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Provider Training Primary Care Case Management (PCCM) Primary Care Provider (PCP) 1December 2012.

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Presentation on theme: "Provider Training Primary Care Case Management (PCCM) Primary Care Provider (PCP) 1December 2012."— Presentation transcript:

1 Provider Training Primary Care Case Management (PCCM) Primary Care Provider (PCP) 1December 2012

2 Agenda Roles and Responsibilities PCP Enrollment in PCCM Member Assignment to PCP Managed Services Referrals Billing for Referred Services PCCM PCP Reports PCCM Fees/Incentives/Initiatives Who to Call 2

3 Verify eligibility and enrollment Delivery of primary care Acceptance of PCCM members Offer all appropriate prevention services Assist in educating members Retain members until changes are complete Member communications Roles and Responsibilities of the PCCM PCP 3

4 Forwarding of medical records Review reports for errors, omissions or discrepancies Processing referrals for managed services (specialty) Oversee & manage a care plan for members with specific chronic conditions Maintain PCP enrollments Roles and Responsibilities of the PCCM PCP 4

5 Verify for PCCM Members: o Eligibility o PCCM enrollment o Referrals in MIHMS Provide delivery of specialty care Complete necessary paperwork in accordance with MaineCare Services policy Roles and Responsibilities of the MaineCare Specialist 5

6 1.Enroll as a MaineCare provider 2.Determine the eligible providers in the practice who provide primary care 3.Request participation in PCCM as a PCP through provider enrollment/maintenance 4.Agree to the MaineCare PCCM Terms and Conditions (PCCM Rider) 5.Have primary care service locations approved as PCCM sites 6.Be approved as a PCCM PCP by MaineCare’s PCP Network Services 7.Follow Primary Care Case Management (PCCM) rules PCCM PCP Enrollment 6

7 Qualifying PCCM PCP Specialties: o Pediatrics o Internal Medicine o Family Practice o General Practice o Obstetrics/Gynecology o Certified Nurse Practitioner o Physician Assistant PCCM PCP Enrollment 7

8 Policy requires that a 60-day notice, in writing, be provided to MaineCare when a PCP is leaving a practice or the practice will close Inform MaineCare, as soon as possible, when a provider or service location will terminate its enrollment with PCCM or MaineCare When change of ownership occurs, notify your Provider Relations Specialist Change in PCCM PCP Enrollment 8

9 Provider Maintenance Demographic Maintenance o Update contact information o Change service location address o Update office hours Full Maintenance o Enroll service location in PCCM o Enroll rendering provider in PCCM o Make changes to PCCM information o Add or terminate service location o Add or terminate rendering provider

10 Provider Maintenance

11 Starting a Maintenance Case

12 Maintenance Portal Navigation

13 Demographic Maintenance - Service Location

14 Demographic Maintenance - Service Location Updates

15 Demographic Maintenance - Service Location Updates, cont’d

16 Full Maintenance - Service Location

17 Full Maintenance - Service Location, cont’d


19 Full Maintenance - Rendering Provider

20 Full Maintenance - Rendering Provider, cont’d



23 Full Maintenance - Rendering Provider Affiliations

24 Submitting Maintenance Case

25 For RHC, FQHC and Direct Individual Providers o Members are assigned to the Pay-To NPI affiliated to the PCCM service location where members are seen For Provider Groups that enroll their rendering providers o Members are assigned to the rendering PCP provider Members assigned to a terminating PCP must be moved to another PCP o To prevent a delay in payment of claims o To ensure the member is able to establish with another PCP PCCM Member Assignment to PCP 25

26 Services provided by a specialist rather than a PCCM member’s PCP Require a referral to the provider rendering the service Some services are exempt from requiring referrals Referrals may be submitted for up to one year Referrals may be submitted only for dates-of-service a member has PCCM eligibility PCCM Managed Services 26

27 The following services require a referral from MaineCare Primary Care Case Management PCP. PCPs are responsible for completing a referral form when patients need to access the following services: PCCM Managed Services Hospital Services (Except lab and medical imaging) Medical Supplies and Durable Medical Equipment Occupational Therapy Services Ophthalmology and Optometry Services Physical Therapy Services Physician Services Podiatry Services Speech and Hearing Agencies Speech/Language Pathology Services Advanced Practice Registered Nursing Services Audiology Services Chiropractic Services Clinic: o Federally Qualified Health Centers o Rural Health Clinics o Indian Health Services Early and Periodic Screening, Diagnosis, and Treatment Services Hearing Aids and Services Home Health Services MaineCare managed care members are responsible for payment of copays as directed by the applicable policy. 27

28 The following services do not require a referral from the MaineCare Primary Care Case Management PCP. These services will remain under regular fee-for-service MaineCare. PCCM Non-Managed Services Ambulance Services Annual Gynecological Examinations and limited follow- up for abnormal PAP Smears Routine Eye Exams Behavioral (Mental) Health Services Community Support Services Consumer Directed Attendant Services Day Health Services Dental Services Hospital Emergency Department Outpatient Services Family Planning Agency Services Genetic Testing and Clinical Genetic Services Home and Community Benefits for the Elderly and for Adults with Disabilities Home and Community Based Waiver Services for Persons with Intellectual Disabilities or Autistic Disorder Hospice Services ICF-MR Services Laboratory Services Licensed Clinical Social Worker Services Medical Imaging Services Nursing Facility Services Obstetrical Services Optician Services Organ Transplant Services Pharmacy Services Private Duty Nursing and Personal Care Services Private Non-Medical Institution Services Psychiatric Facility Services Rehabilitative Services (Brain Injury) School-Based Services Substance Abuse Treatment Services Targeted Case Management Services Transportation Services New MaineCare Benefits Manual, Chapter II Sections MaineCare managed care members are responsible for payment of copays as directed by the applicable policy. 28

29 Current PCCM referrals in MIHMS that extend beyond 1/1/2013 will need no new entry Specialists will no longer receive a WARN message for a claim with dates-of-service 1/1/2013 forward Referrals are made by visit, not at the procedure code level If a referral cannot be processed through the Online Portal contact Provider Services When submitting a referral, if the Pay-To has no rendering providers, the referral is submitted to the Pay-To only Referral Information 29

30 Provider types, with the specialties below, have no renderings in MIHMS: o FQHC o RHC o Hearing Aid Services o Home Health Services o Hospital Services o Durable Medical Equipment (DME) Referral Guidelines 30

31 Specialists should only provide services to PCCM members with a referral in place The following situations do require a referral: o Follow-up services for PCCM members who have received Emergency Department (ED) care o Walk-in clinic services o Services provided at a Pay-To NPI other than the enrolled PCCM PCP, even if under the same Tax ID Off-hour or vacation coverage for a PCCM PCP must be provided by another MaineCare approved PCCM PCP Referral Guideline s 31

32 Prior Authorizations (PA) & Referrals are not interchangeable Some services require BOTH PA and Referral PA vs. Referral PAReferral Requires medical reviewDoes not require medical review Must be submitted by a Maine provider and PCP should receive notification Must be submitted by the member’s PCP If required but not in MIHMS, claim will deny 32

33 Direct Data Entry (DDE) through the Portal Electronic Data Interchange (EDI) batch submission using a 278 file Phone: 1-866-690-5585 o Automated Voice Response (AVR) Fax:1-866-598-3963 Mail: MaineCare Services Prior Authorization/Referral Unit 11 State House Station Augusta, ME 04333-0011 Submitting a Referral 33

34 Interactive Primary Care Roster 34

35 35 Member Eligibility Verification

36 36 Member Eligibility Verification

37 37 Submitting Referrals From the Eligibility Screen

38 38 Submitting Referrals

39 39 Submitting Referrals

40 40 Submitting Referrals

41 Referrals and referral status can be viewed on the MIHMS Health PAS Online Portal by: o The PCP who submitted the referral o The provider to whom the referral was made To check referral status: o Must be a registered Trading Partner to access referral information o Providers may call Provider Services at 1-866-690-5585 Referral Status 41

42 42 Referral Status

43 Specialists must verify a referral is entered prior to providing the service and submitting the claim CMS1500 Box 17, 17a & 17b o Name of the referring PCCM PCP in Box 17 is required o Box 17a should always be left blank o NPI of the PCCM PCP in Box 17b is required UB04 o PCP Name is not required Billing for Referred Services in MIHMS 43

44 Referral Numbers are not to be entered on claims CMS1500 Box 23 o For Prior Authorization Number entry only o Entering a Referral Number will deny the claim UB04 Box 63 o For Prior Authorization Number entry only o Entering a Referral Number will deny the claim Billing for Referred Services in MIHMS 44

45 Enroll/Disenroll Reports o Provider’s newly assigned and removed PCCM members o Report run twice per month PCCM Panel Reports o Provider’s entire listing of assigned PCCM members o Report run once per month PCCM Payment Rosters o PCCM members assigned to non-hospital-based providers for paying monthly management fees o Report run once per month PCCM PCP Reports 45

46 Available only to non-hospital-based groups or individuals, RHC, FQHC, IHS Paid monthly to the Pay-to NPI Based on the number of PCCM members assigned on the Roster Report as of the 21 st of each month Dependent on member assignments, so may vary each month Paid within two-weeks of the Roster Report PCCM Management Fees 46

47 Additional compensation to providers that: o Deliver high quality healthcare to MaineCare patients o Rank above the 20th percentile for certain measures compared to other physicians within their specialty Paid to PCPs practicing Family Practice, General Practice, Pediatrics, Obstetrics/Gynecology, or Internal Medicine FQHC, RHC, IHS and hospital-based sites are excluded Other exclusions may apply For more information, go to PCP Incentive Payments 47

48 Management Fees and PCCM Incentive Payments Primary Care Provider Sites Participating In PCCM Type of Provider Site PCCM / PCMH Management Fee-$3.50/$7.00 PMPM processed 21 st ea month Incentive Payment - PCPIP Bi-annually Utilization Report - Quarterly No Payment of Any Kind Hospital-Based XX Hospital-Affiliated XXX Private Physician Site XXX RHC & Safety Net RHC* XX FQHC XX IHS XX * Safety Net RHC is a Rural Health Center with a special Federal designation allowing a higher Federal match. 48

49 PCMH Expansion/Transition and Health Homes PCMH Multi-Payer Pilot o Application and acceptance process complete o No providers to be added in immediate future o 50 practices added, for a total of 75 beginning 1/1/2013 o Transition to Chronic Condition Model of Health Homes for payments as of 1/1/2013 Health Homes o Application and acceptance process reopened o Providers able to apply through 12/14/12 o Member eligibility based on two pre-determined chronic conditions or one chronic condition while at risk for a second Upcoming Primary Care Initiatives 49

50 Who to Call Molina Provider Services 1-866-690-5585 PCP Network Services 1-866-796-2463, ext 73320 or 287-3320 ext 76349 or 287-6349 Member Eligibility VerificationPCCM PCP/Site Enrollments MIHMS Claims IssuesPCCM Management Fees Provider Enrollment MaintenancePCP Incentive Payments/ UR Reports Technical SupportPCCM PCP Enroll/Disenroll Reports PCCM Referral Submissions/StatusPCCM PCP Panel Reports Prior AuthorizationsPCCM Roster Reports PCCM Managed Services PCCM Policy Chapter VI 50

51 Questions? 51

52 Resources MIHMS Health PAS Online Portal: https://mainecare.maine.gov MaineCare Policy: Member Education Request Form (MERF): Referral Form: PA Request Forms: https://mainecare.maine.gov Provider>Provider Documents>Forms PCP Network Services Email: MaineCare Listserv: 52

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