Frequently Asked Questions: Wisconsin Medicaid (MA) and BadgerCare Plus (BC+) Case Management Benefit Programs

Transcription

1 Frequently Asked Questins - Medicaid Case Management Frequently Asked Questins: Wiscnsin Medicaid (MA) and BadgerCare Plus (BC+) Case Management Benefit Prgrams Bth Targeted Case Management (TCM) and Prenatal Care Crdinatin (PNCC): Require Freedm f Chice: Participants must have free chice f case management prviders and free chice f prviders f ther needed services. Require that services be prvided vluntarily: Participants may nt be frced t accept case management services, even if it may be in their best interest t d s. Require Medicaid t be treated as the payer f last resrt in mst cases (exceptins include, Birth t Three, Indian Health Services, and Title V prgrams). Prhibit duplicate payments fr case management/care crdinatin services made under ther prgrams Include, but are nt limited t the fllwing cre activities: assessment, individualized care plan, nging care crdinatin, mnitring, referral and fllwup. Require participants t be included, t the extent that they can, in all decisins regarding apprpriate services and prviders f services. Targeted Case Management (TCM) What is TCM? Case management services that assist members and, when apprpriate, their families gain access t and crdinate a full array f services, including medical, scial, educatinal, vcatinal, and ther services. Bradly, TCM is defined as: Assessment (persn s abilities, needs, deficits: educatinal, medical, rehabilitative, scial, vcatinal) Case plan develpment (supprt system, service gaps and prblems, planning participants, gals, service frequencies and csts, ) Onging mnitring and service crdinatin. TCM billing is limited t case management activities n direct prvisin f services. Assessments are reimbursable nly if the participant meets the eligibility requirement fr a target grup. It is pssible fr nn-medicaid services t be cvered under TCM. Examples include assisting members in accessing husing, energy assistance, legal advcacy. Examples f services nt cvered: Diagnsis, evaluatin, r treatment f a physical, dental, r mental illness Client educatin and training Infrmatin and referral services that are nt based n a member's current care plan Page 1

2 Frequently Asked Questins - Medicaid Case Management Wh qualifies fr TCM? Participants must be enrlled in MA/BC+ (thugh nt a specific HMO). TCM services are cvered under Medicaid and the BadgerCare Plus Standard Plan. All children enrlled in the Birth t Three Prgram are eligible fr case management. Eligibility fr services varies depending n target grup there are 13 target grups. The mst likely grup receiving TCM thrugh hme visiting is: Families with a child at risk f serius physical, mental, r emtinal dysfunctin (als referred t as family case management). This target ppulatin has 5 subgrups: Families with a child with special health care needs, including children with lead pisning. Families with a child/children wh is/are at risk f maltreatment. Families with a child/children invlved in the juvenile justice system. Families where the primary caregiver has a mental illness, develpmental disability, r substance abuse disrder. Families where the mther required PNCC services. Wh can prvide TCM services? Prviders f TCM are limited t public entities (cunties, tribes, municipalities) Tw exceptins: AIDS Service Organizatins (ASOs) and Independent Living Centers (ILCs) Public entities may cntract with private prviders. Only public entities can bill Medicaid fr TCM Individual case managers must meet the fllwing requirements: Knwledge f the lcal service delivery system, the target grup's needs, the need fr integrated services, and the resurces available r needing t be develped. A degree in a human services-related field (e.g. nursing) and ne year f supervised experience, r tw years f supervised experience wrking with peple in the target ppulatin, r an equivalent cmbinatin f training and experience. Hw d prviders becme certified? T prvide case management services, the case management prvider's cunty, village, r twn bard f supervisrs, city cuncil, r Indian tribal gvernment must elect t prvide the services, as utlined in s (25)(am), Wis. Stats. Eligible private, nnprfit entities d nt need this apprval. A prvider must apply with Wiscnsin Medicaid t becme certified fr TCM services.. Prviders may submit applicatins by mail r nline thrugh the FrwardHealth Prtal. The prtal prvides mre detailed infrmatin abut the criteria specific prviders need t meet, as well as updates t plicies and prcedures. The initial effective date may be as early as the date f nline applicatin submissin r request fr a paper applicatin. Certain cnditins must be met. Page 2

3 Frequently Asked Questins - Medicaid Case Management What is imprtant t knw abut dcumenting TCM services? Prviders are required t maintain case recrds, in writing r in electrnic frmat, which indicate all case management cntacts with, and n behalf f, members (a sample mnthly lg is available n FrwardHealth). The case manager r individuals prviding assessment and case planning must individually list the services in the case recrd. The case recrds must dcument the fllwing: Name f member The full name and title f the persn wh made the cntact. Additinally, if initials are used in the case recrds, the file must cntain a signature page shwing the full name f the persn wh initialed the recrd What the cntent f the cntact was Why the cntact was made Hw much time was spent The date the cntact was made Where the cntact was made Use r disclsure f any infrmatin cncerning applicants and members fr any purpse nt cnnected with prgram administratin, including cntacts with third-party payers that are necessary fr pursuing third-party payment and the release f infrmatin as rdered by the curt, is prhibited unless authrized by the applicant r member. Prviders are required t allw members access t their health care recrds, including thse related t FrwardHealth services, maintained by a prvider in accrdance with Wiscnsin Statutes, excluding billing statements. DHS has the right t inspect, review, audit, and phtcpy prviders recrds. What is imprtant t knw abut filing claims fr reimbursement? Medical prviders must have a Natinal Prvider Identifier, which can be btained thrugh the Natinal Plan and Prvider Enumeratin System website. Wiscnsin Medicaid ffers electrnic billing sftware thrugh the FrwardHealth Prtal at n cst t prviders. Fr assistance installing and using PES sftware, prviders may call the EDI Helpdesk. Where can I find mre infrmatin abut TCM? This dcument des nt serve as a cmplete accunt f prviders respnsibilities when prviding TCM services. Cmprehensive infrmatin regarding rules and regulatins can be fund at: Page 3

4 Frequently Asked Questins - Medicaid Case Management Click n Online Handbks in the left hand menu. Then using the drp dwn menus n the right hand, select BadgerCare Plus and Medicaid and Case Management, Targeted Additinal infrmatin abut case management can be fund in a frequently asked questins dcument in FrwardHealth. Prviders are encuraged t cntact their reginal Prvider Relatins Representatives with questins. They may als cntact representatives assigned t specific prgrams. Prenatal Care Crdinatin (PNCC) What is PNCC? PNCC services help a Medicaid member and, when apprpriate, the member's family, gain access t medical, scial, educatinal, and ther services related t the member's pregnancy. The gal f the PNCC benefit is t imprve birth utcmes amng wmen wh are deemed at high risk fr pr birth utcmes. PNCC services include all f the fllwing: Outreach. Initial Assessment. Care plan develpment. Onging care crdinatin and mnitring. Health educatin and nutritin cunseling services (fr members with an identified need) Outreach invlves identifying eligible, lw-incme pregnant wmen, wh may be unaware f r nt have access t PNCC services, and infrming them abut the benefit. Prviders may use a variety f strategies t market and prmte PNCC services in the cmmunity, such as infrmatinal brchures r cmmunity presentatins. Prviders are nt reimbursed separately fr utreach activities. Wiscnsin Medicaid includes the reimbursement fr utreach activities in the reimbursement fr the initial assessment. Prviders shuld be prepared t ffer all five cmpnents f the PNCC benefit nt just the initial assessment t eligible members. The initial assessment (i.e., Pregnancy Questinnaire) is reimbursable even if the wman is determined ineligible fr services. The fllwing services are nt reimbursable: The prvisin f diagnstic, treatment, r ther direct services, except fr health educatin and nutritin cunseling fr PNCC prviders. Direct services include, but are nt limited t, diagnsis f a physical r mental illness and administratin f medicatins. Member vcatinal training. Page 4

5 Frequently Asked Questins - Medicaid Case Management Legal advcacy by an attrney r paralegal. Onging care crdinatin and mnitring services that are nt based n the member's current care plan. Onging care crdinatin and mnitring services that are nt necessary t meet the CCC r PNCC benefit gal. Transprtatin (prvider r member mileage r travel time). Interpreter services. Missed appintments (n shws). Prviders are encuraged t use the Guidelines and Perfrmance Measurements fr PNCC t help ensure that quality services are prvided and activities are directed tward the prgram's bjectives and gal. Wiscnsin Medicaid als uses the guidelines t mnitr the administratin f the benefit. Wh qualifies fr PNCC? Medicaid-eligible pregnant wmen (d nt have t be enrlled in a specific HMO) with a high risk fr adverse pregnancy utcmes during pregnancy and thrugh the first 60 days fllwing delivery. PNCC services are cvered under Medicaid, BadgerCare Plus Standard and Benchmark plans. All pregnant wmen enrlled in BadgerCare Plus and Wiscnsin Medicaid are eligible fr mental health and substance abuse screening. This als includes brief preventive mental health cunseling and/r substance abuse interventin if the wman is identified as being at risk fr experiencing mental health r substance abuse disrders. Mre infrmatin n this benefit is available here. Wh can prvide PNCC services? PNCC includes a wide range f eligible prviders - bth public and private. They must have staff available t prvide health and nutritinal educatin. The fllwing types f prviders and agencies as eligible fr Medicaid certificatin as PNCC prviders: A cmmunity-based health rganizatin. A cmmunity-based scial services agency r rganizatin. A cunty, city, r cmbined city and cunty public health agency. A cunty department f human services under s , Wis. Stats., r scial services under s r s , Wis. Stats. A family planning agency certified under DHS , Wis. Admin. Cde. An FQHC as defined in 42 CFR (b). An HMO. An IPA. A hspital. A physician's ffice r clinic. Page 5

6 Frequently Asked Questins - Medicaid Case Management A private case management agency. A certified nurse r nurse practitiner. An RHC certified under DHS , Wis. Admin. Cde. A tribal agency health center. A WIC prgram under 42 USC Prviders are defined in ne f tw ways: Care Crdinatin Prvider The entity that meets the requirements as a certified care crdinatin prvider, is assigned a Medicaid billing prvider number, and has legal liability fr the prvisin f care crdinatin services. Care Crdinatr The individual wh is prviding care crdinatin services t members. Hw d prviders becme certified? T becme Medicaid certified, prviders are required t: Meet all certificatin requirements fr their prvider type. Submit a prperly cmpleted prvider applicatin, prvider agreement, and ther frms, as applicable, that are included in the certificatin packet. Prviders may submit applicatins by mail r nline thrugh the FrwardHealth Prtal. The prtal prvides mre detailed infrmatin abut the criteria specific prviders need t meet, as well as updates t plicies and prcedures. Prviders may call Prvider Services fr assistance with cmpleting these materials. Prviders wh ffer a variety f services may be required t cmplete a separate Medicaid certificatin packet fr each specified service/prvider type. If a Medicaid-certified prvider begins ffering a new service after becming initially certified, it is recmmended that he r she call Prvider Services t inquire if anther applicatin must be cmpleted. Medicaid-certified PNCC prviders may subcntract with agencies nt certified by Wiscnsin Medicaid fr PNCC services. Hwever, the Medicaid-certified prvider retains all legal and fiscal respnsibility fr the services prvided by subcntractrs. The initial effective date may be as early as the date f nline applicatin submissin r request fr a paper applicatin. Certain cnditins must be met. An agency must submit an utreach plan t receive certificatin fr prviding PNCC services. These requirements are the standard certificatin expectatins. Agencies may apply fr certificatin if they d nt meet these standards. Applicatin apprval in such cases depends n the agency's demnstratin that it has develped reasnable alternative means t assure adequacy and quality f the PNCC services. Page 6

7 Frequently Asked Questins - Medicaid Case Management What is imprtant t knw abut dcumenting PNCC services? Prviders are required t maintain case recrds, in writing r in electrnic frmat, which indicate all case management cntacts with, and n behalf f, members (a sample mnthly lg is available n FrwardHealth). The member's file must include the fllwing infrmatin, as apprpriate: Verificatin f the member's pregnancy. The member's cmpleted Prenatal Care Crdinatin Pregnancy Questinnaire. The questinnaire must be scred, signed, and dated. The member's care plan, signed and dated as required. The prvider may initial the care plan if a signature page is included in the member's recrd. Cmpleted cnsent dcument(s) fr release f infrmatin. A written recrd f all member-specific care crdinatin and mnitring activities. The recrd must include dcumentatin f the fllwing infrmatin: The member's name. The date f the cntact. The full name and title f the persn wh made the cntact. A clear descriptin f the reasn fr and nature f the cntact. The results f the cntact. The length f time f the cntact (the number f minutes r the exact time; e.g., 9:15-10:05 a.m.). Where r hw the cntact was made. Referrals and fllw up. All pertinent crrespndence relating t crdinatin f the member's prenatal care. Use r disclsure f any infrmatin cncerning applicants and members fr any purpse nt cnnected with prgram administratin, including cntacts with third-party payers that are necessary fr pursuing third-party payment and the release f infrmatin as rdered by the curt, is prhibited unless authrized by the applicant r member. Prviders are required t allw members access t their health care recrds, including thse related t FrwardHealth services, maintained by a prvider in accrdance with Wiscnsin Statutes, excluding billing statements. DHS has the right t inspect, review, audit, and phtcpy prviders recrds. What is imprtant t knw abut filing claims fr reimbursement? Medical prviders must have a Natinal Prvider Identifier, which can be btained thrugh the Natinal Plan and Prvider Enumeratin System website. Wiscnsin Medicaid is the payer f last resrt fr mst cvered services (there are a few exceptins), even when a member is enrlled in a BadgerCare Plus HMO r Medicaid SSI HMO. Page 7

8 Frequently Asked Questins - Medicaid Case Management Electrnic claims fr PNCC services submitted using any transactin ther than the 837P transactin will be denied. Prviders shuld use the cmpanin dcument fr the 837P transactin when submitting these claims. Wiscnsin Medicaid ffers electrnic billing sftware thrugh the FrwardHealth Prtal at n cst t prviders. Fr assistance installing and using PES sftware, prviders may call the EDI Helpdesk. All cunties certified as Medicaid prviders f cmmunity-based services are required t submit cst reprts t FrwardHealth fr the fllwing services: Case management services Child/adlescent day treatment Cmmunity supprt prgram services Hme health services Medical day treatment services Mental health crisis interventin services Outpatient mental health and substance abuse services, including evaluatin, psychtherapy, and substance abuse cunseling and intensive in-hme mental health services fr children under HealthCheck Outpatient mental health and substance abuse services prvided in the hme and cmmunity. (The nn-federal share f this service is prvided by the cunty.) Persnal care services PNCC services Substance abuse day treatment. If Wiscnsin Medicaid is nt billed by the cunty fr case management services, n cst reprt is required. Cst reprts may be submitted nline. Where can I find mre infrmatin abut PNCC? This dcument des nt serve as a cmplete accunt f prviders respnsibilities when prviding PNCC services. Cmprehensive infrmatin regarding rules and regulatins can be fund at: Click n Online Handbks in the left hand menu. Then using the drp dwn menus n the right hand, select BadgerCare Plus and Medicaid and Prenatal Care Crdinatin Additinal infrmatin abut case management can be fund in a frequently asked questins dcument in FrwardHealth. Prviders are encuraged t cntact their reginal Prvider Relatins Representatives with questins. They may als cntact representatives assigned t specific prgrams. Page 8