget and subsequent changes to the Public Welfare Code. OMAP has stated its intention of issuing a Medical Assistance bulletin delineating the exceptions process, but that bulletin is not yet available. However, the need for exceptions is very real and a process has been crafted to meet this need.
Requests can be initiated via telephone with the Prior Authorization Request Line (800-558-4477) or by written request to:
OMAP Fee-for-Service
Programs
Benefit Exception Review
PO Box 8047
Harrisburg, PA 17105
Information needed includes the recipient name and identification number, provider identification number and contact information, ICD-9-CM diagnosis and procedure codes, service requested, and why the service is needed. For budget limit exceptions requests for additional partial hospital hours, information is needed regarding the individual’s Medical Assistance benefit package and eligibility status and the number of partial hospital hours used. Prospective requests for exceptions are preferred. Information will be requested regarding risk for hospitalization, compliance with treatment regimen, existence of any alternative services and supports, treatment goals, and whether there is any active substance abuse.
Callers to the request line will be asked to provide basic information and will be issued a number and told where to fax or send the supporting information. The information will be reviewed by a psychiatrist and the provider will be contacted with the decision.
Information about the benefit limits can be found in Act 42 of 2005 (www2.legis.state.pa.us/WU01/LI/BI/BT/2005/0/HB1168P2560.pdf). Regulations regarding the benefits and exceptions can be viewed on the Pennsylvania Code web site (www.pacode.com/secure/data/055/chapter1101/s1101.31.html). Please contact Betty Simmonds at PCPA with questions.
