Providers
Utilization Management and Case Management Programs
Dear Providers:
We are excited to be working in collaboration with you to assist participants in meeting their health care goals. We realize the importance of understanding your prescribed treatment plan to determine the medical necessity of requested services and to best support participant compliance. Our registered nurses strive to work as an âextensionâ of your staff â focusing on areas of concern that you may have; building on the education your office staff may have provided and sharing pertinent information that we may learn from the participant about their condition(s). We look forward to working with you/your office staff to understand how we can best support you and the participant in meeting health goals. Please watch this site for additional information in the near future.
Utilization Management
Acentra Health (formerly Kepro) manages the utilization review program for Mississippi State and School Employeesâ Health Insurance Plan, completing medical necessity determinations since July 1, 2021. The Provider Portal is available at portal.kepro.com and allows your staff to submit prior authorization requests at their convenience 24 hours/day; 7 days a week. Our easy to use portal allows you to communicate directly with utilization review staff, attach medical records, check the status of each request, and in some cases, receive immediate determination notification at the time of completion â all in the same record. For a list of services that require prior authorization, please see knowyourbenefits.dfa.ms.gov/publications/.
Training videos and step by step guides are available under the "Provider" tab which provide instructions on how to submit prior authorization requests through the portal. The training guides include information on assigning one person from your organization to be the administrator, or owner, of your portal account. To register as the account administrator of a facility, clinic, or doctorâs office, the designated individual will need their NPI and BCBS ID. If you require further assistance, please email our team at MSUM@kepro.com.
If you require further assistance, please email our team at MSUM@kepro.com.
Medical Necessity Criteria
Acentra Health uses InterQual criteria (Change Healthcare) to review services for medical necessity. InterQual is evidence-based criteria that offers guidance in covering medical and behavioral health for all levels of care in addition to care planning, complex care management, durable medical equipment, procedures, and specialty pharmacy. As needed, Acentra Health also utilizes ASAM (American Society of Addiction Medicine) criteria for Substance Use services and MCG (Milliman Care Guidelines), which are also nationally recognized quality criteria references. Criteria is provided upon request and is also available in the Atrezzo Provider Portal under SmartSheets.