July 2007

1. July 2007

2. Overview • Verifying Eligibility • Goal of Program and Basic Concepts • Improvements to the Program • PMP Responsibilities • New Case Management Model • Measures of Success (Quality Assurance) • Improvements to Referral Form

3. Verify Eligibility • Provider Electronic Solutions software • Software developed by the provider’s billing service, using specifications provided by EDS • Automated Voice Response System (AVRS) at 1 (800) 727-7848 • Contacting the EDS Provider Assistance Center at 1 (800) 688-7989 • Web Server https://almedicalprogram.alabama-medicaid.com/secure.

4. Who Can Be a PMP? • Pediatricians • Internists • Family Practitioners • General Practitioners • OB/GYNs • FQHC • RHC • Specialists (ex: special needs child)

5. Goal To improve health care for Medicaid recipients by providing a medical home while containing the escalating cost of providing quality healthcare

6. PMP Responsibilities • Patient Coordination/Management • Provision and/or referral • 24/7 Availability (voice to voice) • Directly or through arrangement • Participate in Agency utilization and quality programs

7. Basic Program Concepts • Providers enroll as a Primary Medical Provider (PMP) • Patients are assigned to a PMP • Services must be provided directly or through referral • PMPs are responsible case managers • Reminder • Patient 1st is a medical home concept • Patient 1st does not affect benefit limits

8. PMP Caseload • May serve multiple counties • Maximum panel collectively is 1200 • Physician Extenders may increase by 400 each up to two extenders (total of 2000) • Practice a minimum of 32 hours per week for FTE 1.0 (32-40 hours)

9. Reports • Initial Assignment Listing • Recipients assigned for future date • Contains recipient demographic information • Not a final list – patient may change before effective • Monthly Enrollment Listing Cover sheet: • Counties currently enrolled in • Age Criteria • Current Caseload information • Max Caseload information • PMP List – indicates if on published list • New patient assignment • Continuous patient assignment • Deleted patient enrollees • Now has reason why deleted from panel

10. Reports • Periodic Re-screen List – EPSDT (monthly) - Mailed with last check-write of the month • Patient 1st Referral Report (monthly) • Emergency Room Management Report (quarterly) • Profiler (quarterly)

11. PMP Responsibilities • EPSDT • PMP performs own screenings or contract with other provider • Vaccines for Children • Enrolled as VFC provider with the Health Department • Medical Home Project • Completes training regarding establishing and maintaining medical home for patients • 24/7 Voice to Voice Availability • Provides direct after hour coverage as specified • Does not automatically refer to Emergency Dept. of hospital • Hospital Admitting • Has hospital admitting privileges and admits own patients

12. PMP Responsibilities • In-Home Monitoring - Disease Management • Agrees to work with Agency/partners to place in-home monitoring services for select patients • InfoSolutions • Agrees to work with BC/BS and utilize the InfoSolutions pharmacy program data • Electronic Notices • Agrees to receive notices from Medicaid/EDS via e-mail • Electronic Educational Materials • Agrees to receive educational items via electronic means/reproduce for assigned Patient 1st patients

13. Program Enhancements • In-Home Monitoring - Disease Management • partnership with USA Hospital and the Alabama Dept. of Public Health • telemetry concept • patient monitoring (disease management) • target chronic diseases - diabetics initial phase • coordinate with Primary Physician • supported with case management • web based with real-time reporting available

14. Program Enhancements • InfoSolutions- inform providers of prescription activity based on paid claims data • Desktop or PDA tool for physicians • Download patient prescription information each morning • Patient specific Preferred Drug information • Alternative treatment options • Monitor on quarterly basis

15. Program Enhancements • e-Prescribing - Download medication history - Automatically alerted to potential drug-to-drug interactions - Prescribe/refill multiple medications - Print prescriptions up to 30 feet away using Bluetooth technology - Establish “favorites” list of frequently prescribed medications - View both the Blue Cross/Medicaid formulary's

16. Program Enhancements • Patient 1st Care Coordinators(aka Case Management) Health Department case managers work with patient to resolve issues identified (no referral form required) • Targeted to: • frequent use of ED • non compliant patients • Available for: • interaction with In-Home Monitoring • identified by Agency and PMP • Located at: www.medicaid.alabama.gov>Programs>Patient 1st>List of Patient 1st Care Coordinators

17. Measures of Success PROGRAM IMPACT • Patient Costs • Emergency Room Usage • Pharmacy • Prescribing Practices • PDL Usage • Generic vs. Brand (Therapeutic Equivalents)

18. Quality Assurance-Provider Report Profiler • Individual report cards sent to each PMP to provide activity information and program measurements • Overall Patient and Cost Comparison • Pharmacy Information (costs and utilization) • Performance Measures

19. Eligibles Included • Sobra Children • MLIF Eligibles (formerly AFDC) • Infants Of SSI Mothers • Aged • Blind • Disabled • Refugees

20. Eligibles Excluded • Foster Children* • SOBRA Adults • Dual Eligibles • Institutionalized* (nursing homes, group homes, MR facilities, DYS) • Lock-Ins • Enrollees of Private HMO* • Medically Exempt* * Not automatically removed from program (1-800-362-1504)

21. Patient Assignment • May be assigned to: • individual physician (use physician number for referrals) • group of physicians (use group number for referrals if provider is enrolled in Patient 1st as a group) • clinics such as FQHC or RHC (use clinic number)

22. Patient AssignmentProcess • Levels To The Assignment Process • Newborn - overrides caseload • Sibling - overrides caseload • Last PMP - overrides caseload • Historical (claims) • Random (based on PMP within recipient county) • Recipients Notified 45 days prior to date

23. They Want to Change . . . • Pick from list of PMPs • Phone Call • In Writing -Change Form • Via Web • 15th of the Month

24. Additions or Dismissals • Must Be in Writing (on requesting physician’s letterhead) and Include • Medicaid Number • Reason For Dismissal • Provider Number • Based on AMA Guidelines and Patient 1st Policy • Letter to the Recipient with copy to Medicaid • Reassignment to another PMP (not in the same group) With Opportunity To Change

25. Referrals • Agency referral form (form 362) or efile referral (www.Efileshare.com) • Referralsmustbe in writing • if oral approval given, PMP must send written referral within 72 hours • Referral can be a duration of up to 12 months • Referral from a previous PMP honored for 6 months • Referral based on EPSDT screening honored for 12 months • Referral number is the provider number that a recipient is assigned to (verify eligibility)

26. Override Process • Used for situations where: • Efforts to obtain referral from the PMP have been exhausted • Thoroughly reviewed on a case-by-case basis • How to obtain: • Complete override form • Mail to: Alabama Medicaid Agency System Support PO Box 5624 Montgomery, AL 36103-5624

27. Responsibilities • EDS • Provider Enrollment • PMP Enrollment • Caseload Change Requests • County Enrollment • Recipient Call Center • Age Limit Overrides • Patient 1st Change Forms • Patient 1st Doctor Assignment Requests to add patient(s) to panel

28. Numbers to Remember • Provider Assistance Center 800-688-7989 • Provider Enrollment Fax 334-215-4271 • Recipient Call Center 800-362-1504 • Recipient Call Center Fax 334-215-4140 • Web Site - www.medicaid.alabama.gov • For additional information, select the Programs tab from the top menu bar