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July 2007

July 2007. 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. Verify Eligibility. Provider Electronic Solutions software

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July 2007

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  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

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