Provider Training

Primary Care Case Management (PCCM)

Primary Care Provider (PCP)

1December 2012

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

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• 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

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• 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

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• Verify for PCCM Members:o Eligibility o PCCM enrollmento Referrals in MIHMS

• Provide delivery of specialty care

• Complete necessary paperwork in accordance with MaineCare Services policy

Roles and Responsibilities of the MaineCare Specialist

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1. Enroll as a MaineCare provider2. Determine the eligible providers in the practice who provide

primary care3. Request participation in PCCM as a PCP through provider

enrollment/maintenance4. Agree to the MaineCare PCCM Terms and Conditions (PCCM

Rider)5. Have primary care service locations approved as PCCM sites6. Be approved as a PCCM PCP by MaineCare’s PCP Network

Services

7. Follow Primary Care Case Management (PCCM) rules

PCCM PCP Enrollment

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• Qualifying PCCM PCP Specialties:oPediatrics

o Internal Medicineo Family Practiceo General Practiceo Obstetrics/Gynecologyo Certified Nurse Practitionero Physician Assistant

PCCM PCP Enrollment

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• 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

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Provider Maintenance

• Demographic Maintenanceo Update contact informationo Change service location addresso Update office hours

• Full Maintenanceo Enroll service location in PCCMo Enroll rendering provider in PCCMo Make changes to PCCM information o Add or terminate service locationo Add or terminate rendering provider

Provider Maintenance

Starting a Maintenance Case

Maintenance Portal Navigation

Demographic Maintenance - Service Location

Demographic Maintenance - Service Location Updates

Demographic Maintenance - Service Location Updates, cont’d

Full Maintenance - Service Location

Full Maintenance - Service Location, cont’d

Full Maintenance - Service Location, cont’d

Full Maintenance - Rendering Provider

Full Maintenance - Rendering Provider, cont’d

Full Maintenance -Rendering Provider, cont’d

Full Maintenance - Rendering Provider, cont’d

Full Maintenance -Rendering Provider Affiliations

Submitting Maintenance Case

• For RHC, FQHC and Direct Individual Providerso 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 providerso Members are assigned to the rendering PCP

provider• Members assigned to a terminating PCP must be moved

to another PCPo To prevent a delay in payment of claimso To ensure the member is able to establish with

another PCP

PCCM Member Assignment to PCP

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• 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

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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 Centerso Rural Health Clinicso 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

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

MaineCare managed care members are responsible for payment of copays as directed by the applicable policy. 28

• 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

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• Provider types, with the specialties below, have no renderings in MIHMS:o FQHCo RHCo Hearing Aid Serviceso Home Health Serviceso Hospital Serviceso Durable Medical Equipment (DME)

Referral Guidelines

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• 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) careo Walk-in clinic serviceso 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 Guidelines

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Prior Authorizations (PA) & Referrals are not interchangeable

Some services require BOTH PA and Referral

PA vs. Referral

PA Referral

Requires medical review Does 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

If required but not in MIHMS, claim will deny

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• 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 ServicesPrior Authorization/Referral Unit 11 State House Station

Augusta, ME 04333-0011

Submitting a Referral

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Interactive Primary Care Roster

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Member Eligibility Verification

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Member Eligibility Verification

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Submitting Referrals From the Eligibility Screen

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Submitting Referrals

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Submitting Referrals

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Submitting Referrals

• 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 informationo Providers may call Provider Services

at 1-866-690-5585

Referral Status

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Referral Status

Specialists must verify a referral is entered prior to providing the service and submitting the claim

• CMS1500 Box 17, 17a & 17bo Name of the referring PCCM PCP in Box 17 is

requiredo Box 17a should always be left blanko NPI of the PCCM PCP in Box 17b is required

• UB04oPCP Name is not required

Billing for Referred Services in MIHMS

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Referral Numbers are not to be entered on claims

• CMS1500 Box 23o For Prior Authorization Number entry onlyo Entering a Referral Number will deny the claim

• UB04 Box 63o For Prior Authorization Number entry onlyo Entering a Referral Number will deny the claim

Billing for Referred Services in MIHMS

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• Enroll/Disenroll Reports o Provider’s newly assigned and removed PCCM memberso Report run twice per month

• PCCM Panel Reportso Provider’s entire listing of assigned PCCM memberso Report run once per month

• PCCM Payment Rosterso PCCM members assigned to non-hospital-based providers

for paying monthly management feeso Report run once per month

PCCM PCP Reports

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• 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 21st of each month

• Dependent on member assignments, so may vary each month

• Paid within two-weeks of the Roster Report

PCCM Management Fees

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• Additional compensation to providers that:o Deliver high quality healthcare to MaineCare patientso 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 http://www.maine.gov/dhhs/oms/provider/pccm.html

PCP Incentive Payments

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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 21st ea month

IncentivePayment -PCPIP Bi-annually

Utilization Report - Quarterly

No Payment of Any Kind

Hospital-Based X XHospital-Affiliated X X X

Private Physician Site X X XRHC & Safety Net RHC* X X

FQHC X XIHS X X

*Safety Net RHC is a Rural Health Center with a special Federal designation allowing a higher Federal match. 48

PCMH Expansion/Transition and Health Homes

• PCMH Multi-Payer Piloto Application and acceptance process completeo No providers to be added in immediate futureo 50 practices added, for a total of 75 beginning 1/1/2013o Transition to Chronic Condition Model of Health Homes for

payments as of 1/1/2013

• Health Homeso Application and acceptance process reopenedo 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

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Who to Call

Molina Provider Services1-866-690-5585

PCP Network Services1-866-796-2463, ext 73320 or 287-3320ext 76349 or 287-6349

Member Eligibility Verification PCCM PCP/Site Enrollments

MIHMS Claims Issues PCCM Management Fees

Provider Enrollment Maintenance PCP Incentive Payments/ UR Reports

Technical Support PCCM PCP Enroll/Disenroll Reports

PCCM Referral Submissions/Status PCCM PCP Panel Reports

Prior Authorizations PCCM Roster Reports

PCCM Managed Services

PCCM Policy Chapter VI

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Questions?

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Resources

MIHMS Health PAS Online Portal: https://mainecare.maine.gov

MaineCare Policy: http://www.maine.gov/sos/cec/rules/10/ch101.htm

Member Education Request Form (MERF): http://www.maine.gov/dhhs/oms/provider/pccm.html

Referral Form: http://www.maine.gov/dhhs/oms/provider/pccm.html

PA Request Forms: https://mainecare.maine.gov Provider>Provider Documents>Forms

PCP Network Services Email: PCP-Network-Services.DHHS@maine.gov

MaineCare Listserv: http://www.maine.gov/dhhs/oms/list_serv/listserv.shtml 52