Case management
AL | CA | GA | MS | MT | NE | NY"PATIENT 1ST REFERRED SERVICES
The following services DO REQUIRE a referral from the Patient's Primary Medical Provider...
Service...
Case Management." Alabama PMP, Attachment 4, unnumbered pages."Article II...
J. Case Management means responsibility for referral, consultation, ordering of therapy, admission to hospitals, follow-up care, and prepayment approval of referred services. It includes responsibility for locating, coordinating, and monitoring all medical care on behalf of a member." California Contract, page 3."Article V
In discharging its obligations under this contract, the Contractor will:
A. Provision of Services
Provide or arrange for the provision of all covered services and provide case management to a voluntarily enrolled population of eligible beneficiaries. Covered services include the capitated services set forth in Attachment A...C. Health Care Services Case Management
Accept responsibility for case management of all health care services for each member." California Contract, page 17."803. Services Exempt from Authorization
The following services do not require authorization by the Primary Care Physician (PCP)...
2. Services delivered by providers enrolled in the following Medicaid programs: ...
Early Intervention Case Management...
Targeted Case Management..." Georgia Agreement, pages VIII-2 - VIII-3."4.07 Functions and Duties of the Primary Care Provider
Responsibilities of the PCPs include the following: ...5. Provide primary care and case management services to each enrollee, as outlined in this section and render necessary services as described in the general information section of the Medicaid Provider Manual.
6. Determine the medical necessity for and approve/authorize, when appropriate, non-emergency care covered under HealthMACS.
7. Make referrals when appropriate. Referrals may include services covered under HealthMACS or Medicaid services not covered under HealthMACS but covered generally under the Mississippi Medicaid program. The referred provider may be another HealthMACS PCP, physician specialist or other provider not participating in HealthMACS, but participating in Mississippi Medicaid.
8. Approve/authorize, as appropriate, any follow-up consultations and/or treatment, subsequent to making a referral to a specialist for consultation and/or treatment of a specific condition, for the duration of the illness. This includes services rendered by the specialist and referrals for related service made by the specialist.
9. Approve/authorize, when appropriate, treatment for urgent or emergency care in accordance with HealthMACS provisions relating to those services.
10. Make a referral for a second opinion if requested by an enrollee when surgery has been recommended.
Treatment subsequent to the second opinion is rendered by the PCP or through a referral by the PCP." Mississippi Manual, pages 76-77.
"E. 'Exempt Services' are those Medicaid services which do not need to be provided or authorized by the enrollee's primary care provider. Exempt services include the following: ...
targeted case management..." Montana Agreement, pages 2-3."ARTICLE III...
3.2. Mandatory and Excluded Clients
3.2.1 Mandatory for the NHC Basic Benefits Package: The following Medicaid eligible clients are required to participate in the NHC, if the client's eligibility assistance case is managed by the Health and Human Services (HHS) District Office in the designated coverage areas, unless excluded pursuant to 9.2.5 of this contract:
(a) Clients participating in the Aid to Dependent Children Program Grant/Medical (Title 468 NAC). For purposes of the NHC, this includes clients participating in the Medical Assistance Programs for Children (i.e., Ribicoff), Medical Assistance for Children (MAC), School Age Medical (SAM) and Kids Connection pursuant to Title 469 NAC." Nebraska Contract, page 22."NON -COVERED SERVICES
The following Medicaid services are not covered by the Contractor. Enrollees may obtain such services directly from Medicaid providers who, in turn, shall bill MMIS directly for payment. The person remains enrolled in Contractor's plan...Comprehensive Medicaid Case Management (CMCM): A program which provides 'social work' case management referral services to a targeted population (e.g., pregnant teens, mentally ill). A CMCM case manager will assist a client in accessing necessary services in accordance with goals contained in a written case management plan. CMCM programs do not provide services directly, but refers to a wide range of service providers. Some of these services are: medical, social, psycho-social, education, employment, financial, and mental health. CMCM referral to community service agencies and/or medical providers requires the case manager to work out a mutually agreeable case coordination approach with the agency/medical provider. Consequently, if an Enrollee of the Contractor is participating in a CMCM program, the Contractor should work collaboratively with the CMCM case manager to coordinate the provision of services covered by the Contractor. CMCM programs will be instructed on how to identify a managed care recipient on EMEVS and informed on the need to contact the Contractor to coordinate service provision." New York Contract, Appendix L, pages 5-6