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Prior Authorization

The Department of Medical Assistance Services contracts with Keystone Peer Review Organization (KePRO) to handle the prior authorization (PA) process for Medicaid, Family Access to Medical Insurance Security (FAMIS) and FAMIS Plus clients in the fee-for-service programs. The KePRO PA contract excludes:

  1) Services managed under a separate contract, including pharmacy, dental, transportation, Mental Retardation & Day Support Waivers, and managed care organization (MCO) vendor services;
2) Authorizations maintained by DMAS Medical Support (Organ Transplants, Gastric Bypass, Cosmetic Procedures, Prostheses, and specific CPT procedures listed in the Physician Manual); and,
3) Certain waiver enrollment/service authorizations maintained by DMAS Long-Term Care.

KePRO accepts PA requests via iEXCHANGE® (an interactive web-based application), telephone, paper, and fax submission. For most services the preferred method of submission is iEXCHANGE®. Registration is required and once completed, providers can expect to receive their iEXCHANGE user login and password by email within 10 business days.
 

Questions regarding the prior authorization process can be sent via e-mail to providerissues@kepro.org  or PAUR06@dmas.virginia.gov .
*** Note: Do not send PHI by email unless it is sent via a secure encrypted email transmission.
 

• Prior Authorization Contractor
  

• iExchange^® Registration

• Provider Resources

  • Prior Authorization Reference Guide  

  • KePRO Provider Training Schedule & Resources

  • DMAS Provider Training Schedule & Resources
     

• Medicaid Memos to Providers

• FAQs - Updated August 5, 2009 (pdf)

• FAQs – KePRO



• Prior Authorization Fax Forms

• Community Based Care Waiver Request - DMAS-98 (pdf)

• Community Based Care Waiver Request - DMAS-98 (editable, doc)

• Inpatient Prior Authorization Request - DMAS-362 (pdf)

• Inpatient Prior Authorization Request - DMAS-362 (editable, dot)

• Inpatient Psychiatric Continued Stay Review - DMAS-362-A (pdf)

• Inpatient Psychiatric Continued Stay Review - DMAS-362-A (editable, dot)

• Outpatient Prior Authorization Request - DMAS-363 (pdf)

• Outpatient Prior Authorization Request - DMAS-363 (editable, dot)

• Substance Abuse Services Prior Authorization Request Form DMAS-363-A

• Substance Abuse Services Prior Authorization Request Form DMAS-363-A (editable, doc)

• Treatment Foster Care Prior Authorization Request Form DMAS-364

• Treatment Foster Care Prior Authorization Request Form DMAS-364 (editable, dot)

• Residential Treatment Care Prior Authorization Request DMAS-365

• Residential Treatment Care Prior Authorization Request DMAS-365 (editable, doc)

• Residential Services for Children & Adolescents Level A/B Prior Authorization Request - DMAS-365AB

• Residential Services for Children & Adolescents Level A/B Prior Authorization Request - DMAS-365AB(editable, doc)



• IIH Prior Authorization Request Form - DMAS-366
  

• IIH Prior Authorization Request Editable Form - DMAS-366 (editable, dot)  

• Community Mental Health Rehab Services PA Request - DMAS-367
  

• Community Mental Health Rehab Services PA Request - DMAS-367(editable, dot)
  

• Codes

  • ICD9 Diagnosis Codes

  • Revenue Codes for Home Health

  • CPT Codes For Radiological Scans
    After clicking the link, please refer to the Table of Contents under the heading titled "Outpatient PET, CAT, and MRI CPT Code Requiring PA".

  • Revenue Codes/Corresponding CPT Codes for Outpatient Rehab Services