Issue Resolved - CAP claims and PA Requirement

As of January 4, 2015, NCTracks validates that an active Community Alternatives Program (CAP) prior approval (PA) is on file for the dates of service submitted on claim(s). This is not a new requirement, but the edit is new. This edit is specific to CAP/Children (CAP/CH), CAP/Choice (CAP/CO), and CAP/Disabled Adults (CAP/DA). (It does not impact Long Term Care Nursing Facility PAs.) Claims submitted for dates of service prior to the approved effective date of the FL2 are denied with an EOB stating that the beneficiary is not eligible for CAP services prior to the approval of level of care determination.

However, the edit requires the claim to match the FL2 request (PA) on Recipient ID and many of the FL2 PAs do not have a recipient ID on them. The recipient ID is not assigned in the county until the FL2 PA is approved. Therefore the claims were denying for NO PA ON FILE.

This issue has been resolved. As of January 29, the disposition of the edit has been changed to "pay and report," which means the EOB will still appear on the Remittance Advice (RA), but the edit will not cause the claim to deny.

Affected providers can now resubmit denied claims to NCTracks.

Alternative approaches to the application of this edit are under consideration. Providers will be notified if any further changes are made to the edit. In the meantime, providers are expected to comply with the requirement that an active Community Alternatives Program (CAP) prior approval (PA) be on file for the dates of service submitted on claim(s).