LETTER OF MEDICAL NECESSITY (LMN)

All MA97 requests use the same Letter of Medical Necessity request template for each request. Representatives simply have to update the template for each request. An example of what needs to be updated is shown below.

The following areas need to be updated on each Letter of Medical Necessity request:

  • The date.
  • The consumer’s full name.
  • The consumer’s date of birth.
  • The doctor’s full name.
  • The requested item’s description, extra and total units per month and total write up.
  • The employee completing the form’s information.

PRESCRIPTION

The final document that should be included with the MA97 is a prescription.

When printing a prescription for incontinence supplies supplies representatives must:

  • Enter the TOTAL units per month on the RX (not the requested extra amount).
  • Create the RX for only the requested items.
    • Be sure if anyone faxes for the other items that they include the TOTAL MA97 amounts or the system will not allow the MA97 units to go to.

After faxing, representative should deleted the requested from the RX list AND from the fax blast.

After completing these steps print out the prescription and highlight the following areas:

  • The diagnosis code.
  • The height.
  • The weight.
  • The refills section.
  • The doctor’s signature.
  • The date.

SENDING ORDER

For convenience the MA97 documentation should be sent to the doctor’s office in the correct sending order. This way is most convenient and diminishes the chances of doctors mistaking the prescription with the Letter of Medical Necessity.

The sending order is listed below:

  • The Doctor Lette.
    • (with the sticky reminding the physician to mail).
  • The letter of Medical Necessity Request.
  • The MA97 form.
  • The MJF.
  • The prescription.

The MA97 must be mailed to the office, the state does not accept faxes.

ENTER A NOTE

Representatives should enter a note in the system that states the following:

  • What the MA97 is for with extra units included.
  • Where the MA97 went.
    • Include the doctor’s mailing address.
  • what went with the MA97.

The topic should always be MA97. If an MA97 has been sent multiples times, representatives should number the requests. MA97 (for the first request) 2ND MA97, 3RD MA97, etc.

An example of how a note will look is shown below:

After sending the MA97, representatives should keep a follow up list handy and continue to follow up with the doctor’s office until the MA97 is sent back to our office correctly.

Marking dates of when representatives should follow up, next to the consumers name is a sufficient way to conduct the follow ups.

Example: An MA97 is sent to the doctor on Thursday, Nov 1st
Representatives call on Tuesday, November 6th to make sure it was received.
The office staff says that we should call onThursday, Nov 8th.
Next to the consumers name representatives should write 11/08 for a follow up.

IMPORTANT TO REMEMBER

  • Before sending the documentation to the doctor’s office, representatives must call to verify the mailing address.

MA97 PRIOR AUTHORIZATION CHECKLIST

There are THREE main areas where representatives need to keep track and document the MA97’s; which are listed below:

  • The main note section.
  • The representatives follow sheet.
  • The MA97 Prior Authorization Checklist.

The MA97 Prior Authorization Checklist should be updated when each step is started and/or completed; and should be kept in the consumer’s file.

Furthermore, once a consumer has a become an MA97 requested the file should be kept a the representatives desk for convenience. The consumer’s file should be organized, with prongs if need be. Prescriptions should be on the right hand side, and any documentations regarding intake, eligibility, service orders, etc. should be on the other. If representatives stay organized while doing the MA97’s it makes the process smooth, and diminishes any issues that may occur.

A copy of an MA97 Prior Authorization Checklist is shown below:

FOLLOW UP

After sending the MA97, representatives should keep a follow up list handy and continue to follow up with the doctor’s office until the MA97 is sent back to our office correctly.

Representatives should remember the following when contacting a doctor’s office regarding an MA97:

  • Be courteous and kind.
    • Office staff will be more willing to “go above and beyond” to assist someone who is pleasant. If you are rude, or have a bite to your tone it could put a damper on the process.
  • Be professionally assertive.
    • As previously stated, representatives should be courteous and kind, however this does not mean that we cannot “fight for our patients”.
    • Remember that the doctor does not get the reimbursed for the MA97.
    • Be understanding of the fact that the MA97 can be a lot of work for the physician. However, the doctor does have an obligation to his or her patients as well.
    • When speaking with the doctor or office staff, the may become frustrated. Sympathized with them, explain that the stateputs very strict guidelines on the MA97. If something is not included, or we do not have as much supporting documentation as possible the request will be denied. Once denied, we will have yo resubmit the MA97, which is why try to be proactive in obtaining all requested documentation from the beginning.
  • Get the name of the person that you are speaking with.
    • By getting the name of the person that a representative spoke to it validates that we actually have called previously. Furthermore, if a consumer wants to know who spoke to, to contact the office themselves; it shows that we are being sufficient in attempting to obtain the documentation.
  • Get a status on the MA97 & do not be afraid to ask for a turn around time.

The First followup: We understand that it will take some time for the doctor to complete; and we are just contacting the office to make sure the documentation was received.

  • Be sure to get the name of the person you speak to.
  • Ask them to note that the documentation must be mailed back to our office.
  • Do not be afraid to ask for a turn around time.

The second followup: Be sure to read the notes thoroughly to get a status from the notes before calling. If previous notes say that the doctor would be mailing it by the 23rd, and by the 28th we still have nothing, make the office staff aware.

Be courteous, develop a relationship with the staff. Since MA97’s are needed for an extended period of time, representatives will become familiar with the staff that they are speaking to.

Continuous followups: If the MA97 is still not returned to our office after two weeks, representatives should be asking to speak with an Office Manager to expedite the request. Representatives should use their judgement. Furthermore, we should be reaching out to the consumer and Caremanager as well.

When calling the Caremanager representatives are just keeping them up to date with the process. We should NOT be asking the Caremanager to assist in anyway. If the Caremanager offers, that is acceptable.

When calling the consumer, representatives are calling to keep them up to date with the process AND suggesting to them that they contact the office to expedite the request.

MA97
BACK FROM THE DOCTOR

Ideally when an MA97 comes back from the doctor all of the following documentation should be included:

  • The MA97
    • With numbers 16-19, and 27 & 29 filled out.
    • Signed by the doctor in numbers 35 & 36.
  • The prescription
    • With refills.
    • The diagnosis code that proves medical necessity.
    • The doctor’s signature and date.
  • The Medical Justification Form(MJF)
    • Should be completed to the best of the doctor’s ability. Sometimes the physician does not have the requested information on file; which is why a Letter of Medical Necessity is requested.
  • The Letter of Medical Necessity (LMN)
    • Sometimes doctors confuse the RX with the Letter of Medical Necessity. Which is why when we send the paperwork we do our best to alleviate that confusion.
  • Lab work/clinical documentation
    • The more documentation that we have to include with the request, the better chance the consumer has of receiving an approval. Any most recent lab work, office notes, or dietician reports that the office may have on file should be included with the request.

If the documentation comes back and any of the following items are missing, representatives should contact the office to rectify the issue: If the prescription, MJF, LMN, or lab work is missing the office staff CAN fax the documentation over to our office. These documents do NOT have to be mailed (but we want to stress initially to do so).

Once the MA97 comes back, even if there are other issues that need to be addressed, the MA97 should go to the consumer.
Example:

  • The MA97 is returned and completed correctly.
  • The MJF & LMN are missing.
  • Follow up with the office for the MJF & LMN but send the MA97 to the consumer.