Update on Changes to PA Process for CAP Participants

Changes are coming to the Prior Approval (PA) process for the Community Alternatives Program (CAP) waiver programs, including CAP/Children (CAP/CH), CAP/Choice (CAP/CO), and CAP/Disabled Adult (CAP/DA). As of February 5, 2017, providers will no longer submit Prior Approval (PA) requests to NCTracks for CAP waiver program participants. Following is an outline of the changes by CAP program.

CAP/CO and CAP/DA

Today, VieBridge makes the level of care (LOC) determination for CAP/CO and CAP/DA participants and sends the service review form (SRF) to the provider. The provider then submits a PA request to NCTracks with the SRF attached, which enables the information to be captured in NCTracks. However, when the changes are implemented, the provider will no longer need to submit a PA request to NCTracks. An adjudicated PA with LOC determination and the SRF for CAP/CO and CAP/DA recipients will be transmitted to NCTracks by VieBridge.

CAP/CH

Today, providers submit a PA request to NCTracks for CAP/CH recipients and the CSRA Fiscal Agent Operations team makes the LOC determination. When the changes are implemented, VieBridge will make the LOC determination for CAP/CH recipients and transmit the information to NCTracks in an adjudicated PA.

All CAP Programs

Historically, NCTracks has not received plan of care (POC) information for any CAP recipients. Beginning with date of service March 1, 2017, the POC for CAP/CO, CAP/DA, and CAP/CH recipients will be transmitted to NCTracks by VieBridge. The NCTracks system will then use the information to validate that submitted claims do not exceed the authorized limits associated with services provided through the waiver programs.

These enhancements will eliminate the manual effort currently required by both providers and NCTracks. CSRA will no longer accept CAP PAs from providers after this enhancement is implemented. However, all CAP PAs received prior to implementation will be processed. VieBridge will submit changes to existing PAs for CAP/CO, CAP/DA, and CAP/CH to NCTracks as needed if the recipient’s circumstances change. Providers can do a search for the CAP PAs on the secure NCTracks provider portal as long as their NPI is associated with the PA record.

If the CAP PA is not on file, the claim for CAP services will deny. After February 5, 2017, any issues with CAP PAs should be referred to VieBridge for resolution.

For more information on CAP services, refer to the CAP web page on the N.C. Division of Medical Assistance (DMA) website.