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Managed Care
7.1 Medicaid Managed Care 7-4
7.1.1 Overview 7-4
7.1.2 Third Party Resources 7-4
7.1.3 Client Enrollment 7-5
7.1.3.1 Managed Care Eligibility and Effective Date 7-5
7.1.3.3 Automatic Re-enrollment 7-5
7.1.4 Primary Care Provider Changes 7-5
7.1.4.1 Client-Initiated Primary Care Provider Changes 7-5
7.1.4.2 Provider-Initiated Primary Care Provider Changes 7-6
7.1.4.3 Medicaid Managed Care-Initiated Primary Care Provider Changes 7-6
7.1.5 Health Plan Changes 7-6
7.1.5.1 Client-Initiated HMO Plan Changes 7-6
7.1.5.2 Health Plan Managed Care Administrator-Initiated Changes 7-6
7.1.6 Client Rights and Responsibilities 7-7
7.1.6.1 Client Rights 7-7
7.1.6.2 Client Responsibilities 7-7
7.1.6.3 Advance Directives 7-8
7.1.7 Primary Care Provider Requirements and Information 7-8
7.1.7.1 Continuous Access 7-10
7.1.7.2 Cultural Competency and Sensitivity 7-10
7.1.7.3 Primary Care Provider-to-Client Ratio and Capacity 7-11
7.1.8 Medicaid Managed Care Complaints and Fair Hearings 7-11
7.1.9 Claims Filing Information 7-11
7.1.9.1 Claims for Pregnant Women (TP40) 7-12
7.2 STAR Program 7-12
7.2.1 Overview 7-12
7.2.1.1 STAR HMO Model 7-12
7.2.2 Client Eligibility 7-13
7.2.3 Client Enrollment 7-14
7.2.3.1 STAR Help Line (STAR Enrollment Broker) 7-15
7.2.3.2 Enrollment of Pregnant Women (Type Program 40) 7-15
7.2.4 Service Area and STAR HMO Choices 7-16
7.2.5 STAR Program Benefits 7-16
7.2.5.1 Annual Adult Well-Check 7-16
7.2.5.2 Spell of Illness 7-17
7.2.5.3 Prescriptions 7-17
7.2.6 Claims Filing Information 7-17
7.2.6.1 Newborn Claims Submission 7-17
7.3 STAR+PLUS Program 7-17
7.3.1 Overview 7-17
7.3.1.1 HMO Model 7-17
7.3.1.2 Service Areas 7-18
7.3.1.3 Client Eligibility 7-18
7.3.1.4 Dual Eligible Clients 7-18
7.3.1.5 Ineligible Clients 7-19
7.3.2 STAR+PLUS Program Benefits 7-19
7.3.3 Claims Filing Information 7-19
7.3.3.1 STAR+PLUS Mental Health Claims 7-19
7.4 NorthSTAR Program 7-20
7.4.1 Overview 7-20
7.4.2 Provider Requirements and Information 7-20
7.4.3 Service Area 7-20
7.4.3.1 Client Eligibility 7-20
7.4.4 Client Enrollment 7-20
7.4.4.1 NorthSTAR Enrollment Broker 7-21
7.4.4.2 Guidelines for Working with NorthSTAR Clients 7-21
7.4.5 Claims Filing Information 7-21
7.4.5.1 Hospital Billing 7-21
7.4.5.2 Behavioral Health Billing 7-21
7.4.5.3 Prior Authorization Requirements 7-21
7.4.6 Complaints and Appeals 7-21
7.5 PCCM 7-23
7.5.1 Overview 7-23
7.5.2 Contact Numbers 7-24
7.5.3 Client Eligibility 7-24
7.5.4 Client Enrollment 7-24
7.5.5 Online Provider Lookup 7-25
7.5.6 Client Rights and Responsibilities 7-25
7.5.6.1 Client Rights 7-25
7.5.6.2 Client Responsibilities 7-26
7.5.7 Primary Care Provider Selection and Changes 7-26
7.5.7.1 Selecting a Primary Care Provider 7-26
7.5.7.2 Primary Care Provider Changes 7-26
7.5.7.3 Provider Initiated Primary Care Provider Changes 7-27
7.5.8 Provider Enrollment 7-27
7.5.8.1 Credentialing Committee 7-27
7.5.8.2 Members of the Credentialing Committee 7-28
7.5.8.3 Credentialing Committee Frequency/Logistics 7-28
7.5.8.4 Credentialing Committee Action 7-28
7.5.8.5 Credentialing Grievance Committee 7-28
7.5.8.6 Primary Care Provider Termination/Disenrollment 7-29
7.5.8.7 Additional Criteria for Primary Care Providers 7-29
7.5.8.8 Miscellaneous Provisions 7-29
7.5.9 Support Services 7-29
7.5.9.1 Provider Support Services 7-29
7.5.9.2 Client Support and Education 7-30
7.5.9.3 Monthly Client Panel Report 7-30
7.5.10 Covered Services 7-31
7.5.10.1 Self-Referred Services 7-31
7.5.10.2 Community Health Services (CHS) 7-32
7.5.10.3 Behavioral Health Services 7-33
7.5.11 Provider Responsibilities 7-33
7.5.11.1 Office and Medical Records Standards 7-34
7.5.11.2 Medical Records Standards 7-34
7.5.12 Monitoring Provider Performance 7-36
7.5.13 Referrals 7-36
7.5.13.1 Open Specialty Referral Network 7-37
7.5.13.2 Referral Form 7-37
7.5.14 Specialist Responsibilities 7-37
7.5.14.1 Specialist-to-Specialist Referrals 7-37
7.5.15 PCCM Inpatient Authorization Process 7-37
7.5.15.1 Definitions 7-37
7.5.15.2 Professional Services 7-38
7.5.15.3 Facility/Hospital Services 7-38
7.5.15.4 ER Services 7-39
7.5.15.5 Observation Services 7-39
7.5.15.6 Urgent and Emergent Admissions 7-39
7.5.15.7 OB/Newborn Notification 7-40
7.5.15.8 Scheduled Inpatient Admissions 7-40
7.5.15.9 Appeals of Denied Requests for Authorization 7-40
7.5.15.10 Out-of-Network Inpatient Services 7-40
7.5.16 Outpatient Prior Authorization Process 7-41
7.5.17 Transportation Services 7-42
7.5.17.1 Nonemergency Transportation 7-42
7.5.18 Provider Complaints and Appeals 7-42
7.5.18.1 Conflict Resolution 7-42
7.5.18.2 Provider Complaints 7-43
7.5.18.3 Authorization Appeals 7-43
7.5.19 Claims Filing Information 7-44
7.5.19.1 Case Management Fee 7-44
7.5.19.2 PCCM Newborn Claims Filing 7-45
7.5.19.3 Network Hospitals 7-45
7.5.19.4 Out-of-Network Hospitals 7-45
7.5.19.5 Emergency Outpatient Services 7-45
7.5.19.6 Nonemergency Outpatient Clinic Services 7-45
7.5.19.7 PCCM Claims Details 7-45
7.5.19.8 Claims for Specialist Services 7-45
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