MA 97 FOR INCONTINENCE
- There are very specific requirements that a consumer must meet in order to be eligible for an MA97 process. These guidelines are set forth by the State of Pennsylvania, not our company.
IMPORTANT TO KNOW
- The state requires the original MA97 documentation so this process must go through the mail. Faxed MA97’s are NOT acceptable
- If a consumer has a Managed Care Organization (MCO) the request must go through that company NOT the state.
- The process is listed below:
- A valid prescription is sent to MSI.
- Representatives write up the MA97 documentation.
- The MA97 is sent to the doctor’s office for completion.
- The MA97 is then sent to the consumer to sign and date.
- The MA97 is then send to the sate for decision. Once at the state level it takes approximately 3-5 weeks for the state to come to a decision.
- Please note: The MA97 MUST be sent in this order, per state of Pennsylvania. Sometimes if the doctor’s office is not responding to our requests we can mail the forms to the patient to have completed. This is usually suggested around the 3rd time of resending documentation.
TURN AROUND TIME
- The oversll turn around time on the MA97 requests vary for each consumer.
- The time frame on the Waiver Program Exception requests, depend on how fast and how accurately the doctor’s office and consumer respond to requests.
- The average time an MA97 may take is approximately 2-4 MONTHS.
1.) In order to be eligible for the process, representatives should keep the following in mind:
- The consumer must be at their max.
- If at max, evaluate the consumer’s standing order and ask the needed questions.
- If not at max, evaluate the consumer’s standing order and make the changes accordingly.
- To evaluate the consumer’s standing order keep the following in mind:
- Please note: It is extremely important to evaluate the consumer’s standing order, and make any needed changes BEFORE starting the MA97.
- Once in the MA97 process, consumers cannot change the order if it will effect the write up units of the documentation.
- If the consumer is requesting more, check and see if they are receiving the most absorbent products that we carry.
- Suggest the following items to the consumer to assist with absorbency if they are not already receiving them:
- If already receiving is the consumer in the most absorbent product that we carry?
- Washables or Gloves
- Remind of the copay on both
- Large, Disposable Underpads
2.) When the consumer calls in representatives should be ASKING the following questions:
a.) What has changed in the patient’s condition to necessitate the increase?
- There must be a valid medical reason in order for a consumer to be eligible for he MA97 process. If the reason the patient wants more is because “they just like them” they are NOT eligible for the process.
b.) Is the doctor aware of the need?
- If the doctor is not aware that the patient is requesting an additional amount, the consumer must contact the physician to see if they feel it is medically necessary or not AND also to see if they would be willing to fill out the documentation.
c.) How many more bags and of what type of product does the patient need?
- An MA97 is needed for EACH product, so if a consumer wants an increase on gloves and bedpads there should be TWO MA97’s.
- MA97’s are written by units, not bag count (consumers will not know units which is why we ask bags.)
- Ex: Jane Doe wants 3 more bags of bedpads. There are 10 units to 1 bag of bedpad so the MA97 would be for 30 extra units of Large, Disposable Underpads.
d.) How many per day does the consumer use/
- If the patient is und=sure, have them estimate, or representatives can figure it out for them.
- The daily usage the consumer uses MUST match the TOTAL amount that they will be using per month if the MA97 were to be approved.
- Ex: Jane Doe wants 3 extra bag of chux (30 extra untis). The total would be 90 per month (60 thru PA/MA + 30 thru MA97)
- Jane Doe’s TOTAL daily usage should be 3 per day.
- 3 multiplied by 30 (30 days in a month) is 90.
3.) Once eligibility is confirmed, representatives should tell the consumer the following:
a.) Explain the MA97 process to the consumer in detail.
- Be sure to emphasize how lengthy the process it, how the state requires the original documentation; and that we will contact them with any updates.
b.) We are going to fax the requested changes over the doctor.
- If the doctor feels the request is medically necessary, he or she will complete the RX and send it back to our company.
- If we have to send samples beforehand do NOT fax the RX over until the changes are in place. If consumers have not received an item before we will need to fax for an RX for the changes if they want them in order. This is just another reason why the changes must go into effect BEFORE an MA97 is started.
- When faxing an RX over, representatives must include the TOTAL UNITS (Ex: MA97 is for 40 units of 31927 +)
c.) UPON RECEIPT of the RX representatives will write up the prior authorization documentation NOT before.
- By signing the RX the doctor is acknowledging that the MA97 is necessary, cannot start the paperwork until this is done.
d.) Suggest to the consumer that they contact the doctor to make them aware of the RX that will be faxed over to them on regards to the process.