Western Highlands Network
Friday E-Mail Newsletter
Number 09
07/01/2005
The Friday E-Mail is a weekly update for providers by the Services Management Department of Western Highlands Network. Please distribute to all your staff.
IPRS Target Population Primer-Part 2
Hope you are having a great Friday and have a safe, restful 4th of July holiday!! We are concluding the primer on IPRS today.
IPRS has a few Target Population "concurrencies" that are not allowable:
- A consumer cannot be CMMED and CMSED
- A consumer cannot be AMSPM and AMSMI
- Only one DD Target Population can be assigned per consumer
Not all Target Populations pay for all services. You can check for the diagnoses and services that are covered by each Target Population on the Division's website.
"Look behinds" indicate that clinicians often make errors in assigning Target Populations. You can find an IPRS training manual on the WHN website.
The LME will not authorize a service if it is not covered by the consumer's Target Population. You will get a denial. There are a few exceptions and they are noted on your Letter of Authorization.
Only the case responsible agency can complete the initial Target Population or make any change.
Now you know why the IPRS form is so important. It's just like the insurance card you carry and that your doctor checks each time you see him or her.
The other form that is critical, because the LME cannot bill the State without the information, is the Demographics form. This is why you can't get a service authorized without Demographics or a current IPRS Target Population.
In conclusion, here's a good way to think about IPRS. Pull out your insurance card from your wallet or purse. For example, you may have BC/BS. So IPRS is an uninsured consumer's "insurance card." And on your BC/BS insurance card, it spells out the specific type of coverage that you have under your plan. On the IPRS "insurance card" that's the Target Population. The Target Population specifies what services that the consumer is eligible to receive under IPRS
Please e-mail us if you still have questions about IPRS and Target Populations.
Pended SARS Will Not Be Automatically Denied
As you know, we no longer administratively deny SARs, but pend them instead. We had announced that pended SARs would be automatically denied after 10 days. The volume of pended SARs is so great that we will NOT automatically deny.
Richard Munger
Director of Services Management
Western Highlands Network
356 Biltmore Avenue
Asheville, NC 28801
Telephone: (828)258-3511 x2915
FAX: (828) 225-2779
E-Mail: richardm@westernhighlands.org
Website: westernhighlands.org
