Idaho Medicaid Primary Care Programs

1. Idaho Medicaid Primary Care Programs

2. Idaho Medicaid • Primary Care Programs • Healthy Connections • Idaho Medicaid Health Home • Patient centered model of care with a focus on comprehensive care coordination for participants with complex or chronic diseases • All Healthy Connections policies, procedures and requirements, including referrals, apply to Health Home providers and participants

3. Referrals • Method of referral: • Electronic • On-Line through Trading Partner Access • www.idmedicaid.com • Referral Form • HC Referral Form • Prescription Pad • Admit orders, etc. • Verbal • Calling orders to a specialist • Documented in both the referred from and referred to patient records or entered online

4. Referral Requirements • Name of the PCP granting the referral • Date referral issued • Duration of referral-best practice not to exceed 1 year • Number of visits • Specific scope of services being referred • Reason for referral • Diagnosis or condition

5. Referral Requirements • A referral may be passed on by a specialist to other providers to treat the condition indicated in the original referral under the following referral approval reasons: • Diagnose and Treat • Diagnose and Treat to include surgery • Diagnose, Treat and Forward to specialty provider for this condition • Follow patient jointly • Assume Care

6. HC Policies • Referrals remain active for duration of referral and do not expire if participant changes HC PCP • Referral not required: • Emergency medical services when condition meets emergency definition • Acute symptoms of sufficient severity, including severe pain that could result in placing the health of the individual in serious jeopardy, impairment of bodily functions or dysfunction of any body parts, if left untreated Pregnancy related services Provided by an OB/GYN-to include hospital based services when directed by an OB/GYN specialist • Hospital Admissions • Subsequent to an Emergency Room visit • Discharge in coordination with PCP

7. Questions • Is the Patient Accounting System considered to be part of the records? • Screening procedure that does not require referral, condition then found that requires a referral? • Patient comes in with order from specialist, patient has not established care with PCP?

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