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…
DJ 1: Our first question is: “What’s the first step in making sure Medicaid will pay if your patient has Managed Care?”
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 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.
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 1: And MCOs?
DJ 2: You pretty much always need prior authorization from the participant's MCO.
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 SCDHHS.gov it is labeled "Schedule of Copayments."
DJ 1: In that case, you’ll have to check with the specific plan. Go to SCChoices. That's www.SCChoices.com.
DJ 2: You’ll find the plan copayment specifics there.
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: 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 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!