PRIMARY CARE CLINICIAN (PCC) PLAN PROVIDER HANDBOOK Table of Contents iii Letter from the Director 1 Part 1: Membership Information 1 Member Enrollment 2 PCC Plan Enrollment Roster 3 Orienting PCC Plan Members 5 Initial Visit 6 Member Eligibility 6 Special Managed Care Rules for Newborns 7 Member Outreach and Care Coordination 8 Member Rights 10 Part 2: Service Delivery 10 Hours of Operation and Appointments 10 Referrals 11 Prior Authorization (PA) and Other Authorizations 12 Emergency and Urgent Care 12 Hospitalizations 13 Non-emergency Transportation Services 13 Pregnancy and Family Planning Services 13 Health Care for Children, Adolescents, and Young Adults 18 Part 3: Administration 18 Billing 20 Prospective Interim Payments 21 PCC Changes 21 Credentialing 22 Part 4: Quality Management and Reporting 22 Performance Improvement Management Services 23 Reporting 25 Part 5: Behavioral Health Services 29 Part 6: Supplements 30 Services That Do Not Require a Referral 33 MassHealth Referral Form 35 Notification of Incorrect Assignment 37 PCC Plan Community Support Program Referral Form 39 PCC Plan Member Outreach Form 41 Request for Provider Training 43 Request for Assistance with Billing Issues Dear Primary Care Clinician: MassHealth is pleased to provide you with a copy of the Primary Care Clinician (PCC) Plan Provider Handbook. The goal of the Handbook is to provide quick access to important information about the PCC Plan, a managed care option for managed care- eligible enrollees. We hope you will find the information contained in the Handbook useful. Upon enrollment into the PCC Plan, members are able to select a PCC from among MassHealth- participating PCC Plan network providers. The member’s PCC is responsible for providing and/or coordinating most of the member’s medical care, and, as necessary, referring the member to other MassHealth providers for nonprimary care services. PCC Plan members are also enrolled with a behavioral health care plan that provides and manages all behavioral health care services for enrolled members. The current behavioral health carve-out contractor is the Massachusetts Behavioral Health Partnership (MBHP). MassHealth offers a number of supports to assist PCCs in fulfilling their roles and responsibilities. These supports include: • Performance Improvement Management Services (PIMS) activities. PIMS activities include PCC profiling, site visits, and support for quality improvement from Regional Network Managers; • operational and clinical support from PCC Plan staff, the MassHealth Office of Clinical Affairs (OCA), and the MassHealth pharmacy program; and • a PCC Plan Hotline, and educational forums for PCCs. Assistance with outreach to enrolled members is also available to PCCs. Additionally, PCCs can access other services available through MassHealth, such as training for billing. This Handbook provides additional information about all of these services. The Handbook comprises six major sections. Each section provides an overview of key points to assist with coordination and collaboration with the PCC Plan and MassHealth. If you are new to the PCC Plan, welcome! If you are not a new PCC, thank you for your ongoing participation in the PCC Plan provider network. Remember: if you have a question about the PCC Plan, you can always contact the PCC Plan Hotline for assistance at 1-800-495- 0086. Sincerely, Primary Care Clinician Plan (PCC Plan) Part 1 Membership Information Member Enrollment Managed Care Enrollment MassHealth enrollees who are under 65 and managed care eligible are required to enroll in a managed care plan, either the PCC Plan or a MassHealth-contracted managed care organization (MCO). Once determined eligible, managed care-eligible enrollees are notified of available managed care options, and are encouraged to select a health plan, including the PCC Plan. Members are instructed to contact MassHealth Customer Service and speak to a customer service representative (CSR), who will answer questions and assist with plan selection. MassHealth Customer Service can be reached at 1-800-841-2900 (TTY: 1-800-497-4648 for people with partial or total hearing loss), Monday to Friday from 8:00 A.M. to 5:00 P.M. MassHealth Customer Service provides services such as a PCC Plan member hotline and distribution of a variety of written materials, including information about managed care enrollment options and the PCC Plan Member Handbook. Members may also contact MassHealth Customer Service to have any of the materials supplied by MassHealth translated or provided in an alternative format. Members who do not make a plan selection within the required timeframes are assigned to a health plan in their service area, in accordance with the auto-assignment algorithm policy in place at the time of enrollment. Certain health plan enrollments become effective on the same business day. Others become effective in one business day plus one calendar day. The MassHealth CSR can confirm the enrollment effective date. Members who select the PCC Plan are required to further select a PCC, or are assigned to a PCC by MassHealth if they fail to make a selection. All members receive written notification of the selected or assigned PCC. If the member selects or is assigned to a group practice, community health center, hospital-licensed health center, or hospital outpatient department, the PCC practice site is required to assign the member to a qualified PCC at that practice. PCCs can view their respective monthly enrollment roster via the Provider Online Service Center (POSC). Automatic Reenrollment If a PCC Plan member loses MassHealth eligibility, but regains eligibility within one year, and is still managed care eligible, MassHealth will automatically reenroll the member to the PCC with whom the member was most recently enrolled. Changing Managed Care Plans and Providers Changing PCC-to-PCC PCC Plan members may select a different PCC at any time. To make these changes, members may call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people with partial or total hearing loss). The transfer to a new PCC becomes effective on the same business day. Changing PCC-to-MCO PCC Plan members may also transfer to a different MCO at any time. To make these changes, members may call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people with partial or total hearing loss). Disenrollment Requests A PCC may submit a request to disenroll a member from his or her panel. All such requests must be made in writing and submitted to the following address. MassHealth PCC Plan Attn: Member Operations Coordinator 100 Hancock Street, 6th floor Quincy, MA 02171 Please Note: PCCs may not request disenrollment of a member for the following reasons: • an adverse change in a member’s health status; • utilization of medical services; • diminished mental capacity; or • uncooperative or disruptive behavior resulting from a member’s mental capacity (except where his or her continued enrollment seriously impairs your ability to furnish services to either the particular member or other members). Submitted requests must demonstrate that: • the member has a pattern of noncompliant or disruptive behavior that is not the result of the member’s special needs; • the continued enrollment of the member seriously impairs your ability to furnish services to either this particular member or other members; or • you are unable to meet the medical needs of the member. Submitted requests are reviewed against the criteria outlined above, and, if warranted, MassHealth may request additional information. It is MassHealth’s expectation that the PCC will continue to provide primary care and referrals as appropriate while the review is being conducted. If it is determined that the request is warranted, MassHealth will provide notification about the approval and the disenrollment effective date. PCCs are required to forward all relevant medical records to the new PCC. If MassHealth denies your request to disenroll a member, you must continue to provide primary care and referral services to that member in accordance with the terms and conditions outlined in the PCC Plan Provider Contract. PCC Plan Enrollment Roster All PCCs have access to a monthly Enrollment Roster. The roster includes basic demographic information for each member and lists the PCC’s current members, in addition to new and disenrolled members. At the end of the report, there is a four-month Outreach Report that shows members who have not been seen within the first four months of enrollment in your practice. These reports can be accessed through the POSC. Orienting PCC Plan Members PCCs are required to provide outreach and orientation to all new enrollees by mail or phone within three weeks of enrollment. For new members with no prior history with a practice, the PCCs are required to provide an initial visit within four months of the date of the member’s enrollment into the PCC’s panel (see chart below for more information on the timing of the initial visit). The member orientation activities may be combined with the initial appointment. Member orientation materials may be obtained by calling the PCC Plan Hotline at 1-800-495-0086. Please document in the member’s medical record all attempts to make initial contact with the member. If you are unable to reach a member after several attempts, please call the PCC Plan Hotline at 1-800-495-0086 for member outreach assistance. Contents of the PCC Plan Orientation PCC orientation for new members must include the following emphases. 1. The Importance of Primary Care Explain the importance of primary care, including preventive care, and explain that as the PCC you will provide and coordinate access to needed care. Also, explain that the member will need a PCC referral for most specialty care. 2. Referral Requirements Members should be notified that while most specialty services will require a PCC referral, there are certain exceptions to that rule. Examples of services not requiring a referral are: • behavioral health (mental health and substance abuse) services; • clinical laboratory services; • emergency services; • family planning services; • all elective and nonelective hospital admissions; • HIV testing and counseling; and • obstetric services for pregnant and postpartum members. See page 30 of this Handbook for a more comprehensive list of services that do not require a PCC referral. See 130 CMR 450.118(J) for the most current list. 3. Member Complaints and Grievances PCCs are required to make an attempt to address most member concerns. However, members may also call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people with partial or total hearing loss) and a customer service representative (CSR) can assist them with a particular issue. If neither of those options provides a satisfactory resolution of the member’s compliant, the member may file a formal grievance with MassHealth at the following address. Executive Office of Health and Human Services MassHealth ATTN: Director, MassHealth Member and Provider Services 100 Hancock Street, 6th floor Quincy, MA 02171 4. Emergency and Urgent Care Members should be informed that in the event of an emergency for either a medical or behavioral health condition, they should call 911 or go to the nearest emergency department (ED) or emergency services program (ESP). Members should be encouraged to contact their PCC for follow-up care after they have been seen by an ED or an ESP. If the emergency service was for a behavioral health condition, the members should also be encouraged to contact their behavioral health provider for follow-up care. For urgent conditions, members should be instructed to contact their PCC to receive care. An urgent condition may be defined as any health problem that the member believes is serious but not an emergency. 5. PCC Plan Member Handbook PCCs should provide an overview of the PCC Plan Member Handbook, informing them that the Handbook is a valuable tool that can assist them to understand PCC Plan rules. If the member needs a copy of the Member Handbook, he or she should be instructed to call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people with partial or total hearing loss). 6. MassHealth Card Encourage members to carry their MassHealth card with them whenever they seek medical care. You may also want to keep a photocopy of the member’s MassHealth card on file. 7. Updating Enrollee Information PCCs should emphasize the importance of providing updated address, telephone numbers, and other contact information to MassHealth. Remind members that failure to do so could result in a loss of eligibility if MassHealth is unable to contact them. 8. PCC Practice Specifics PCCs should provide members with basic information about their respective practices, including, at a minimum, the following information: • the days and hours that your practice is open; • how long members should expect to wait for an appointment for primary and urgent care (for more information, see “Hours of Operation and Appointments”); • appointment cancellation procedures; • alternate phone numbers; • procedures for contacting the practice after normal business hours, including whom to contact, who will call the member back, and how long members should expect to wait for a return call (for more information, see “Hours of Operation and Appointments”). 9. Helpful Telephone Numbers for Enrollees Provide members with other helpful telephone numbers, including numbers for: • MassHealth Customer Service; and • MBHP Customer Service for behavioral health services. Initial Visit PCCs are required to conduct an initial visit for most members at enrollment. During an initial visit, PCCs are required to take a full medical history and perform a comprehensive physical examination. Recommended timelines for the initial visit are listed below. Timeline for conducting initial visit Type of member Member is new to your practice. Initial visit required? Yes Timeline for conducting initial visit Contact the member within three weeks of enrollment to schedule an initial visit within four months of enrollment in the PCC practice. Type of member Member is over 21 and is not new to your practice. Initial visit required? No, if a physical exam has been provided in the last 12 months. Timeline for conducting initial visit None required. Type of member Member is a pregnant woman (new or not new to your practice). Initial visit required? Yes Timeline for conducting initial visit Contact the member within seven days of the PCC’s learning of the member’s pregnancy to ensure that a relationship with an obstetric provider has been established. Type of member Member is under age 21 (new or not new to your practice). Initial visit required? Yes Timeline for conducting initial visit Contact the member within the period described in the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Appendix W: EPSDT Services: Medical and Dental Protocols and Periodicity Schedules (for more information, see “Health Care for Children, Adolescents, and Young Adults” on page 13 of this Handbook). Note: It is understood that the frequency of a complete physical exam may vary by age and risk factors. Member Eligibility Eligibility Verification System (EVS) The Eligibility Verification System (EVS) is the MassHealth system that contains information about members’ eligibility, coverage type, PCC Plan or MCO enrollment status, and third-party coverage. PCCs must verify each member’s health care coverage and PCC Plan enrollment before providing services. You may access the system the following ways. 1. If you have Internet access with a high speed connection: • POSC publications to insert link. 2. By telephone: • Automated Voice Response (AVR) system. For more information about any of these access methods, call the EVS Help Desk at 1-800-554-0042. You may also review the EVS User Guides at www.mass.gov/masshealth. • Click the Provider tab at the top of your screen. • Under Client Eligibility & Benefits Assistance, click the Insurance link. • Click on MassHealth Eligibility Verification System (EVS). • Click on EVS User Guides. For PCC Plan members, the EVS message includes the name and telephone number of the member’s PCC and indicates that members can access behavioral health services through the behavioral health contractor, currently the Massachusetts Behavioral Health Partnership. Check EVS Regularly Possession of a MassHealth card does not guarantee eligibility. Checking EVS is important, as a member’s enrollment and eligibility may change from day to day. PCCs should verify member information both when scheduling an appointment and again on the day of the appointment. Doing so will minimize billing problems later, because you will learn if a member is still eligible for MassHealth or still enrolled in your panel (and not enrolled with another PCC or MCO). Managed Care Rules for Newborns Newborns of MassHealth-eligible mothers are automatically eligible for MassHealth from birth until the child is one year old. The following managed care enrollment rules apply for newborns. Mother Is Enrolled in the PCC Plan If a child’s mother is enrolled in the PCC Plan, the mother will be asked to choose a PCC for her baby. Failure to do so within the allotted time will result in the baby being assigned to a PCC. The mother should call MassHealth Customer Service at 1-800-841- 2900 (TTY: 1-800-497-4846 for people with partial or total hearing loss) to enroll her child in her plan of choice, which could be either the PCC Plan or an MCO. Until the baby is enrolled with a plan, any MassHealth provider can see the child. Information about the managed-care enrollment status of the baby will be found on EVS. It is important to check EVS at each visit to avoid potential billing issues. Mother Is Enrolled in an MCO If a child’s mother is enrolled in an MCO, the child will be enrolled automatically in her MCO retroactive to the date of birth. The child’s mother can choose another MCO or the PCC Plan for her baby. That enrollment choice will not be retroactive. You may be able to provide care to the newborn if you are a contracted provider with the mother’s MCO. If you are not part of that MCO network, you should instruct the mother to contact her MCO to select or call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4846 for people with partial or total hearing loss) to select a managed care plan in which you participate. Please note that MassHealth MCOs are contractually required to reimburse in- and out-of-network providers for newborn services until the child’s enrollment is established. Member Outreach and Care Coordination PCCs are required to provide outreach to newly assigned members and to other members on an ongoing basis. MassHealth offers services to PCCs to assist with this requirement. New Member Outreach New members to your practice must be contacted within three weeks of enrollment by mail or phone for an orientation to the PCC Plan and your practice. The contents of this orientation were previously described in the “Orienting Your New Patients to the PCC Plan” section of this handbook. If, after making reasonable attempts, a PCC is unable to reach a new enrollee, the PCC may contact the PCC Hotline at 1-800- 495-0086 and request assistance. A CSR from MassHealth Customer Service will attempt to provide outreach to the member. Targeted Outreach Provided by Local Community Support Programs (CSPs) PCCs should also provide outreach and assistance to an established member and facilitate access to care or services to address the following services or issues. • access to behavioral health services (mental health or substance abuse); • transportation difficulties; • childcare problems; or • language or cultural obstacles. PCCs may refer members to a Community Service Provider (CSP) for targeted outreach services. To obtain additional information on the CSP providers available in your service area and to obtain information on how to make a referral to a CSP, call the MBHP Assessment Unit at 1-800-495-0086. Care Management The PCC Plan offers other levels of care management to PCC Plan members through MBHP, including care coordination and intensive clinical management (ICM). Care managers from MBHP may contact a PCC to request assistance with coordinating care for MassHealth members on their respective panels. MBHP provides individual care plan (ICP) reports to PCCs. These reports are tools to assist PCCs coordinate care and improve service delivery and outcomes. PCCs may refer members for assessment by the MBHP Assessment Unit if they believe that the care management services provided by MBHP would assist with the management of a member’s medical or behavioral health conditions. Please contact the Assessment Unit at 1-800-495-0086, extension 5633, to inquire about the types of care-management services available to PCC Plan members. Member Rights The PCC Plan provides all enrolled members a PCC Plan Member Handbook to help them understand their rights. Members can get an additional copy of the member handbook by calling MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people with partial or total hearing loss). The PCC Plan Member Handbook informs members that they have the following rights. • A PCC cannot refuse to provide medically necessary treatment, but a PCC may refer a member to a specialist for treatment. • Employees of the PCC Plan and providers must treat members with respect and dignity. • The PCC Plan and all participating providers must keep a member’s health information and records private. They may not disseminate a member’s protected health information to another party unless the member gives consent or the provider is required to do so by the law. • Members must be informed, in a manner that the member understands, in advance of all treatment and alternatives that should be considered. • Providers must include members in the decision-making processes about the member’s health care. A member may refuse treatment (as far as the law allows). A member must be notified of the consequences if he or she decides to refuse recommended care and treatment. • A member may request and be provided copies of his or her medical records and may request changes to the records as the law allows. • Members who speak a language other than English may request an interpreter when the member calls MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-496-4748 for people with partial or total hearing loss). • Members who read a language other than English may request that the information be read to them in their respective language by calling MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-496-4748 for people with partial or total hearing loss). • Sight-impaired members may request the same services for materials provided by MBHP materials by calling MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-496-4748 for people with partial or total hearing loss). • Members have the right to select their own primary care clinician (PCC), and PCC selections may be changed at any time. Most managed care eligible members may also switch to an MCO at any time. To change PCCs or health plans, members must call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-496-4748 for people with partial or total hearing loss). • Members must be provided access to health care within the time frames described in “Hours of Operation and Appointments” on page 10. If a member does not get behavioral health care when he or she should, the member may file an appeal with MBHP. If a member does not get other medical care when he or she should, the member may file a grievance with MassHealth. • Members may file a grievance with MassHealth Customer Service or appeal to the Board of Hearings and request a fair hearing if the member disagrees with certain actions or inactions by MassHealth or MBHP. • Members must be notified of all benefits, services, rights, and responsibilities that they have under MassHealth. • Members may request a second opinion from another provider. • Members have the right to emergency care 24 hours a day, seven days a week. • Members may not be physically held, or kept away from other people, or be forced to accept treatment. • Members should not be treated differently by providers because they choose to assert their rights or make care decisions in accordance with their rights. PART 2 Service Delivery Hours of Operation and Appointments PCCs must provide assigned members telephone access 24 hours a day, seven days a week, even if their office is not open. Members’ calls to that number must be responded to within an hour. If a PCC is unavailable for a period of time, arrangements must be made for another MassHealth-participating provider to deliver health care services in the PCC’s absence. Below is a list of services and the time frames within which they must be provided to members. • Emergency care. Instruct the member to go to the nearest emergency department, call 911, or (for a behavioral health emergency) call the Emergency Service Program (ESP) in the area, as appropriate. • Post-stabilization care. PCCs are required to provide any necessary referrals for post- stabilization care upon request. • Urgent care. These services must be provided within 48 hours of the member’s request. • Primary care (non-urgent. symptomatic care). These services must be provided within 10 calendar days of the member’s request. • Primary care (routine, non-symptomatic care). PCCs must provide care within 45 calendar days of the member’s request unless the EPSDT Schedule requires a shorter time frame. (See Appendix W of your MassHealth provider manual.) See page 14 for EPSDT information. • Care for children in the care or custody of the Department of Children and Families (DCF). For children newly placed in the care or custody of DCF, PCCs are required to: - perform a health care screening within seven calendar days after the parent or a DCF worker asks for it. - Give the child a full medical exam within 30 calendar days after the parent or a DCF worker asks for it unless the EPSDT Schedule requires a shorter time frame. Referrals Making a Referral PCCs are responsible for providing primary care and referring members to MassHealth-covered reimbursable services when medically appropriate, such as specialty care and certain ancillary services. Many services covered by MassHealth require a referral. See page 30 of this Handbook for a list of services that do not require a PCC referral. All other services require a referral. Please keep in mind that the services requiring a referral may change. Check MassHealth regulations 130 CMR 450.118(J) for the most current list of services that do not require a PCC referral. When making referrals, consider the member’s prior relationship with a specialist; the member’s choice; location; and whether the specialist is a MassHealth provider. MassHealth will not pay for the services unless they are provided by a contracted MassHealth provider. Please document all referrals in the member’s medical record. Also include a copy of any medical report received from the referred-to-provider in the member’s medical record. Referrals to a sufficient number of physicians and other practitioners enrolled in MassHealth will ensure that MassHealth- covered services can be furnished to members promptly and without compromising quality of care. For information on available MassHealth specialty providers, you can contact the PCC Plan Hotline at 1-800-495-0086. When referring a member to another provider, always inform the provider of the reason for referral and the number of visits prescribed. How to Make a Referral From the MassHealth POSC home page: 1. Click Manage Service Authorizations. 2. Click Referrals. 3. Click Enter New Referral. (The Referral information panel is displayed.) Retroactive Referrals If a PCC Plan member sees a specialist without seeking a referral, and the specialist has already provided care to the member, you, as the PCC, have the right to approve or disapprove a request for a retroactive referral. Prior Authorization (PA) and Other Authorizations PA Some services require PA from MassHealth or from MBHP. The process for submitting PA requests differs according to the services requested and the type of provider delivering the service. It is the responsibility of the servicing provider to obtain a PA before delivering the service. MassHealth PA Request PCCs should familiarize themselves with all services requiring PA and, if required, obtain PA before providing the service, or refer the member to a participating provider for non-primary care and other specialty services. PCCs may obtain assistance from MassHealth to identify an appropriate provider by contacting MassHealth Customer Service at 1-800-862-8341. The provider to whom the referral was made is responsible for obtaining PA if required. (See “Referrals” section on page 10 of this handbook) for the documentation required to support a request for PA. MBHP PA Request PCCs should submit a request to MBHP for a behavioral health service that requires PA. MBHP may be contacted at 1-800-495- 0086. Please Note: Members have the right to appeal any decision by MassHealth or MBHP denying a request for services, or, in the case of a change or modification, such adjustments to the scope and duration of services, time period, or scope of services asked for. Members may also appeal if MassHealth or MBHP does not act on the PA request within noted time frames for certain services. Members’ appeal rights are fully described in MassHealth’s regulations and in the PCC Plan Member Handbook. For additional information on MassHealth’s PA process, please refer to your MassHealth provider manual. Failure to obtain PA for required services will result in a denial of payment for furnished services. Other Authorizations Some services require other types of authorizations. See below for authorization requirements for “Hospitalizations” and “Non- Emergency Transportation Services.” Emergency and Urgent Care Members should be instructed to seek emergency care whenever they experience a serious health care problem that they think needs to be treated right away. However, PCCs have the authority and responsibility to provide and manage care for all assigned members’ care. PCCs are personally responsible for the provision of a member’s primary and preventive care and to coordinate and refer members for other medically necessary nonprimary and preventive care services. PCCS may deny requests for referrals to services that they believe are not medically necessary. Emergency and PCC services delivered to PCC Plan members in an ED or ESP do not require a PCC referral or prior authorization. When services are delivered to PCC Plan members in the ED, including services delivered by an ESP provider, hospitals are required to notify the PCC of the visit within 48 hours. Members are also encouraged to notify their PCC of all ED visits. PCCs are required to provide follow-up care, as appropriate, including the coordination and tracking of referrals for recommended physical or behavioral health services. Hospitalizations Hospital Admissions Hospitals are not required to obtain a referral from a member’s PCC for elective or non-elective admissions for a PCC Plan member. However, it is the hospital’s responsibility to notify the member’s PCC in writing of an admission within 48 hours of the admission, per MassHealth regulations, and within 48 hours of discharge, per MassHealth’s agreement governing payment for hospital services. Preadmission Screening (PAS) MassHealth performs preadmission screening for all elective inpatient medical and surgical admissions when MassHealth is the primary insurance. PAS requests are reviewed by MassHealth’s vendor, Permedion. Permedion notifies the member’s PCC of the results of all preadmission screening requests. Questions about preadmission screenings should be directed to Permedion at 1-877-735-7416. Non-Emergency Transportation Services Authorization MassHealth Standard and CommonHealth members are eligible for transportation to and from MassHealth-contracted providers for medically necessary services. Transportation is by land ambulance, taxi, or wheelchair van. MassHealth will approve a request for nonemergency transportation when personal transportation resources are unavailable and public transportation is either unavailable or not suitable to the member’s health condition. PCC referrals are not required for transportation services. To arrange for nonemergency transportation, PCCs are required to request authorization in advance by submitting a completed Prescription for Transportation (PT-1) form to the MassHealth Transportation Authorization Unit. The Prescription for Transportation (PT-1) form may be completed electronically. A copy of the form is also available for download from the MassHealth website at www.mass.gov/masshealth. Instructions to complete the form electronically can be found at www.mass.gov/eohhs/gov/newsroom/masshealth/providers/how-to-complete-and-submit-the-pt-1-online.html and www.mass.gov/eohhs/docs/masshealth/bull-2006/all-157.pdf. If a provider does not have access to the Internet, a paper copy of the PT-1 may be requested by calling MassHealth Customer Service at 1-800-841-2900. Questions about the process for authorization should be directed to the MassHealth Transportation Authorization Unit at MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people with partial or total hearing loss). Pregnancy and Family Planning Services Members are encouraged to make an appointment with their PCC, obstetrician/gynecologist (OB/GYN), or nurse midwife when planning a pregnancy to discuss their health status and the steps necessary to have a healthy birth. PCCs should encourage pregnant members to make an appointment with an OB/GYN or a nurse-midwife as soon as they become aware of a pregnancy. When MassHealth knows about a member’s pregnancy, we will provide notice via the MassHealth Health Needs Referral form. If pregnant, members do not need a PCC referral to see an OB/GYN or nurse-midwife. Members may obtain family-planning services from their PCC or any MassHealth family-planning provider. Members do not need a PCC referral to see a family-planning services provider. Health Care for Children, Adolescents, and Young Adults Introduction Early and Periodic Screening, Diagnosis and Treatment (EPSDT) for MassHealth Standard and CommonHealth members under the age of 21. EPSDT includes screening and diagnosis services and treatment services. MassHealth has also established a program of preventive health care screening and diagnosis (PPHSD) services for MassHealth members under the age of 21 who are enrolled in MassHealth Prenatal, Basic, Essential, and Family Assistance. Preventive health care includes screening, diagnosis services and covered treatment services. For more information, please see 130 CMR 450.140 through 450.150 in your MassHealth provider manual. Well-Child Visits/Screening Services PCCs are required to perform well-child visits and screenings for all enrolled MassHealth members under the age of 21. Screenings assist with the identification of health problems. These screenings include health, vision, dental, hearing, behavioral health, developmental, and immunization-status screenings. As appropriate, PCCs are required to make treatment recommendations or make referrals to other providers as applicable. Appendix W: EPSDT Services: Medical and Dental Protocols and Periodicity Schedules (the EPSDT Schedule) of all MassHealth provider manuals lists the ages at which you must conduct well-child visits. The ages are: • one to two weeks • one month • two months • four months • six months • nine months • 12 months • 15 months • 18 months • ages two through 20, annually. PCCs may perform medically necessary checkups at any time, even if they fall outside of the usual and customary periodicity schedule. This allows PCCs to provide care whenever there is a concern about a child’s medical or behavioral health, or when or a parent, guardian, or other clinician identifies a concern. Additional information about the schedule for check-ups, recommended screenings, and resources can be found in the EPSDT Schedule. PCCs are required to document the results of the screens in the child’s medical record. If a PCC is unable to perform any screenings according the EPSDT Schedule, the PCC must refer the child to another MassHealth provider to perform the screen. Results of such referred screenings are to be obtained and included in the child’s medical record. If a child has a documented prior screen from another provider, PCCs should not repeat that screen unless it is required for the member’s next age- appropriate visit or there is a medically necessary reason to repeat the screening. It is the PCC’s responsibility to arrange for needed follow-up care. Required follow-up treatment may be provided by the PCC or a referral made to other providers as clinically indicated. Behavioral Health Screenings PCCs are required to use one of the approved, standardized behavioral health screening tools listed in the EPSDT Schedule to perform behavioral health screens. Responses and results from the BH screening tools are to be shared and discussed with the child or his or her parent(s). The results of the BH screenings should be used to determine if a child needs further assessment by a behavioral health provider or other medical professional. PCCs should consider enrolling with the Massachusetts Child Psychiatry Access Project, a DMH-funded service, managed by MBHP that provides telephone consultation with a child psychiatrist within 30 minutes of a call. PCCs can enroll for this free service through the MCPAP website at www.MCPAP.com. Children identified as having a potential need for behavioral health treatment services must receive or be referred for needed BH services. PCCs may obtain additional information on how to access behavioral health services or find a behavioral health provider by contacting the PCC Plan’s behavioral health contractor, the Massachusetts Behavioral Health Partnership (MBHP), at 1-800-495-0086. For more information on the screening tools, go to www.mass.gov/masshealth/cbhi. Diagnosis and Treatment Services If a screen indicates that a child has a potential need for further diagnosis or treatment, the PCC is required to diagnose and treat the child or refer the child to an appropriate provider for treatment. MassHealth covers required and medically necessary services for diagnosed health conditions as follows. • Further treatment for children enrolled in MassHealth Basic, Essential, Prenatal, and Family Assistance. For children under the age of 21 and enrolled in MassHealth Basic, Essential, Prenatal, or Family Assistance, MassHealth pays for all medically necessary services covered under the child’s coverage type. This means that when the child’s PCC (or any other clinician) discovers a health condition, MassHealth will pay for any medically necessary treatment that is included in the child’s coverage type and delivered by a qualified MassHealth provider. • Further treatment through the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program for children enrolled in MassHealth Standard or CommonHealth. For children who are under the age of 21 and enrolled in MassHealth Standard or CommonHealth, MassHealth pays for all medically necessary services that are covered by federal Medicaid law, even if the services are not provided by the PCC Plan or MBHP. This coverage includes health care, diagnostic services, treatment, and other measures needed to correct or improve defects and physical and mental illnesses and conditions. When you (or any other clinician) discover a health condition, MassHealth will pay for any medically necessary treatment covered under Medicaid law, if it is delivered by a provider who is qualified, and if a MassHealth-enrolled physician, nurse practitioner, or nurse-midwife supports in writing the medical necessity of the service. PCCs may seek assistance from MassHealth to identify providers who may be available to provide these services and assist members to obtain the services outside of the network, if necessary. Most of the time, these services are covered by the child’s MassHealth coverage type. If the service is not already covered, the clinician or provider delivering the service may contact MassHealth to request a PA for the service. MassHealth uses this process to determine if the service is medically necessary. The procedure for requesting such a service follows the same procedure as any other PA request. You can access the Automated Prior Authorization System (APAS) at www.masshealth-apas.com, call the PA Unit at 1-800-862-8341, or send a written request to the following address. MassHealth Attn.: Prior Authorization Unit 100 Hancock Street, 6th floor Quincy, MA 02171 Dental Services PCCs are required to perform a dental assessment at well-child checkups according to the EPSDT Schedule. Detected problems with a child’s teeth or oral health must be referred to a dentist. PCCs should also recommend that the child visit a dentist at least twice a year when the first tooth erupts, but no later than 12 months of age. Children do not need a referral to see a MassHealth dentist. During a routine dental appointment, the dentist will provide a full dental exam, teeth cleaning, and fluoride treatment. It is important to review and emphasize the need for children get the following dental care: • a dental checkup every six months; • a dental cleaning every six months; and • any other dental treatments needed if you find problems with a child’s teeth or oral health. MassHealth covers additional and medically necessary dentals services as follows. • Children who are under the age of 21, and enrolled in MassHealth Standard or CommonHealth, can get all medically necessary treatment covered under Medicaid law, including dental treatment, even if the service is not otherwise covered by MassHealth. • Children who are under the age of 21, and enrolled in MassHealth Basic, Essential, Prenatal, or Family Assistance, can get all medically necessary services covered under their coverage type, including dental treatment. Fluoride Varnish Program In an effort to intercept and prevent early childhood caries in children at moderate-to-high risk for dental caries, the application of fluoride varnish is recommended. Qualified personnel including physicians, nurse practitioners, registered nurses, licensed practical nurses, physician assistants, and medical assistants who complete online training may apply fluoride varnish to eligible MassHealth members during a well-child check-up. While the service is primarily intended for children up to age three, it is, however, allowed for children up to age 21. Fluoride varnish application is not recommended to exceed one application every 180 days from first tooth eruption (usually at six months) to the third birthday. Qualified personnel who complete any of the following online training courses are eligible to apply fluoride varnish: • one of two MassHealth-approved self-administered web-based trainings: a. Smiles for Life Oral Health Trainings: www.smilesforlifeoralhealth.org; or b. AAP Oral Health Risk Assessment: Training for Pediatricians and Other Child Health Professionals: http://www2.aap.org/ORALHEALTH/pact/pact-home.cfm; or • Massachusetts Department of Public Health’s BLOCK Oral Disease and Fluoride Varnish online training. For more information about the fluoride varnish program, training, and reimbursement, visit www.mass.gov/eohhs/consumer/wellness/disease-prevention/oral-health/block-oral-disease-education-materials-and- trainings.html. Please contact Megan Mackin at 617-886-1728 for training assistance. School-Based Health Centers To increase access to primary-care services, PCCs may refer school-age members to a MassHealth-participating school-based health center (SBHC) in your geographic area. SBHCs are located in some elementary, middle, and high schools, and require a PCC referral to deliver most services. SBHCs are expected to provide prompt information about the care and services provided to the member’s PCC. For a current list of contracted SBHCs, please call or write the Department of Public Health (DPH) at the following address. Department of Public Health Bureau of Family and Community Health School-Based Health Center Program 250 Washington Street Boston, MA 02108 617-624-6015 617-624-6062 (fax) www.mass.gov/dph PART 3 Administration Billing Introduction All MassHealth statutes, regulations, rules, billing instructions, and provider bulletins governing claims submission apply to PCCs. Please consult your MassHealth provider manual for additional billing information. Please note that providers may not bill MassHealth members for services covered by MassHealth. PCC Enhancement MassHealth pays PCCs an enhanced rate of $10 for certain types of primary and preventive care visits. The enhanced fee will be added to your visit rate. Please refer to the PCC Plan Provider Contract for a list of codes that are eligible for the PCC enhancement. Special Billing for Screening Services/Well-Child Care Provided in Accordance with the EPSDT Schedule MassHealth pays PCCs who are physicians, nurse practitioners, and acute-hospital outpatient departments an enhanced rate plus certain additional payments for check-ups and screens performed when the appropriate service codes and billing modifiers are submitted. Correctly billing for these visits is important because it allows MassHealth to accurately track the provision of well-child care and ensures that PCCs receive the enhanced rates when applicable. For more detailed information on Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services and Preventive Pediatric Healthcare Screening and Diagnosis (PPHSD) billing guidelines for MassHealth physicians and mid-level providers, please review the EPSDT Schedule and the special billing guidelines about well-child care. Providers may request a copy of these guidelines by sending a request to the following address. MassHealth Customer Service Provider Enrollment and Credentialing P.O. Box 9118 Hingham, MA 02043 1-800-841-2900 617-988-8974 (fax) 1. Enhanced Fee for Well-Child Care Checkups PCCs who are physicians, nurse practitioners, and acute-hospital outpatient departments are paid an enhanced fee in addition to the published rate for the well-child care visit when the services are delivered to members under the age of 21 in accordance with the EPSDT Schedule and 130 CMR 450.140 through 150. To obtain reimbursement for the enhanced fee, PCCs must submit a claim for the visit in accordance with the applicable billing instructions and include the add-on code (S0302) in addition to the visit code. Current rates for these services are published in the Division of Health Care Finance and Policy (DHCFP) regulations at www.mass.gov/dhcfp. 2. Fee for Fluoride Varnish Application Physicians and independent nurse practitioners may submit claims for fluoride varnish services when directly applied by these providers to a MassHealth member. These are the only MassHealth provider types who may bill for this service independently. PCCs may bill for an office visit, in addition to the fluoride varnish application, only if fluoride varnish was not the sole service, treatment, or procedure provided during the visit. PCCs may also submit claims for fluoride varnish services that are provided by other qualified personnel under the supervisor of the PCC, such as nurse practitioners, registered nurses, licensed practical nurses, physician assistants, and medical assistants. Services provided by such qualified personnel should be submitted with Service Code D1206 on the MassHealth claim. Please Note: Physicians should not use the mid-level modifiers (SA, SB, or HN) when submitting a claim for fluoride varnish services provided by qualified personnel. 3. Fee for Behavioral Health Screens The EPSDT Schedule requires a behavioral health screen at every well-child care visit. MassHealth pays for the administration and scoring of the standardized behavioral health-screening tool in addition to the office visit when claims are submitted using Service Code 96110 and the appropriate “U” modifier. The billing modifier depends on the type of provider conducting the screen and the disposition of the screen. Clinicians must exercise their professional judgment as to whether the screen identifies a potential behavioral health need. 4. Fee for Laboratory Services, Audiometric Hearing Tests, and Bilateral Tests of Visual Acuity For certain services, the EPSDT Schedule requires laboratory services (for example, an audiometric hearing test or a bilateral test of visual acuity is included in a visit). When these services are provided in accordance with the EPSDT Schedule, they are payable in addition to the visit. Appendix Z of the MassHealth provider manual lists the applicable billing codes for these services. The current rates for these services can be found in the DHCFP regulations at www.mass.gov/dhcfp. Special Billing for Diagnosis and Treatment Services Provided to Children in Accordance with the EPSDT Schedule In general, MassHealth reimburses PCCs for diagnosis and treatment services performed in accordance with the EPSDT Schedule and as described in the general administrative and billing regulations in your MassHealth provider manual. Providers may obtain a copy on the MassHealth Web site at www.gov/masshealth. To view these regulations online, follow these steps from the MassHealth home page: • Click on MassHealth Regulations and other Publications. • Click on Provider Library. • Click on Physician Manual. MassHealth will cover treatment for some services not otherwise covered by MassHealth (and for which there is no established fee) when provided to a member enrolled in MassHealth Standard or CommonHealth, and for which MassHealth has issued a PA. For circumstances like these, MassHealth will establish the appropriate payment rate for such services on an individual- consideration basis in accordance with 130 CMR 450.271. Billing After Hours MassHealth will pay PCCs an additional fee for urgent care provided in at the PCC’s practice “after hours.” This payment is to encourage PCCs to provide extended hours for urgent care, thereby diminishing the member’s need to visit a hospital emergency department or an emergency services program. PCCs should use Subchapter 6 of their provider manual, in conjunction with the American Medical Association Current Procedural Terminology (CPT) code book, to locate the appropriate “after-hours” service code. The current rates for these services can be found in the DHCFP regulations at www.mass.gov/dhcfp. For additional billing assistance, please visit the MassHealth website at www.mass.gov/masshealth. From the home page, follow these steps: • Click on the Providers tab at the top of your screen. • Under the heading Insurance (including MassHealth), click on MassHealth. • Click on MassHealth Claims Submission. Questions For answers to billing and claims payment questions, call MassHealth Customer Service at 1-800-841-2900, send a fax to 617-988-8974, or send an e-mail to providersupport@masshealth.net. Prospective Interim Payments Providers may choose to receive a Prospective Interim Payment (PIP), with the option for providers to receive a monthly cash advance based on a percentage of submitted claims. To open or close a PIP account, providers must notify MassHealth Provider Enrollment and Credentialing in writing. Requests must include the provider’s MassHealth provider ID and tax identification number. Send written request to the following address. MassHealth Customer Service Provider Enrollment and Credentialing P.O. Box 9118 Hingham, MA 02043 1-800-841-2900 Requests via courier, UPS, or FedEx should be sent to the following address. MassHealth Customer Service Provider Enrollment and Credentialing 75 Sgt. William B. Terry Drive Hingham, MA 02043 For additional information on the PIP questions option, call MassHealth Customer Service at 1-800-841-2900, send a fax to 617-988-8974, or send an e-mail to providersupport@masshealth.net. PCC Changes PCCs are required to notify MassHealth of any changes to their status as a PCC, including, but not limited to, the following: • voluntary withdrawal from the PCC Plan or MassHealth for any reason; • changes to information contained in the PCC Plan Provider Application or any other application submitted by the PCC to the Executive Office of Health and Human Services (EOHHS); • changes to address and other demographic information; • changes to managed care contact; and • changes to hours of operation or designation of PCC specialty. Notification of changes must be sent in writing and at least 14 days in advance of such changes to the MassHealth Provider Enrollment and Credentialing unit at the following address. MassHealth Customer Service Provider Enrollment and Credentialing P.O. Box 9118 Hingham, MA 02043 Ph: 1-800-841-2900 Fax: 617-988-8974 Notifying Your Members About PCC Changes Members must be notified of changes that will impact their access to care and services, such as changes to location, hours of operation, or other PCC status changes, with exceptions noted for changes to provider type or ownership. Changes to provider type or ownership will not result in an automatic transfer of current PCC Plan members to a PCC’s new practice. Please Note: PCCs should not discuss with or notify members about these changes before consulting with MassHealth Provider Enrollment and Credentialing at 1-800-841-2900 to determine if current PCC Plan members may be transferred to a new practice. MassHealth will work with PCCs on a plan for notifying current members if changes will impact their continued enrollment with the PCC. Credentialing Credentialing is the process by which MassHealth determines that a provider meets the criteria established to participate in the MassHealth PCC Plan. A provider must meet the criteria set for the specific provider type in which the provider wishes to enroll. Providers participating in the PCC Plan must meet not only the MassHealth provider credentialing criteria but also the eligibility criteria set for the PCC Plan. Questions Additional questions about changes to provider information should be directed to Provider Enrollment and Credentialing at 1- 800-841-2900. PART 4 Quality Management and Reporting The PCC Plan supports quality-improvement initiatives undertaken by PCCs in an effort to improve the quality of care provided to members. The PCC Plan works with the MassHealth Office of Clinical Affairs, the PCC Plan’s network management vendor (currently MBHP), and clinical advisory committees, which include PCCs, to identify specific clinical and utilization measures for evaluation and reporting. Performance Improvement Management Services (PIMS) Introduction The PCC Plan contracts with MBHP to provide Performance Improvement Management Services (PIMS). PIMS is a comprehensive, clinically focused management system that monitors, measures, and analyzes health care delivery by PCCs. The major goal of PIMS is to support PCCs in managing their PCC Plan members’ care to improve health outcomes. PIMS responsibilities include the following. • PCC Plan Hotline. PCCs can call the PCC Plan Hotline at 1-800-495-0086 to ask to questions about the PCC Plan, discuss concerns, arrange for member outreach, and order health-education materials, among other things. • Provider Satisfaction Survey. The biennial survey measures PCC satisfaction with the various components of the PCC Plan, including provider enrollment, ease of finding specialists, and overall satisfaction with the PIMS program. The purpose of the survey is to identify areas in need of improvement and to develop plan-wide improvement goals. • PCC Plan Quarterly Newsletter. The PCC Plan Quarterly newsletter informs PCCs of the latest policy updates and contains articles about medical and behavioral health-integration issues. The newsletter includes stakeholder viewpoint columns from consumers, providers, trade associations, and public agencies, as well as clinical information on best practices and current research from medical journals. • PCC Plan Health Highlights Newsletter. The Health Highlights newsletter is mailed twice a year to all PCC Plan members. This newsletter includes health information, illness prevention, and other topics conveying key concepts and messages of importance to the PCC Plan. • PCC Plan Health Education Materials Catalog. The catalog provides current health-education materials for PCCs and PCC Plan members. PCCs can call the PCC Plan Hotline at 1-800-495-0086 to order materials from the catalog free of charge. • Quality Forums. The PCC Plan conducts quality forums for PCCs on an ongoing basis to promote improvement in the provision of health care services and the improvement goals of the PCC Plan. Additionally, quality forums on topics related to integrating behavioral and medical health care services are offered to both PCC and behavioral health providers. • Provider Contract Compliance. The PCC Plan monitors PCC compliance with contractual requirements on an annual basis. • MBHP website. The MBHP website contains information and materials of interest to PCCs. Visit the MBHP website at www.masspartnership.com, then click on the tab “For PCCs.” The website also lists MBHP’s behavioral health network providers that are available to serve PCC Plan members. • PCC Site Visits. A site visit is provided to select PCCs, including those with 180 or more members. Regional Network Managers (RNMs) perform these visits in order to review with the PCC the PCC Profile Report, the PCC Reminder Report, and the PCC Care Monitoring Registries. By reviewing the reports and discussing how rates reflect the PCC practice’s performance, RNMs assist practices to identify areas for improvement and to develop action plans to improve performance and the delivery of high-quality health care to members. RNMs are available as a resource to respond to PCC’s concerns, assist in resolving issues, and inform and educate clinicians and staff on PCC Plan policies and procedures. Reporting Healthcare Effectiveness Data and Information Set (HEDIS) HEDIS, issued by the National Committee for Quality Assurance (NCQA), is a set of health plan performance measures that standardize the way health plans collect and report information on health care quality and service utilization. Examples of measures contained in HEDIS include breast and cervical cancer screening, childhood immunization, and well-care visits for children and adolescents. HEDIS uses claims and medical records in calculating its measures. The PCC Plan uses HEDIS measures on an annual basis as one of its measurement activities to identify opportunities for improvement. PCCs can help the PCC Plan by responding promptly to all requests from MassHealth for medical records. HEDIS results for the PCC Plan and other MassHealth plans can be accessed online at www.mass.gov/masshealth. Click on the Researchers tab at the top of the screen. then click the Insurance (including MassHealth) category and select MassHealth Annual Reports. Member Surveys Every other year, MassHealth conducts a member survey to capture the experience of adult and pediatric members with their primary care practitioners. MassHealth is interested in two dimensions of care: 1) Quality of doctor-patient interactions: • communication (how well doctors communicate with patients); • integration of care (how well doctors work with other providers in furnishing care to patients); • knowledge of the patient (how well doctors know their patients); and • health promotion (how well doctors give preventive care and advice). 2) Organizational features of care: • organizational access (patients get timely appointments, care, and information); • visit-based continuity (patients see their own doctor); • clinical team (patients receive quality care from other doctors and nurses in the office); and • office staff (patients receive quality care from staff in the doctor’s office). The survey results may be used to identify and develop opportunities for improvement in the primary care setting. PCC Profile Report The PCC Profile Report provides information on selected clinical measures, such as pediatric behavioral health, well-child care, and women’s cancer screening, that may be used to improve health care delivery and, ultimately, the health outcomes of PCC Plan members. Most of the profile measures display rates of performance for a PCC’s practice as well as rates for each service location, if applicable, and for the PCC Plan as a whole. Prior rates for PCC practices and the PCC Plan are also presented to show trended rates for these clinical indicators. Summary data are provided to help with the identification of barriers to care. PCC Reminder Report Reminder systems improve patient compliance with a variety of scheduled health visits and procedures. Studies have shown that members prefer to receive reminders from their primary care provider rather than their health plan. The PCC Reminder Report is produced and mailed to PCC and PCC service locations semiannually, and provides data on members in a PCC’s panel who may be in need of selected preventive services, such as well-child care and women’s cancer screening. The Reminder Report lists the most currently available addresses and telephone numbers to assist providers with outreach for those members who may be in need of a particular service. PCC Care Monitoring Registry The PCC Care Monitoring Registry is produced and mailed to all PCC and PCC service locations semiannually and provides the most current data available for members on a PCC’s panel with chronic conditions of asthma and diabetes, members with high pharmacy utilization, and members with two or more visits to the emergency department (ED) in a six-month period. This information is provided to help PCCs monitor and manage the treatment of these members in accordance with applicable guidelines and to support efforts for members to receive care in the most appropriate setting. The Care Monitoring Registry lists the most currently available member addresses and telephone numbers to assist with outreach activities for those members who may be in need of service. Both the Reminder Report and the Care Monitoring Registry are available electronically. Please contact your RNM or the PCC Plan Hotline for instructions on how to access this information. PART 5 Behavioral Health Services The Massachusetts Behavioral Health Partnership (MBHP) Behavioral health (mental health and substance abuse) services are provided to PCC Plan members through the Massachusetts Behavioral Health Partnership (MBHP). MBHP is the PCC Plan’s behavioral health services contractor. Covered Services PCC Plan members receive inpatient services, outpatient services, outpatient day services, diversionary services, emergency- services-program services, and emergency behavioral health services through a network of MBHP providers including, but not limited to, hospitals, acute residential programs, outpatient clinics, psychiatrists, psychologists, day-treatment programs, detoxification facilities, and emergency-services programs (ESP). Covered services include crisis counseling, substance-abuse services, medication-management services, and community-support services. In addition, PCC Plan members who are under 21 can currently receive a number of “community based” and “home-based” behavioral health services when medically necessary. These services include Intensive Care Coordination (for Standard and CommonHealth members), Family Support and Training, In-Home Behavioral Services, Therapeutic Mentoring and In-Home Therapy Services, Community-based Acute Treatment (CBAT), and Mobile Crisis Intervention. PCC Plan members may also be eligible for enrollment in care-management programs such as Intensive Care Management, Care Coordination, or Targeted Outreach. For more information about these programs, see “Member Outreach and Care Coordination.” For a more information about the behavioral health services covered by MBHP, call MBHP at 1-800-495-0086 or visit MBHP at www.masspartnership.com. Your Role as the PCC Members do not need a PCC referral to access behavioral health services. However, PCCs should assist members to access needed behavioral health services. PCC Plan members may also arrange for services by calling MBHP directly. Either the PCC or the member may call 1-800-495-0086 to locate an appropriate behavioral health provider in their area. Although PCCs are not required to authorize behavioral health services, it is important for the PCC to screen for behavioral health conditions, suggest appropriate behavioral health services, inquire about prescription medication, and encourage members to discuss their behavioral health treatment and assist with care coordination. Communicating with Behavioral Health Providers PCCs and behavioral health providers are encouraged to communicate and coordinate as appropriate and applicable with any provider delivering behavioral health services to your PCC members, including the following. • all specialists • home health agencies • state agency case managers • care or disease managers • school-based health centers • local educational authorities • discharge planners Behavioral health providers are encouraged to use the Combined MCE Behavioral Health Provider/Primary Care Provider Communication Form, which can be downloaded at: www.masspartnership.com/provider/pdf/Combined_MCE_BH_ProviderTwo-wayForm101610.pdf. The use of this form is intended to increase the frequency and the quality of the content of communication between behavioral health providers and primary care clinicians. Coordination also includes the review and acknowledgement of an Individual Care Plan (ICP) from the behavioral health contractor upon receipt of the ICP. Referring Children Under Age 21 to Behavioral Health Providers PCCs are required to provide or refer children for behavioral health diagnosis and treatment services in accordance with the EPSDT Schedule whenever there is a potential need identified. For more information about well-child visits and screens and coverage of diagnosis and treatment services, see page 14 of this Handbook. Questions For more information or questions about accessing behavioral-health services for PCC Plan members, call 1-800-495-0086 or visit the Partnership at www.masspartnership.com. (Blank) (Blank) Part 6 Supplements 30 Services That DoNot Require a Referral 33 MassHealth Referral Form 35 Notification of Incorrect Assignment 37 PCC Plan Community Support Program Referral Form 39 PCC Plan Member Outreach Form 41 Request for Provider Training 43 Request for Assistance with Billing Issues Services That Do Not Require a Referral The following is a list of the currently available MassHealth-reimbursable services that do not require a referral from a PCC. Please keep in mind that MassHealth services and benefits requiring a referral from a PCC change from time to time. This list is for your general information only. MassHealth’s regulations at 130 CMR 450.118(J)(5) take precedence. (a) abortion services (b) annual gynecological exams (c) chiropractor services (d) clinical laboratory services (e) diabetic supplies (f) durable medical equipment (items, supplies, and equipment) described in the durable medical equipment regulations at 130 CMR 409.000) (g) fiscal intermediary services as described in 130 CMR 422.419(B) (h) fluoride varnish administered by a physician or other qualified personnel as described in 130 CMR 433.449(B) (i) functional skills training provided by a MassHealth personal care management agency as described in 130 CMR 422.421(B) (j) hearing instrument specialist services (k) HIV pre- and post-test counseling services (l) HIV testing (m) hospitalization (i) elective admissions (all elective admissions are exempt from the PCC referral requirement and are subject to the MassHealth agency’s admission screening requirements at 130 CMR 450.208(A). The hospital must notify the member’s PCC within 48 hours following an elective admission) (ii) nonelective admissions. Nonelective admissions are exempt from the PCC referral requirement. The hospital must notify the member’s PCC within 48 hours following a nonelective admission (n) medical nutrition therapy/diabetes self-management training (o) obstetric services for pregnant and postpartum members provided up to the end of the month in which the 60-day period following the termination of pregnancy ends (p) orthotic services (q) oxygen and respiratory therapy equipment (r) pharmacy services (prescription and over-the-counter drugs) (s) prosthetic services (t) radiology and other imaging services with the exception of magnetic resonance imaging (MRI), computed tomography (CT) scans, and positron emission tomography (PET) scans, which do require a referral (u) services delivered by a behavioral health (mental health and substance abuse) provider (including inpatient and outpatient psychiatric services) (v) services delivered by a dentist (w) services delivered by a family planning service provider, for members of childbearing age (x) services delivered by a hospice provider (y) services delivered by a limited service clinic (z) services delivered in a nursing facility (aa) services delivered by an anesthesiologist (bb) services delivered in an intermediate care facility for the mentally retarded (ICF/MR) (cc) services delivered to a homeless member outside of the PCC office pursuant to 130 CMR 450.118(K) (dd) services delivered to diagnose and treat sexually transmitted diseases (ee) services delivered to treat an emergency condition (ff) services provided under a home- and community-based services waiver (gg) sterilization services when performed for family planning services (hh) surgical pathology services (ii) tobacco-cessation counseling services (jj) transportation to covered care (kk) vision care in the following categories (see Subchapter 6 of the Vision Care Manual): visual analysis frames, single-vision prescriptions, bifocal prescriptions, and repairs (Blank) MassHealth MassHealth Referral Form To be completed by the referring provider. Member’s name:___________________________ Member’s ID #: ___________________________ Referring provider: ________________________ Telephone: ___________________________ Is referring provider the primary care clinician (PCC)? ___Yes ___No PCC’s name (if other than referring provider): ___________________________ PCC’s MassHealth provider no.:_______________ PCC’s telephone no.:____________________ Reason for referral:___________________________ Services requested:___________________________ Number of visits or services authorized:_______________ Duration of referral:___________________________ To be completed by the provider of the referral services, and returned to the referring provider. Findings: (physical exam, treatment, recommendation) ___________________________ ___________________________ ___________________________ Date(s) of service: ___________________________ ___________________________ ___________________________ Signature of the provider of the referral services ___________________________ Date ___________________________ MHREF-1 (Rev. 12/07) (Blank) MassHealth PCC Plan Commomwealth of Massachusetts Notification of Incorrect Assignment Occasionally, a member is incorrectly assigned to a Primary Care Clinician’s (PCC) panel. If you believe that this has happened and you would like to request that the member be transferred to another PCC, please complete this form and fax it to the PCC Hotline at the fax number below. When MassHealth has determined that the member was incorrectly assigned, the member will be transferred to another PCC. You will be informed of the result of your request within 30 days. Date: ________________ I believe that (member name) ________________ (member ID) ________________ (member phone number if available) ________________ has been incorrectly assigned to my PCC panel, for the following reason (please check one): ___ adult assigned to pediatrician ___ child assigned to internal-medicine practice ___ current patients only (restriction currently in place) ___ no new enrollees (restriction currently in place) ___ male patient assigned to an OB/ GYN specialty practice ___ other ________________ Please follow-up with (contact name) _______________________, at (provider/site name) _________________________, about this request. My phone number is_______________________. My provider number is ____________________________. I have attached a copy of the member’s Notification of Enrollment letter. ___ Yes ___No Thank you for your assistance. _____________________________ (Signature) ______________________________ (Title) Please return this form to PCC Plan Hotline Massachusetts Behavioral Health Partnership 100 High Street, 3rd Floor Boston, MA 02110 Fax: 617-790-4138 PCC-NIA (Rev. 07/12) (Blank) Member Stamp (PCC Use Only) MassHealth PCC Plan Commomwealth of Massachusetts Primary Care Clinician (PCC) Plan Community Support Program Referral Form The Community Support Program (CSP) is a group of community-based agencies that provide expertise in engaging members in treatment and resolving barriers to care. The CSP provides member-focused, in-person intervention that focuses on short-term problem resolution to help PCC Plan members access the health care they need. CSP services are most effective for established members who are not complying with their treatment plan and, as a result, are putting themselves at risk. To make a referral, complete all of the information below and call the MBHP Assessment Unit at 1-800-495-0086 to get the name of a CSP in your area. Send the completed form to that CSP, to the attention of the contact person. The CSP will contact your office within five business days to confirm receipt of the referral and to gather any additional information. The CSP will contact the member by telephone and seek consent from the member to provide these services. They will coordinate with your office and provide periodic updates with the member’s permission. Section I. PCC Information PCC and practice name:____________________ PCC provider number:____________________ Office contact person:____________________ Telephone no.:____________________ Address:____________________ Referral date:____________________ Primary language:____________________ Section II. Member Information Name:____________________ Member ID:____________________ Address:____________________ Telephone no.:____________________ Date of birth:____________________ Gender ___ M ___ F Section III. Reason for Referral: ____________________ ____________________ ____________________ PCC-CSP (Rev. 07/12) (Blank) MassHealth PCC Plan Commomwealth of Massachusetts For PCC Use Only Primary Care Clinician (PCC) Plan Member Outreach Form Member outreach is a service for PCCs who are experiencing difficulty contacting a new or existing member. The PCC Hotline can help facilitate member outreach through MassHealth Customer Service. PCCs may request Member Outreach by calling the PCC Hotline at 1-800-495-0086. PCCs can also complete the following information and fax this form to 617-790-4138 or mail it to the address below. The PCC Hotline staff will contact the PCC to indicate if the attempts by MassHealth Customer Service were successful. Section I. Primary Care Clinician Information Name of contact at PCC office: ____________________ Telephone no. of contact:____________________ PCC name:____________________ PCC provider number:____________________ Date of EVS check:____________________ Section II. Member Information Name:____________________ If a family, attach sheet w/additional names and RIDS Member ID:____________________ Address:____________________ Telephone no.:____________________ Section III. Reason for Referral: ____________________ ____________________ ____________________ Please return this form to: PCC Plan Hotline Massachusetts Behavioral Health Partnership 100 High Street, 3rd Floor Boston, MA 02110 Fax: 617-790-4138. For MBHP Use Only Inquiry Number: PCC-MOR (Rev. 07/12) (Blank) MassHealth Commonwealth of Massachusetts EOHHS www.mass.gov/masshealth Request for Provider Training Masshealth Customer Service is dedicated to offering billing training to MassHealth providers throughout Massachusetts. To help us better evaluate your training needs, please answer the questions below and send this form by fax or mail to the attention of MassHealth Customer Service. Date:____________________ Provider name:____________________ Address:____________________ MassHealth/PCC provider number:____________________ Contact name:____________________ Telephone no.:____________________ Fax no.:____________________ Describe your billing problem:____________________ Are you a Medicare provider? ___ Yes ___ No If yes, what is your Medicare number? ____________________ Are you currently submitting your MassHealth claims electronically? ___ Yes ___ No Please indicate the date and time that you are available to meet with training staff. ____________________ ____________________ Thank you for your request. MassHealth Customer Service will contact you shortly to discuss your billing issues and schedule training. We look forward to assisting you with all of your MassHealth billing needs. Fax completed requests to: MassHealth Provider Outreach at 617-988-8974 or mail to: MassHealth ATTN: MassHealth Customer Service P.O. Box 9118 Hingham, MA 02043. Visit the MassHealth website at www.mass.gov/masshealth RPT (Rev. 07/12) (Blank) MassHealth Commonwealth of Massachusetts EOHHS www.mass.gov/masshealth Request for Assistance with Billing Issues Masshealth Customer Service is dedicated to offering billing assistance to MassHealth providers throughout Massachusetts. To help us evaluate your billing concerns, please complete this form when you are unable to resolve a billing issue after reviewing the billing manual or calling 1-800-841-2900. Please send the form by fax or mail to the attention of MassHealth Customer Service. Please note that this form is a request for assistance only; do not use this form to check the status of a claim. Date:____________________ Provider name:____________________ Address:____________________ MassHealth/PCC provider number:____________________ Contact name:____________________ Telephone no.:____________________ Fax no.:____________________ Describe your billing problem (Please give the member’s ID, the date of service, and as much detail about the problem as possible): ____________________ ____________________ ____________________ Are you currently billing MassHealth electronically? ___ Yes ___ No Please indicate the best time to contact you:____________________ MassHealth Customer Service will contact you about your billing issue (s). We look forward to assisting you. Fax the completed request to : MassHealth Customer Service at 617-988-8974 or mail to: MassHealth ATTN: MassHealth Customer Service P.O. Box 9118 Hingham, MA 02043 Visit the MassHealth website at www.mass.gov/masshealth RAB (Rev. 07/12) MassHealth PCC Plan PCC-H (Rev. 07/12)