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MIHMS PROVIDER COMMUNITY TRAINING
Primary Care Case Management (PCCM)Primary Care Provider (PCP)
Version 1.1
Prov_Training_PCCMPCP_v1.1_20100726
Today’s Agenda
• Introduction
• Roles and Responsibilities of a MaineCare PCCM-PCP
• Enrollment as a PCCM-PCP
• PCP Management Fee
• PCP Reports
• Services Requiring Referral
• Submitting Referrals
• Billing for Referred Services
• Who to Contact
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Roles and Responsibilities of the PCCM-PCP
• Verify eligibility and managed care enrollment
• Provide or arrange for delivery of primary care
• Provide 24/7 coverage as approved by OMS
• Use no discrimination in the assignment or continued enrollment of a MaineCare member
• Accept appropriate MaineCare members selected or assigned
• Offer all appropriate immunizations
• Be a Prevention, Health Promotion and Optional Treatment Services’ provider for children <20
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Roles and Responsibilities (continued)
• Assist MaineCare Services in educating members• Keep a PCCM member until another PCP is selected if
a change is needed• Submit all materials about PCCM to MaineCare
Services for review prior to use• Review Monthly Panel Reports for errors, omissions or
discrepancies• Forward medical records when appropriate and
requested in writing– At no cost and within 10 days
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Roles and Responsibilities (continued)
• Furnish to MaineCare Services medical records pertaining to:– Request for exemptions, managed care enrollment and claims– At no cost and upon request
• Complete necessary paperwork in accordance with MaineCare Services policy
• Oversee & manage a care plan for members with specific chronic conditions (i.e., Chronic Obstructive Pulmonary Disease)
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Management Fees and PCCM Incentive Payments
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May 2009 Primary Care Provider Sites Participating In PCCM
Type of Provider Site
ManagementFee ($3.50 PMPM processed 21st ea month)
IncentivePayment (PCPIP Bi-annually)
Utilization Report No Payment of Any Kind
Hospital Employed X XHospital Affiliated X X XPrivate Physician Site
X X X
RHC & Safety Net RHC
X X
FQHC X XIHS X X
Safety Net RHC is an Rural Health Center with a special Federal designation allowing a higher Federal match.
• Advanced Practice Registered Nursing Services
• Ambulatory Surgical Center Services
• Audiology Services
• Chiropractic Services
• Clinic:– Ambulatory Care Clinics– Federally Qualified Health Centers– Rural Health Clinics
• Developmental and Behavioral Evaluation Clinic
• Early and Periodic Screening, Diagnosis, and Treatment Services
• Hearing Aids and Services
• Home Health 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
The following services require a referral from MaineCare managed care PCP. PCPs are responsible for completing a referral form when patients need to access the following services:
MaineCare Managed Care Services
MaineCare managed care members are responsible for payment of copays as directed by the applicable policy.
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• Ambulance Services
• Annual Gynecological Examinations andLimited follow-up for abnormal PAP Smears
• Annual Routine Eye Exams
• Community Support Services
• Consumer Directed Attendant Services
• Day Habilitation Services for Persons with Mental Retardation
• Day Health Services
• Day Treatment Services
• Dental Services
• Early Intervention Services
• Hospital’s Emergency Department Services
• Family Planning Agency Services
• Genetic Testing and Clinical Genetic Services
• Home Based Mental Health Services
• Home and Community Benefits for the Elderly andfor Adults with Disabilities
• Home and Community Based Waiver Services– For Persons with Mental Retardation– For the Physically Disabled
• Hospice Services• ICF-MR Services • Laboratory Services
The following services do not require a referral from the MaineCare managed care PCP.These services will remain under regular fee-for-service MaineCare.
Non-Managed MaineCareServices
• Licensed Clinical Social Worker Services
• Medical Imaging Services
• Mental Health Clinic Services
• Mental Health and Substance Abuse 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
• Psychological Services
• Rehabilitative Services
• School-Based Clinics and Well Child Clinics
• School-Based Rehabilitation Services
• Substance Abuse Treatment Services
• Targeted Case Management Services
• Transportation Services
• V.D. Screening Clinic Services
• New MaineCare Benefits Manual, Chapter II Sections
MaineCare managed care members are responsible for payment of copays as directed by the applicable policy.
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PCCM-PCP Enrollment
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Making a Referral• The PCCM-PCP submits a referral form by:
– Direct Data Entry (DDE) through the portal – Electronic Data Interchange (EDI) batch submission using a
278 file format – Phone: 1-866-690-5585
• Automated Voice Response (AVR)• Provider Services Specialist
– Fax:1-866-598-3963– Mail:
MaineCare ServicesPrior Authorization/Referral Unit 11 State House StationAugusta, ME 04333-0011
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Making a Referral• PCCM Referral Information
– Current PCCM referrals that extend beyond 8/31/2010 will expire
– PCCM-PCPs will need to resubmit referrals with an 9/1/2010 start date
– Beginning 8/9/2010, Primary Care Providers (PCCM-PCPs) will have to initiate new Referrals for service dates on or after the 9/1/2010 Go-Live date for services that require a referral
• Information– Referrals are made by visit, not at the procedure code level – Diagnosis codes are required
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Referral Status
• Referral and referral status can be viewed on the MyHealthPAS portal by:– The PCP who submitted the referral – The provider to whom the referral was made
• To check Referral status – Must be a registered trading partner to access referral
information– Providers may call Provider Services at 1-866-690-5585
starting 8/9/2010
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Eligibility Verification Request
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Eligibility Verification Submission
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Eligibility Information - MyHealthPAS
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Plan Plan Type Coverage Codes (Financial)
MaineCare Medical
Adult and Children Services, Adults Non-Categorical, Defined Emergency Services Only, Defined Benefits
Primary Care Case Management Medical
Adult and Children PCCM, Adults Non Categorical PCCM
Office of Elder Services Medical PA Only Adult and Elder Services
Maine CDC-Maine Breast and Cervical Health Program Medical Breast and Cervical Health ScreeningOffice of Child and Family Services Medical Adult and Children ServicesMaine CDC CSHN Medical Children Special Health NeedsMaine Eye Care Medical Medical Eye CareMaine RX Pharmacy Maine Rx
Buy-In Medical Qualified Medicare Beneficiary (QMB)Drugs for the Elderly Pharmacy DEL
Referral Submission
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Referral Submission Diagnosis
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Referral Submission - Provider Search
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Diagnosis History
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PCP Roster
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You may also print a report
Billing for Referred Services in MIHMS
• Specialists are required to include the NPI of the referring PCCM-PCP provider – Referral ID numbers used in MeCMS will not be used
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– CMS1500 Box 17b• Specialists enter the NPI of the PCCM-PCP• Do not enter the MeCMS referral ID in 17A
– UB04 Box 63 Line A• Specialists should NOT enter the MeCMS referral ID on the UB04
claim form Box 63 Line A
Molina Provider Services866-690-5585
State Provider Relations
800-321-5557
Member Eligibility Verification (8/9/2010) MeCMS Claims
IssuesMIHMS Claims Issues(9/1/2010)Provider Maintenance(as of 12/14/09)Technical Support(as of 12/14/09)
PCP Network Services 866-796-2463, extension 7-4827
PCCM Referrals(8/9/2010)
Prior Authorizations (8/9/2010)call or contact by Fax: 866-598-3963
PCCM-PCP Issues
Who to call?
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The End - Final Screen
This is the final screen in this presentation.
Please remember to submit your evaluations.
Thank you!
THE END
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