For adults age 21 and older, prior authorization is not required for up to eight units of the above codes combined. This is a change from the previous limit of nine units.

For children and adolescents younger than age 21, prior authorization is not required for up to 16 units of the above codes combined.

Prior authorization is still required for any units beyond these limits in a 12-month period for Medicaid recipients. Prior authorization is still required for all testing under the state-funded benefit plan.

Prior authorization is not required for testing under the above Medicaid benefits, but providers must adhere to the medical necessity guidelines for testing in Clinical Coverage Policy 8C and in the Smoky Guidelines for Psychological Testing. Please note the following guidelines:

• Diagnostic interviewing should be conducted first, unless determining eligibility for intellectual or developmental disability (I/DD) services. Psychological testing should be performed only when a clinical interview cannot provide all necessary information.
• Smoky values psychological testing to clarify diagnoses and assist with treatment recommendations when issues cannot be identified through diagnostic interviewing.
• Psychological testing is not covered in the following situations:
• Testing for predominantly educational purposes, including cognitive abilities, learning disabilities and academic achievement
• Vocational referrals, including the need for vocational rehabilitation services, job placement, vocational interests and aptitudes or fitness for duty
• Referrals for preparation for a civil or criminal court proceeding
• Routine testing for the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD)

Smoky will conduct post service reviews of psychological testing for which claims are paid; providers could be at risk for corrective action or recoupment if the above guidelines are not followed.

These changes are designed to reduce the administrative burden for providers and provide faster access to services for consumers.

Quality and Integrity Operations: Helpful tips

In the April provider communication bulletin, we omitted a step that makes viewing Back-up Staffing (BUS) reports easier. We apologize for the oversight. Please review the correct process below to determine if you have any 'saved' or 'hand over to provider' incidents to be resolved.

Three easy steps to check if a report has been sent back to you:

1. Filter
2. Status - hand over to provider /or/ saved
3. Search

Click the "X" button in the right hand corner of the screen to open the incidents. A "1" and "3" will appear where the "X" was located. Click "3" to open the incident.

Please note: the person who entered the information is the only one who can correct the report. 

Medical records requested for critical incidents

Medical records requested for critical incident review must be sent to:

ayofemi.powell@smokymountaincenter.com or mailed to 200 Ridgefield Court, Suite 206, Asheville, NC 28806. Please call 828-586-5501, ext. 1104, if you have any questions.