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Managed Care
7.1 Medicaid Managed Care 7-5
7.1.1 Overview 7-5
7.1.2 Third-Party Resources (TPR) 7-5
7.1.3 The Health Insurance Premium Payment (HIPP) Program 7-6
7.1.4 Client Enrollment 7-6
7.1.4.1 Managed Care Eligibility and Effective Date 7-6
7.1.4.2 Automatic Reenrollment 7-7
7.1.5 Primary Care Provider Changes 7-7
7.1.5.1 Client-Initiated Primary Care Provider Changes 7-7
7.1.5.2 Provider-Initiated Primary Care Provider Changes 7-7
7.1.5.3 Medicaid Managed Care-Initiated Primary Care Provider Changes 7-8
7.1.6 Health Plan Changes 7-8
7.1.6.1 Client-Initiated HMO Plan Changes 7-8
7.1.6.2 Health Plan Managed Care Administrator-Initiated Changes 7-8
7.1.7 Client Rights and Responsibilities 7-8
7.1.7.1 Client Rights 7-8
7.1.7.2 Client Responsibilities 7-9
7.1.7.3 Advance Directives 7-9
7.1.8 Primary Care Provider Requirements and Information 7-10
7.1.8.1 Continuous Access 7-11
7.1.8.2 Cultural Competency and Sensitivity 7-12
7.1.8.3 Primary Care Provider-to-Client Ratio and Capacity 7-13
7.1.9 Medicaid Managed Care Complaints and Fair Hearings 7-13
7.1.10 Prior Authorizations 7-13
7.1.11 Claims Filing Information 7-13
7.1.11.1 National Drug Code (NDC) Claims 7-14
7.1.11.2 Claims for Pregnant Women (Type Program 40) 7-15
7.2 STAR Program 7-15
7.2.1 Overview 7-15
7.2.1.1 STAR HMO Model 7-15
7.2.2 Client Eligibility 7-15
7.2.3 Client Enrollment 7-17
7.2.3.1 STAR Help Line (STAR Enrollment Broker) 7-18
7.2.3.2 Enrollment of Pregnant Women (Type Program 40) 7-18
7.2.4 Service Areas (SAs) and STAR HMO Choices 7-19
7.2.5 STAR Program Benefits 7-19
7.2.5.1 Annual Adult Well-Check 7-20
7.2.5.2 Spell of Illness 7-20
7.2.5.3 Prescriptions 7-20
7.2.5.4 National Drug Code 7-20
7.2.6 Claims Filing Information 7-21
7.2.6.1 Newborn Claims Submission 7-21
7.3 STAR+PLUS Program 7-21
7.3.1 Overview 7-21
7.3.1.1 HMO Model 7-22
7.3.1.2 Service Areas (SAs) 7-22
7.3.1.3 Client Eligibility 7-22
7.3.1.4 Dual Eligible Clients 7-23
7.3.1.5 Ineligible Clients 7-23
7.3.2 STAR+PLUS Program Benefits 7-23
7.3.3 Spell of Illness Limitation 7-23
7.3.4 Claims Filing Information 7-23
7.3.4.1 STAR+PLUS Mental Health Claims 7-24
7.4 Integrated Care Management (ICM) Program 7-24
7.4.1 Overview 7-24
7.4.2 ICM MCO Model 7-24
7.4.2.1 Service Areas (SAs) 7-24
7.4.3 Client Eligibility 7-24
7.4.3.1 Dual Eligible Clients 7-24
7.4.3.2 Ineligible Clients 7-25
7.4.4 Client Enrollment 7-25
7.4.5 ICM Program Benefits 7-25
7.4.6 Spell of Illness Limitation 7-25
7.4.7 Authorization 7-25
7.4.8 ICM Claims Filing 7-26
7.4.8.1 National Drug Code (NDC) Claims 7-26
7.4.8.2 Personal Care Services (PCS) 7-27
7.5 NorthSTAR Program 7-27
7.5.1 Overview 7-27
7.5.2 Provider Requirements and Information 7-28
7.5.3 Service Area (SA) 7-28
7.5.3.1 Client Eligibility 7-28
7.5.4 Client Enrollment 7-28
7.5.4.1 NorthSTAR Enrollment Broker 7-28
7.5.4.2 Guidelines for Working with NorthSTAR Clients 7-28
7.5.5 Claims Filing Information 7-29
7.5.5.1 Hospital Billing 7-29
7.5.5.2 Behavioral Health Billing 7-29
7.5.5.3 Prior Authorization Requirements 7-29
7.5.6 Complaints and Appeals 7-29
7.6 STAR Health Program 7-30
7.6.1 Overview 7-30
7.6.2 STAR Health Model 7-30
7.6.3 Client Eligibility 7-30
7.6.4 STAR Health Claims Filing 7-30
7.7 PCCM 7-31
7.7.1 Overview 7-31
7.7.2 Contact Numbers 7-32
7.7.3 Client Eligibility 7-32
7.7.4 PCCM+PLUS 7-32
7.7.4.1 PCCM+PLUS Goals 7-33
7.7.4.2 PCCM+PLUS Plan of Care 7-33
7.7.4.3 Services Offered through PCCM+PLUS 7-33
7.7.5 Client Enrollment 7-33
7.7.6 Online Provider Lookup 7-33
7.7.7 Client Rights and Responsibilities 7-34
7.7.7.1 Client Rights 7-34
7.7.7.2 Client Responsibilities 7-34
7.7.8 Primary Care Provider Selection and Changes 7-35
7.7.8.1 Selecting a Primary Care Provider 7-35
7.7.8.2 Primary Care Provider Changes 7-35
7.7.8.3 Provider Initiated Primary Care Provider Changes 7-36
7.7.9 Provider Enrollment 7-36
7.7.9.1 Credentialing Committee 7-36
7.7.9.2 Members of the Credentialing Committee 7-36
7.7.9.3 Credentialing Committee Frequency/Logistics 7-36
7.7.9.4 Credentialing Committee Action 7-37
7.7.9.5 Credentialing Grievance Committee 7-37
7.7.9.6 Primary Care Provider Termination/Disenrollment 7-37
7.7.9.7 Additional Criteria for Primary Care Providers 7-38
7.7.9.8 Miscellaneous Provisions 7-38
7.7.10 PCCM Reimbursement 7-38
7.7.10.1 Case Management Fee 7-38
7.7.11 Support Services 7-38
7.7.11.1 Provider Support Services 7-38
7.7.11.2 Client Support and Education 7-39
7.7.11.3 Monthly Client Panel Report 7-39
7.7.12 Covered Services 7-40
7.7.12.1 Self-Referred Services 7-40
7.7.12.2 Community Health Services (CHS) 7-41
7.7.12.3 Behavioral Health Services 7-42
7.7.13 Provider Responsibilities 7-43
7.7.13.1 Office and Medical Records Standards 7-43
7.7.13.2 Medical Records Standards 7-44
7.7.14 Monitoring Provider Performance 7-45
7.7.15 Referrals 7-46
7.7.15.1 Open Specialty Referral Network 7-46
7.7.15.2 Referral Form 7-46
7.7.16 Specialist Responsibilities 7-46
7.7.16.1 Specialist-to-Specialist Referrals 7-47
7.7.17 PCCM Inpatient Authorization Process 7-47
7.7.17.1 Definitions 7-47
7.7.17.2 Professional Services 7-47
7.7.17.3 Facility/Hospital Services 7-47
7.7.17.4 Emergency Room (ER) Services 7-48
7.7.17.5 Observation Services 7-49
7.7.17.6 Urgent and Emergent Admissions 7-49
7.7.17.7 Obstetrical/Newborn Notification 7-49
7.7.17.8 Scheduled Inpatient Admissions 7-49
7.7.17.9 Appeals of Denied Requests for Authorization 7-50
7.7.17.10 Out-of-Network Inpatient Services 7-50
7.7.18 Outpatient Prior Authorization Process 7-51
7.7.19 Transportation Services 7-52
7.7.19.1 Nonemergency Transportation 7-52
7.7.20 Provider Complaints and Appeals 7-52
7.7.20.1 Conflict Resolution 7-52
7.7.20.2 Provider Complaints 7-52
7.7.20.3 Authorization Appeals 7-53
7.7.21 Claims Filing Information 7-54
7.7.21.1 PCCM Newborn Claims Filing 7-54
7.7.21.2 Personal Care Services (PCS) 7-54
7.7.21.3 Network Hospitals 7-54
7.7.21.4 Out-of-Network Hospitals 7-54
7.7.21.5 Emergency Outpatient Services 7-54
7.7.21.6 Nonemergency Outpatient Clinic Services 7-55
7.7.21.7 PCCM Claims Details 7-55
7.7.21.8 National Drug Code (NDC) 7-55
7.7.21.9 Claims for Specialist Services 7-56
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