Script for podcast - A Patient Comes In With Managed Care


(Switching radio stations until it gets to...)

DJ 1: Welcome back to Medicaid Radio. Do you serve Medicaid patients that have what’s called “Managed Care?”  How do you determine what kind they have? And what difference does it make when you’re trying to file the claim? That’s what we’ll look at now…

Determine insurance

DJ 1: Our first question is: “What’s the first step in making sure Medicaid will pay if your patient has Managed Care?”

DJ 2: That’s a good question. First, you’ll need to determine what type of insurance they have: FFS, MCO, or MHN.

DJ 1: That’s right. In all cases, the patient will most likely show you their Healthy Connections card. But for Managed Care Organizations, or MCOs, they should give you an additional card.

DJ 2: But what if they don’t?

DJ 1: Of course, you should ask for all cards. But you can look the patient up on the Web Tool and determine if the patient is enrolled in an MCO.

DJ 2: So, a patient is part of an MCO, but the practice isn’t. What happens then?

DJ 1: If you’re not an MCO network provider, you may be granted a one-time referral or authorization. Long-term, you may consider participating as one of the network providers in a Managed Care Organization.

DJ 2: Otherwise, you’ll need to make the patient aware that they’ll have to self-pay. It’s the same if you don't participate in traditional fee-for-service Medicaid. Just make sure the Medicaid participant knows that you’re not participating, and they’ll have to pay out-of-pocket.

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Prior Authorization

DJ 2: Ok, so let’s assume that the practice handles all of those – FFS, MHN, and MCO. Our next question then is: “What kind of prior authorization is required?”

DJ 1: Ah, very good! If it’s a fee-for-service patient, then it’s a matter of looking up those procedure codes in section 2 of the Provider Manuals. Also, be aware of any waiver limitations on that patient’s Medicaid status.

DJ 2: Now if the patient is enrolled in an MHN, you’ll want to research who the primary care physician is and get a referral number for any claims you file.

DJ 1: And MCOs?

DJ 2: You pretty much always need prior authorization from the participant's MCO.

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DJ 1: Exactly! Now here’s one: “How do I know if I should be collecting a copay from the patient?”

DJ 2: Moreover, how much is it, right?

DJ 1: Right! For fee for service, you’ll need to check the copay schedule.

DJ 2: Yes, it varies according to service type. And where’s that found?

DJ 1: In the Appendix section of your provider manual at it is labeled "Schedule of Copayments."

DJ 2: What if the patient has an MHN or an MCO?

DJ 1: In that case, you’ll have to check with the specific plan. Go to SCChoices. That's

DJ 2: You’ll find the plan copayment specifics there.

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Send Claim to the Right Place

DJ 2: That brings us to our last question.

DJ 1: What’s that?

DJ 2: “Where do I send the claim?” For fee-for-service and MHNs, you send them to South Carolina Department of Health and Human Services.

DJ 1: But not for MCOs?

DJ 1: Nope. Send the MCO claims directly to the MCO plan itself.

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DJ 1: Let’s recap. First, figure out what type of Medicaid the patient has. Ask to see all their cards; and check the Web Tool.

DJ 2: Or, if you use a vendor or clearinghouse to check.

DJ 1: That’s right!

DJ 2: Next, make sure you get prior authorizations and any MHN referrals squared away. And lastly?

DJ 1: Lastly, send your claim to South Carolina DHHS, unless it’s MCO – send those to the MCO.

DJ 2: Very good!

DJ 1: But how will our listeners remember all this next week when it happens?

DJ 2: Check out our links to quick reference guides on this podcast’s outline. And have a great day!


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Last modified: Thursday, April 10, 2014, 9:46 AM