Reconsideration Request for Initial Authorization for PCS
The Reconsideration Request for initial authorization only applies to beneficiaries receiving State Plan Personal Care Services.
Citations: NC Medicaid State Plan Personal Care Services 3L-Section 5.6
Effective Date: July 1, 2016
The Reconsideration Process
A Reconsideration may be requested by a beneficiary who is at least 21 years old who receives an initial approval of less than 80 PCS hours per month. The Reconsideration request is a request to increase hours above the initial approval. It can be submitted if the beneficiary does not agree with the initial level of service as determined. The Reconsideration process does not apply to beneficiaries seeking hours in accordance with Subsection 5.3.1b of the PCS Policy 3L.
The following should apply to all requests:
- The request for Reconsideration can only be made for initial assessments (requests made for all other assessment types will not be processed).
- The request for hours in excess of the initial approval is not based on a Change of Status (A Change of Status may be submitted at any time if the change of status criteria are met).
- To submit a Change of Status, either Medical or Non-Medical, submit a Request for Independent Assessment for Personal Care Services DMA-3051 Form.
- The request should provide supporting documentation that specifies, explains, and supports why additional authorized hours of PCS are needed and which Activities of Daily Living (ADL) and tasks are not being met with the current hours.
- Supporting documentation should also provide information indicating why the beneficiary believes that the prior assessment did not accurately reflect the beneficiary’s functional capacity or why the prior determination is otherwise insufficient.
Time Period for Filing a Reconsideration Request
A request for reconsideration may be submitted no earlier than 31 calendar days and no later than 60 calendar days from the date of the approval notification.
A request after the 60 day time period must be in the form of, and meet the requirements for, a Change of Status request. Reconsideration requests submitted outside of the indicated time period will not be processed.
How to Submit a Reconsideration Request
Complete the Request for Reconsideration of PCS Authorization Form (DMA 3114). Submit the form to the Independent Assessment Entity (IAE) along with supporting documentation that specifies, explains, and supports why additional authorized hours of PCS are needed and which ADLs and tasks are not being met with the currently approved hours. Submit Request and supporting documentation via fax to Liberty Healthcare Corporation 919-322-5942 or 1-855-740-0200.
Note: A beneficiary may only request a Reconsideration by submitting the Reconsideration Request Form (DMA 3114) and supporting documentation via fax to the IAE (Liberty Healthcare of North Carolina). Incomplete, illegible, or requests submitted without supporting documentation as indicated above, will not be processed. A reconsideration request is not considered complete without supporting documentation as indicated in PCS Policy 3L 5.6(c and d).
Independent Assessment Entity (IAE) Reconsideration Processing Actions
Once a reconsideration request has been received by the IAE, complete and timely requests will be sent to a nurse reviewer. The nurse reviewer is then responsible for reviewing the Request for Reconsideration of PCS Authorization Form and the supporting documentation to determine if additional hours are warranted. Additional hours may be awarded through a new face-to-face assessment or a modification to the previous assessment depending on the documentation submitted. If the reconsideration determines a need for additional PCS hours, additional hours will be authorized according to policy.
If additional hours are authorized, this constitutes an approval and no adverse notice or appeal rights are provided. The provider will be required to complete a new service plan to reflect the increase in hours before receiving prior approval. If the reconsideration determines that the PCS hours authorized during the initial assessment are sufficient to meet the beneficiary’s needs, an adverse decision will be issued with appeal rights.
Those with questions about the Reconsideration process, or who wish to check on the status of a Reconsideration request, should contact Liberty Healthcare of North Carolina at 1-855-740-1400 or 919-322-5944. Reconsideration Requests will be processed between 3-5 business days from the date the completed request is received.
To reach NC Medicaid staff about the Reconsideration process, please call 919-855-4360.