Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth All Provider Bulletin 194 June 2009 TO: All Providers Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Primary Care Clinician (PCC) Referral Process Background The purpose of this bulletin is to clarify the changes to the MassHealth PCC Plan’s referral process under NewMMIS. PCC Referral Process Before NewMMIS Before the implementation of NewMMIS on May 26, 2009, PCCs issued referrals using their seven-digit PCC provider number to servicing/ specialty-care providers for their PCC Plan members. In order for the claim to be paid, servicing/specialty-care providers needed to include the PCC’s referral number on the claim. Changes to the PCC Referral Process In an effort to improve the PCC’s ability to track and monitor PCC Plan member care provided by specialty-care providers, a new referral system was implemented as part of NewMMIS. This system generates a unique referral number for each PCC Plan member, for each specialty-care provider referral. The PCC Plan has also decreased the number of services that require PCC referral under NewMMIS. Please refer to All Provider Bulletin 188, issued in early May 2009, for more information about the services that require PCC referral. NewMMIS PCC Referral Process MassHealth now requires PCCs to enter their referral information by direct data entry (DDE) through the Provider Online Service Center (POSC). Once the referral data is entered, NewMMIS generates a unique nine- digit referral number for the member. When using the POSC, PCCs and servicing/specialty-care providers can access the unique referral numbers issued for members by clicking on Manage Service Authorizations, then Referrals, then Inquire Referral. The Referral Search panel is then displayed so that you can locate the referral number. A job aid containing specific instructions for reviewing referrals is available at www.mass.gov/masshealth/newmmis. Click on Need Additional Information or Training, then on Get Trained. The job aid is listed under “Referrals.” Nine Digits Required for Claims Processing Because servicing/specialty-care providers are now likely to provide services for which they had already obtained a referral using a now obsolete seven-digit PCC provider number, MassHealth will continue to recognize these referrals through November 30, 2009. In order for claims using these seven-digit referral numbers to be processed by NewMMIS, servicing/specialty-care providers must place two zeros in front of the old seven-digit PCC referral number when submitting the claim for payment. PCCs Who Do Not Have the Capability to Access the POSC NewMMIS has automated many functions required for providers to conduct their day-to-day business with MassHealth, including making and receiving referrals, accessing the PCC Panel reports, obtaining remittance advices, and requesting prior authorization. It is important that PCC Plan providers make the operational shift with MassHealth to this efficient, streamlined way of doing business via the POSC. Providers who have not yet registered to use the POSC should do so without further delay. Please refer to the letters sent to you with your PIN (personal identification number) for registration instructions. If you do not have access to the Internet at all, please contact MassHealth Customer Service immediately, so that the appropriate temporary arrangements can be made while you arrange for Internet access. Discontinuation of the Old Seven-Digit Referral Process Effective immediately, PCCs must stop issuing referrals using their former seven-digit provider number. This is regardless of whether or not you have the ability to conduct your business via the POSC. NewMMIS will process claims for services referred with old PCC provider numbers only through November 30, 2009. Referrals for Services That Require Prior Authorization As has been the current practice, when a service requires both a referral from the PCC and a prior authorization (PA) from MassHealth, please be reminded that ? The PCC is responsible for issuing the referral; and ? The servicing/specialty provider is responsible for obtaining the MassHealth PA. Questions If you have any questions about the information in this bulletin, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974.