Provider Training Primary Care Case Management (PCCM) Primary Care Provider (PCP)

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

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

3. Roles and Responsibilities of the PCCM PCP 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

4. Roles and Responsibilities of the PCCM PCP 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

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

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

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

8. Change in PCCM PCP Enrollment 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

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

18. Full Maintenance - Service Location, cont’d

19. Full Maintenance - Rendering Provider

20. Full Maintenance - Rendering Provider, cont’d

21. Full Maintenance -Rendering Provider, cont’d

22. Full Maintenance - Rendering Provider, cont’d

23. Full Maintenance -Rendering Provider Affiliations

24. Submitting Maintenance Case

25. PCCM Member Assignment to PCP For RHC, FQHC and Direct Individual Providers 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 Members are assigned to the rendering PCP provider Members assigned to a terminating PCP must be moved to another PCP To prevent a delay in payment of claims To ensure the member is able to establish with another PCP

26. PCCM Managed Services 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

27. 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: • Federally Qualified Health Centers • Rural Health Clinics • Indian Health Services • Early and Periodic Screening, Diagnosis, and Treatment Services • Hearing Aids and Services • Home Health Services 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: MaineCare managed care members are responsible for payment of copays as directed by the applicable policy.

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

29. Referral Information 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

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

31. Referral Guidelines Specialists should only provide services to PCCM members with a referral in place The following situations do require a referral: Follow-up services for PCCM members who have received Emergency Department (ED) care Walk-in clinic services 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

32. PA vs. Referral Prior Authorizations (PA) & Referrals are not interchangeable Some services require BOTH PA and Referral

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

34. Interactive Primary Care Roster

35. Member Eligibility Verification

36. Member Eligibility Verification

37. Submitting Referrals From the Eligibility Screen

38. Submitting Referrals

39. Submitting Referrals

40. Submitting Referrals

41. Referral Status Referrals and referral status can be viewed on the MIHMS Health PAS Online 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

42. Referral Status

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

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

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

46. PCCM Management Fees 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

47. PCP Incentive Payments Additional compensation to providers that: Deliver high quality healthcare to MaineCare patients 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

48. Management Fees and PCCM Incentive Payments *Safety Net RHC is a Rural Health Center with a special Federal designation allowing a higher Federal match.

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

50. Who to Call