Kansas HealthWave 21 Network

Transcription

Medicaid & CHIP 101
“From the Top”
Presented by
Cayla Wright & Chris English
Medical Assistance
Cash
Assistance
Food Assist &
Nut Program
KHPA , Policy Studies Institute (PSI) & Local
SRS Offices determine eligibility
Title XXI
Title XIX
(CHIP)
(Medicaid)
(Medical Health)
Unicare
(Medical Health)
Cenpatico
(Behavioral Health
& Substance
Abuse)
Children’s
Mercy Family
Health Partners
(Medical Health)
Unicare
(Medical Health)
Kansas Health
Solutions
(Behavioral
Health)
Value Options
(Substance
Abuse)
Disabled adults and
children receive care
through HealthConnect
Kansas (HCK) & FeeFor-Service (FFS)
Fee-For-Service
Children’s
Mercy Family
Health Partners
HealthWave 19 children
and moms receive care
through Managed Care
Organizations (MCOs)
HealthWave 19
HealthWave 21
receive care through
Managed Care
Medical
Transportation
Management
(MTM)
Kansas Health
Solutions
(Behavioral
Health)
Value Options
(Substance
Abuse)
Steps to Good Health!!!
Apply
– Beneficiaries apply at the HealthWave
Clearinghouse or through the Regional SRS office
Enroll
– Once eligible to receive Medicaid/CHIP a member
must enroll in managed care (if applicable)
“Insure” Health
– MCOs assist member to receive services
necessary to be healthy
Apply for Coverage
9Persons apply by completing an
application and mailing it to the
HealthWave Clearinghouse or through the
Regional SRS office.
9Applications can be obtained by:
o Picking one up at an SRS office or access site (Listed
at - http://www.srskansas.org/locations.htm)
o Completing and printing the online application at
http://www.srs.ks.gov/Pages/Default.aspx
Eligibility
Family Poverty Level
Newborns under age 1
Children ages 1-5
Children ages 6-18
226-241% FPL
$75 Monthly Premium Per Family
201-225% FPL
176-200% FPL
151-175% FPL
≤150% FPL
Medicaid
≤133% FPL
Medicaid
Medicaid
CHIP - No Premium
Medicaid
Medicaid
Medicaid
CHIP Premium
≤100% FPL
CHIP – No Premium
Medicaid
CHIP - No Premium
Enroll in Managed Care
¾Once deemed eligible to receive Medicaid
or CHIP, a member may receive a packet
of information asking them to enroll in a
Managed Care program.
¾If a person is considered Fee-For-Service,
they will not enroll but will receive a
benefits booklet explaining their new
coverage.
“Insure” Health
Persons eligible for Medicaid and CHIP
receive a comprehensive medical package
and are “insured” through:
– Fee for service
– Managed Care
Fee-for-Service
Fee-for-Service
– SSI & MediKan (HealthConnect Kansas)
– Persons with a managed care TPL/Medicare
– Persons participating in HCBS
– Persons residing in a nursing facility
– Persons waiting for managed care
assignment
– Claims are sent to the Fiscal Agent
Managed Care
HealthWave is the managed care program
in Kansas. It consists of:
• Medicaid - HealthWave 19
– Temporary Assistance to Families (TAF)
– Poverty Level Eligible (PLE)
• CHIP – HealthWave 21
– Children’s Health Insurance Program
Managed Care Companies
Medical
– Children’s Mercy Family Health Partners
– UniCare Health Plan of Kansas
Mental Health/Substance Abuse
– Cenpatico (CHIP only)
– Kansas Health Solutions (Medicaid only)
– Value Options (Medicaid only)
Transportation (fee for service)
– Medical Transportation Management (MTM)
Managed Care Service Regions
Medical Assistance
Cash
Assistance
Food Assist &
Nut Program
KHPA, Policy Studies Institute (PSI) & Local
Title XXI
Title XIX
(CHIP)
(Medicaid)
(Medical Health)
Unicare
(Medical Health)
Cenpatico
(Behavioral Health
& Substance
Abuse)
Children’s
Mercy Family
Health Partners
(Medical Health)
Unicare
(Medical Health)
Kansas Health
Solutions
(Behavioral
Health)
Value Options
(Substance
Abuse)
Disabled adults and
Fee-For-Service
Children’s
Mercy Family
Health Partners
HealthWave 19
HealthWave 21
Managed Care
Medical
Transportation
Management
(MTM)
Kansas Health
Solutions
(Behavioral
Health)
Value Options
(Substance
Abuse)
2010 Kansas Medicaid &
CHIP Workshop
Who We Are and What We Do
Children’s Mercy Family Health Partners
(CMFHP) is a not-for-profit safety net health
plan owned by Children’s Mercy Hospitals
and Clinics
CMFHP contracts with the states of Kansas and
Missouri to provide health insurance benefits
to Medicaid and the Children’s Health
Insurance Program (CHIP) enrollees
CMFHP covers Medicaid (Title 19) and CHIP
(Title 21)
– Adults and Children
– Pregnant Women
– Caregivers
CMFHP covers about 125,000 participants in KS
and 72% market share in regions 1 and 2
We bring it all together for you
Why we do what we do …
Care management
• Live and local
• Facilitate communication for
delivery of care and support of
the member and his or her
family
• Act as a liaison to community
resources
• Serve as an advocate and
educator for the member and
family
• Facilitate the member
reaching maximum medical
potential
First Touch
Program
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Personal help
Care for high-risk
Cell phones
Snugli for seeing
doctor
• Gift when baby
comes
• Selecting baby’s
PCP
Lead Poisoning
Prevention Program
• Ensure kids are tested
• Education on why it is
important
• Care Managers
Disease Management
Programs
• Asthma
• Diabetes
• On-site Physician
education
• Health Coaches
Healthy Lifestyle
Program (HeLP)
• On-site weight
management physician
education
• Work with whole family
• Evidence-based
• Focus on healthy
habits
• Education tools
• Health Coaches
Nurse Advice Line
• Accurate information for
members and their
families
• Helps avoid trips to the
ER
• 1-800-347-9369 (on
member card)
Transportation Services
• We provide a ride to all nonemergent appointments
• Rides are also available to
the pharmacy or WIC
• Gas reimbursement
• 1-800-890-6026 (on member
card)
Customer Service
• In-house, live, local and ready to
assist
• Call us at 1-877-347-9363
– on member card
• Hablamos Español:
– 5 bilingual Customer Service reps
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Language and TDD lines
Can review claims status and eligibility
Average over 5 years of experience with CMFHP
Available
– 7am-6pm Monday-Thursday
– 7am to 5pm on Friday
In the
Community
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Baby Showers
Water bottles
Body Venture
Power Panther
Nutrition
Exercise
Hand washing
Back to school fairs
Quality Improvement Measures
• Performance Improvement Projects
– Chlamydia Screening
– Comprehensive Diabetes Care
• Consumer Assessment of Healthcare
Providers and Systems (CAHPS)
• Provider Satisfaction
• Health Effectiveness Data Information Set
(HEDIS)
• Post Member Call Surveys
Resources
CMFHP Website
• Members
– Update Language/Race/Ethnicity
– Enter or update email, address and phone number
– Change PCP
• Providers
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Verify member eligibility
Access Provider Resources
Download Documents/Forms
Print ID cards
Submit and view status of claims
View & Print Remittance Advice
Check for latest announcements and newsletters
Newsletters
• Member
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Latest news on benefits
Health stories
English and Spanish
Disease Management
• Advocate
• Provider
– E-mail (sign up via
www.fhp.org)
– Fax
– Hard copy
– Web site
• Teen
Outreach Tools
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Website
Face Book
YouTube
Text4Baby
Interactive Voice
Response (IVR)
reminder calls
Provider Relations
CMFHP HealthWave Card
Look for the HW logo
Important
Information on
benefits
Member Name
All Important
Phone Numbers
Provider Name
Title 19 (state-issued) HealthWave
Card
•There is no Title 21 state-issued card.
What paperwork is required to
credential new provider?
• The complete CAQH (Council for Affordable Quality Healthcare)
application or the Standardized Credentialing Application
• A signed and dated attestation page (Statement of Application)
• Current copies of all licenses (Medical, CLIA, DEA), current copy of
Certificate of Malpractice Insurance, W-9
• The appropriate CMFHP contract/agreement
• Please contact your Provider Relations Representative to request the
appropriate application/contract
• Once complete, return all paperwork to your Provider Relations
Representative for review and processing
• Credentialing takes 60-90 days as our contract with Kansas requires
CMFHP to follow NCQA credentialing standards
• You will receive a postcard from CMFHP to notify you that your
application has been received
What types of providers have to be
credentialed?
• CMFHP credentials most provider types including:
Physicians
Physician Assistants
ARNPs
Hospitals
PT/OT/ST (home services only)
DME Providers
Ambulatory Surgical Centers
Home Health/Hospice
CRNA’s (pain mgmt only)
• CMFHP does not credential hospital-based providers:
Radiologists
Hospitalists
Pathologists
Emergency Room Providers
Anesthesiologists (excluding pain management)
Can I have our payments sent through Electronic
Funds Transfer? If so how do I do this?
• CMFHP can make provider payments through
electronic funds transfer
• Access the Beneficiary Bank Info for EFT form
on the CMFHP website under Provider
Resources
• Complete the form and send it to your Provider
Relations Representative
• It will take 2-3 weeks to process the information
and set up the electronic funds transfer as this
allows time to test the transaction with your
financial institution before going live
Online Claims Submission
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You can now enter CMS 1500 and UB-04 claims through our Website at
no charge to you (www.fhp.org). You will need a separate sign-on ID.
Using the website claim submission will eliminate a clearinghouse or using
paper claims
Currently you can not enter secondary claims or claims that need
corrections made
If you elect to submit claims in a batch, your claim results will be displayed
by the next business day. If you elect to submit claims “Real Time’, your
claim results will be displayed within minutes. Your payment will appear
in the next check cycle
After entering the member information and enter the date of service, you
will know then if the member was not eligible
There are edits that have been programmed if you have entered a diagnosis
incorrectly, entered an incorrect CPT code, or if the total billed amount
does not match what you have entered
Online Claims Submission
• To sign up, go to our website and click on the
Providers section
• On the right hand side, click on Sign Up for Online
Claims Submission
• Fill out the form (you can pick your own ID and
password) and click on Submit
• You will receive an email stating you have been
approved
• There are on-line training manual for you to use to
help you maneuver through the process
Provider Website Resources
•
Eligibility information is available through the CMFHP website.
– Access the Office Manager link on the left side of the screen and click on
Eligibility Inquiry.
– You can search by the member’s ID number or name.
•
Other helpful information available through the CMFHP website
includes:
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an eligibility summary
current COB/TPL information
a summary of the member’s history
the ability to print the member’s ID card.
PCP Panel List
Member ER Utilization Report
Capability to print down CMFHP’s Remittance Advice
Member eligibility can be verified through the KMAP website at
www.kmap-state-ks.us.
How do I bill for newborn services when the
baby does not have a Medicaid ID number?
• Newborn services may be billed under the mother’s ID#
for the first 45 days for inpatient newborn hospital
charges only.
• Newborn charges billed under the mother’s ID# on a
HCFA will deny with a denial code 77 – “Baby billed
under mother’s member number”. The baby’s ID# must
be utilized.
• If the mother is uninsured, the newborn’s permanent
beneficiary number will have to be received before
payment is rendered.
• Timely filing (for newborn services only) is one year from
the date of service. All other services are 180 days.
Can I receive payment for services if I am not the
member’s designated primary care physician?
• CMFHP will not deny payment for any claim
solely based on the member having received
services from a provider other than his/her
designated PCP.
• As long as the provider is in our network and the
member is eligible for coverage, we will process
the claim for payment.
• CMFHP will also not deny payment for the
services of any participating provider solely
based on no referral from the PCP.
Ensuring Success
• Incorrect Place of Service (denial code 50):
– FQHC’s must bill with POS 50,
– RHC’s must bill with POS 72
• Member Not Eligible (denial code B)
• Member has Primary Insurance/Submit EOB
(denial code 12)
• Timely Filing (denial code 14)
• Non Covered Item/Service (denial code 90 & 91)
You can help our members
keep their coverage!
• Keep the address
updated with the State
and CMFHP
• Renewal and retention
posters and tear off
sheets
• Complete reapplication
on time
Provider Relations
Questions?
Call us at 1-877-347-9363
Updated June 2010
Morning
Break
Medical Assistance
Cash
Assistance
Food Assist &
Nut Program
Title XXI
Title XIX
(CHIP)
(Medicaid)
(Medical Health)
Unicare
(Medical Health)
Cenpatico
(Behavioral Health
& Substance
Abuse)
Children’s
Mercy Family
Health Partners
(Medical Health)
Unicare
(Medical Health)
Kansas Health
Solutions
(Behavioral
Health)
Value Options
(Substance
Abuse)
Disabled adults and
Fee-For-Service
Children’s
Mercy Family
Health Partners
HealthWave 19
HealthWave 21
Managed Care
Medical
Transportation
Management
(MTM)
Kansas Health
Solutions
(Behavioral
Health)
Value Options
(Substance
Abuse)
KAMU
July-November 2010
UniCare Health Plan of Kansas
Today’s Agenda
– Contact Information
– Member Outreach
– Healthy Habits Count Programs
– Provider Education
– Website
Contact Information
825 S. Kansas Ave
Topeka, KS 66612
P 877-604-0462
327 North Hillside Ste 200
Wichita, KS 67214
P 877-264-4534
Attention: Claims
PO Box 751017
Topeka, KS 66675-1017
Attention: Complaints/Appeals
PO Box 3553
Topeka, KS 66601-3553
Attention: Utilization Management
PO Box 3553
Topeka, KS 66601-3553
Attention: Customer Service
PO Box 3553
Topeka, KS 66601-3553
Member Services
• Member Services
• 1-866-408-7105
TTY: 1-866-408-7190
• MedCall 24-Hour Nurse Help Line
• 1-888-814-7565
TTY: 1-800-368-4424
• Interpreter Services
• 1-866-408-7106
• 1-866-814-7565 (After Hours)
• LogistiCare (Non-Emergent Medical Transport)
• 1-866-712-1062
Healthy Habits Count
Programs
• Free programs for better member health
• Asthma, Diabetes, Heart Health, Stop Smoking,
Prepare for Childbirth, Preventive Care, Help Kids
Learn Healthy Habits
• 1-866-513-8352
Provider Services
• Contracting and Credentialing
• Timely filing, claims follow-up
and appeals process
• Prior authorization
• Carve outs
• Pharmacy
• Refund process
• Website
Contracting/Credentialing
• Who do we credential?
• Required forms State Sponsored Business (SSB) form
• Committee for Affordable Quality Healthcare (CAQH)
https://upd.caqh.org/OAS/
• Please let us know when your practice changes!
Timely filing, claims follow-up and
appeals process
• Timely claim filing is 180 calendar days
• Claim Follow-Up Form
• Appeals timeliness: 365 days from remittance advice
date please use Provider Dispute Resolution (PDR) form
• State Fair Hearings: 30 days from date of appeal
notification letter (UniCare appeal process exhausted)
• Claim Identification numbers from your Remittance Advice or
Reference numbers from your customer care center contacts are
very helpful!
Prior Authorization
• Prior Authorization (PA) required for all out of network providers
• Pre-service, concurrent and post-service reviews
• Member self-referrals
• PA may be reached at 1-866-408-7107. PA form may be faxed to
1-866-408-7194
• Prior Authorization Toolkit online
Carve Outs
• Some HealthWave services are handled by other
entities/plans
– Vision (Vision Service Plans-UniCare)1-800-877-7195 TTY: 1-800-428-4833
– Dental (State) 1-800-766-9012
– Mental Health/Substance Abuse
Mental Health
HealthWave 19
Kansas Health
Solutions
1-888-547-2878
Substance Abuse
HealthWave 19
Value Options
1-866-645-8216
Mental Health/Substance
Abuse
HealthWave 21
Cenpatico
1-866-896-7293
Pharmacy
• Preferred Drug List (PDL) located online
• UniCare utilizes a pharmacy benefit management
program known as Express Scripts, Inc.
• Completed PA requests may be faxed to 866-408-7108
using the Universal Medication Request Prior
Authorization form available online
• Pharmacy Services may be reached at 1-866-629-1611
Refunds
• Please return overpayments including overpayment
request letter within 30 days
• Providers may also refund directly without written
request from UniCare please include copy of RA with refund payment
• If overpayment is not received, the amount in question
will be withheld from future payment
• No automatic offset process in place at this time
may request offset on a case by case basis
providers
UniCare Website
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•
•
•
•
http://www.unicare.com/home-providers.html
UniCare Provider Website
Web based claim submission
Access Point feature
Provider Finder feature
https://www.mdon-line.com/mdonline/index.asp?brand=unicare
Website
Step 1
Step 2
Website
Website
Provider Finder
Provider Finder
1
2
3
Provider Finder
City, State, Zip
radius
County search
AccessPoint
• Secured portion of UniCare website-login and
password required for eligibility, claim status, reports
• Effective July 1, 2008, PCPs no longer received
hardcopy membership reports
• Providers may retrieve reports off website
• Separate reports for HealthWave 19 (SKS) and
21(SKC)
• Site code required
• https://provider2.unicare.com/wps/portal/ebpmyunc
THANK YOU!
• Do you have questions?
• Sally Stevens P 316-681-5052 F 877-225-0593
[email protected]
• Bryan Swan, CPC P 785-270-1081 F 866-408-7191
[email protected]
Lunch,
Panel
Discussion &
Q/A
Medical Assistance
Cash
Assistance
Food Assist &
Nut Program
Title XXI
Title XIX
(CHIP)
(Medicaid)
(Medical Health)
Unicare
(Medical Health)
Cenpatico
(Behavioral Health
& Substance
Abuse)
Children’s
Mercy Family
Health Partners
(Medical Health)
Unicare
(Medical Health)
Kansas Health
Solutions
(Behavioral
Health)
Value Options
(Substance
Abuse)
Disabled adults and
Fee-For-Service
Children’s
Mercy Family
Health Partners
HealthWave 19
HealthWave 21
Managed Care
Medical
Transportation
Management
(MTM)
Kansas Health
Solutions
(Behavioral
Health)
Value Options
(Substance
Abuse)
Family Medical
Programs
October 2010
79
Family Medical Programs
provide medical coverage for:
Children 0-18
Pregnant
Women
Low-income
caretakers of
children
80
General Requirements
A signed application must be received.
All legally responsible persons (parent to
child and spouse to spouse) need to be
included on the application.
All persons living in the household need
to be included on the application.
81
The applicant must be…
Able to act in their
own behalf.
Living in Kansas
with an intent to
stay here.
Cooperative with the
application process
and provide all
needed information.
A citizen of the U.S.
or eligible noncitizen.
82
Applications for Family Medical
programs can be accepted at the
HealthWave Clearinghouse or at a
Regional SRS office.
Any application initially approved by
SRS is transferred to the HealthWave
Clearinghouse because all active cases
are kept there.
83
The HealthWave Application
84
The HealthWave Application
85
Commonly Required Verifications
Gross Household Income
Private Health Insurance
Citizenship and Identity
86
Citizenship and Identity
Verification of
citizenship and
identity is needed for
all household
members requesting
medical coverage.
The HealthWave
Clearinghouse
assists consumers
with this
requirement by
accessing birth and
immunization
records from the
Kansas Department
of Health and
Environment.
87
CHIPRA allows Tribal documents to
be used to verify Citizenship and
Identity.
88
can be divided up into two
main groups based on the
funding source:
Medicaid / Title XIX
SChip / Title XXI
89
Medicaid
Family Medical
Programs
MA CM
MA WT
MA EM
MP
90
Medical Assistance Caretaker
Medical, or MA CM, is a
program for low-income parents
and caretakers of children under
the age of 19.
The income guidelines of this program are at
approximately 32% of the Federal Poverty Level or FPL.
91
MA WT
Medical Assistance Work Transition
Program for households that have
been receiving MA CM coverage but
are now not eligible due to an
increase in wages or earnings.
The children in the household receive
12 months of coverage.
As of July 1, 2010 parents also
receive 12 months of coverage.
92
MA EM
Medical Assistance Extended
Medical
Program for
households that were
receiving MA CM but
are no longer eligible
due to an increase in
child or spousal
support.
Children receive 12
months of coverage.
The parent receives 4
months of coverage.
93
HealthWave 19
Title XIX Medical Program
Children from
birth to the age
of 0-18
Pregnant
Women up to
150% of the
Federal Poverty
Level
Includes 2
months of post
partum
coverage
94
SCHIP
HealthWave 21
95
HealthWave 21
provides medical
coverage for
children from
birth to the age of
18.
It is designed to
provide coverage
for families who
are over the
income guidelines
for the Medicaid
programs.
96
The income
guidelines for
HealthWave 21
coverage were
set at 200% of
the Federal
Poverty Level,
but January 1,
2010 marked a
change for this
program.
97
Effective on this date, the income
guidelines for HealthWave 21 were
expanded to 241% of the Federal
Poverty Level.
This means that a household of four earning $4,429
a month can now qualify for the HealthWave 21
program.
98
Although some HealthWave 21
recipients are assigned a
premium, Native American
households are exempt from this
requirement.
99
Dependents of state employees are
not eligible for HealthWave 21
coverage due to their access to the
state’s health insurance plan.
This also applies to persons employed by
cities, counties, and school districts that
participate in the state’s health insurance
plan.
100
The HealthWave
Clearinghouse
101
The Clearinghouse is where new applications and
annual reviews are processed.
All case maintenance
actions that occur on
a case are also
worked at the
Clearinghouse.
Case maintenance
actions include
change of address,
adding persons to a
case, and new
requests for
coverage.
102
The Clearinghouse is staffed by
PSI
KHPA
103
PSI staff complete the initial screenings
on all applications, reviews, and case
maintenance actions. They also
complete the determinations on HW 21
cases.
KHPA staff complete the determinations
on any case that has Title 19
involvement.
104
Backlog
1. Budget cuts
2. Staffing decreased
by 24 ESs
3. New Clearinghouse
vendor, PSI,
assumed contract
01/10
4. Significant backlog
from previous
vendor
105
We are working to reduce the backlog
through policy changes, overtime, and
an overall simplification of the eligibility
determination process.
If there is a case that needs to be
worked as soon as possible due to a
medical need, please contact me.
106
Questions?
107
Christie Jacox
Family Medical Training
and Outreach Manager
KHPA
LSOB – Suite 900
900 SW Jackson
Topeka, Kansas
66612
Phone (785) 296-8359
Fax
(785) 296-4813
108
Medical Assistance
Cash
Assistance
Food Assist &
Nut Program
Title XXI
Title XIX
(CHIP)
(Medicaid)
(Medical Health)
Unicare
(Medical Health)
Cenpatico
(Behavioral Health
& Substance
Abuse)
Children’s
Mercy Family
Health Partners
(Medical Health)
Unicare
(Medical Health)
Kansas Health
Solutions
(Behavioral
Health)
Value Options
(Substance
Abuse)
Disabled adults and
Fee-For-Service
Children’s
Mercy Family
Health Partners
HealthWave 19
HealthWave 21
Managed Care
Medical
Transportation
Management
(MTM)
Kansas Health
Solutions
(Behavioral
Health)
Value Options
(Substance
Abuse)
About Cenpatico
Cenpatico, a division of Centene Corporation, is one of the
nation’s most experienced behavioral health companies
providing behavioral healthcare services through a
comprehensive network of qualified providers.
We have been in business since 1994 and are one of the
nation’s most experienced behavioral health companies in
managing behavioral health benefits for individuals
enrolled in Medicaid, Medicare Advantage and the State
Children’s Health Insurance Program (CHIP).
About Cenpatico
Cenpatico is a Managed Behavioral Healthcare Organization dedicated
both to enhancing the recovery of those with mental illness and
substance abuse disorders, as well as, providing solutions for
government to provide the most cost effective and affordable care.
We offer health plans and state agencies a continuum of services
(benefits) for individuals at risk of, or suffering from, mental, addictive
or other behavioral health disorders.
Our success stems from our commitment to managing behavioral
healthcare services that can be clinically integrated into our programs,
while enhancing consumer access to care. Cenpatico provides a
centralized point of access and clinical availability 24 hours a day, 7
days a week, simplifying the referral process for consumers and
providers.
About Cenpatico
Cenpatico currently operates in Arizona, Florida, Georgia,
Indiana, Kansas, Massachusetts, Ohio, Texas and
Wisconsin.
As an integral part of our core philosophy we believe that
quality behavioral healthcare is best delivered locally. We
are a clinically driven organization that is committed to
building collaborative partnerships with providers.
Quality Improvement
Quality Improvement is woven through every fiber of our
company.
– Cenpatico’s CEO and COO co-chair the Quality Improvement
Committee to continually monitor the efficacy and efficiency of our
operations.
– Our committees are also peer-supported with committees and
workgroups comprised of our network providers.
– Through strong partnerships with our providers, health plans, state
agencies and school districts – we have been successful in
meeting the needs of our members.
Accreditation
In June 2010, Cenpatico was awarded Full Managed
Behavioral Health Care Organization (MBHO)
accreditation by the National Committee for Quality
Assurance (NCQA).
Accreditation by NCQA is an industry standard of
excellence. The accreditation process is based on a
comprehensive review of all service areas within an
MBHO including quality improvement, clinical programs,
credentialing, service and appointment accessibility,
culturally appropriate care, customer service, provider
network management and utilization review.
Cultural Competency
We are committed to the development, strengthening and
sustaining of healthy provider/participant relationships.
Cenpatico, as part of its credentialing and site visit process,
evaluates the cultural competency level of our provider
network and provides access to training and tool-kits to
assist our Network Providers in developing culturally
competent and culturally proficient practices.
Cenpatico in Kansas
Cenpatico partners with the State of Kansas to
provide quality, cost-effective behavioral
healthcare services for members under the Title
XXI Children’s Health Insurance Program (CHIP),
also known as HealthWave XXI or 21.
Federal Children’s Health Insurance Program (CHIP)
•
Overseen by the Centers for Medicare and Medicaid Services or
CMS.
•
Children began receiving insurance through CHIP in 1997 and the
program helped states expand health care coverage to over 5
million of the nation's uninsured children.
•
The program was reauthorized on February 4, 2009, when the
President signed into law the Children's Health Insurance Program
Reauthorization Act of 2009 (CHIPRA or Public Law 111-3).
•
CHIPRA finances the Children's Health Insurance Program (CHIP)
through FY 2013.
•
For more information about the program visit the CMS CHIP website at http://www.cms.hhs.gov/home/chip.asp
Kansas Children’s Health Insurance Program
•
CHIP, also known as Title XXI, was implemented in Kansas in 1999.
•
It is a federal-state partnership program. Under CHIP, the federal
government provides approximately 72 percent of the cost up to a
maximum allotment, and the State provides the remaining 28
percent and any excess spent above the federal allotment.
•
In 2001, CHIP was brought together with the state’s health program
under one umbrella, HealthWave, to help ensure a seamless
product. HealthWave enables families with children who are eligible
for CHIP and Medicaid to have the same health plan and health
provider for all family members. The HealthWave program not only
serves CHIP eligible children, but also Medicaid-eligible adults and
children in the Temporary Assistance to Families (TAF) and Poverty
Level Eligible (PLE) programs.
Kansas HealthWave Umbrella
• Medicaid or Title XIX is the Kansas Medicaid
Program
• CHIP or Title XXI is the Kansas State Children’s
Health Insurance Program (CHIP)
• Fee for Service and HealthConnect Kansas is
under Title XIX (Medicaid)
•
KHPA was required by state procurement laws and federal law to
conduct a competitive Request For Proposal (RFP) process in
contracting for the CHIP services.
•
RFP 09072 was issued on January 6, 2006 for Capitated Managed
Care Mental/Behavioral Health Services by the Kansas Department
of Administration, Division of Purchases.
•
Cenpatico was awarded the contract with the date of award through
June 30, 2008 with four (4) additional optional one-year renewal
periods.
•
The RFP outlines the General Provisions, Special Provisions, and
Statement of Work.
•
The benefits are mapped to the Medicaid Fee for Service program.
Kansas CHIP Expansion
• In 2008, Kansas authorized expanding eligibility for HW
21. Beginning Jan. 1, 2010 the FPL threshold increased
to 250% of the 2008 FPL.
• The CHIP expansion funded in the FY 2010 budget will
lead to affordable health coverage for more than 9,000
uninsured children in Kansas.
• The CHIP expansion will be funded with a combination
of federal funds, state funds and premiums charged to
beneficiaries.
• For more information visit the Kansas Health Policy
Authority (KHPA) web-site at http://www.khpa.ks.gov/
HealthWave XXI Physical Health Partners
Members have a choice of two health plans for
management of their physical health benefits:
– UniCare: 1-866-408-7105
– Children’s Mercy – Family Health Partners:
1-877-347-9363
CHIP Service Regions
•
Kansas provides free or low-cost health insurance coverage to
children in this program who:
Are under the age of nineteen;
Do not qualify for Medicaid;
Have family incomes under the 250% of the 2008 FPL; and
Are not covered by state employee health insurance or other
private health insurance.
•
Eligibility is continuous for twelve months and re-established
annually. The family must meet all eligibility criteria and have paid
any applicable premiums from the prior year to be re-enrolled for a
new twelve-month period.
Monthly Income Standards (effective January 2010)
Number of
Persons
Included in
household
1
2
3
4
5
6
HealthWave 19
HealthWave 21
100% of federal
poverty level
133% of federal
poverty level
150% of federal
poverty level
241% of federal
poverty level
(ages 6 thru 18)
(ages 1 thru 5)
(pregnant women
& ages under 1)
(ages 0 thru 19 &
income exceeds
Medicaid)
$ 903
$1,215
$1,526
$1,838
$2,150
$2,461
$1,201
$1,615
$2,030
$2,444
$2,859
$3,273
$1,354
$1,822
$2,289
$2,757
$3,224
$3,692
$2,175
$2,927
$3,678
$4,429
$5,180
$5,931
If the family’s income is at the HealthWave 21 level, additional rules apply.
HealthWave 21 Requirements
• For the HealthWave 21 program, children must not already
be covered by comprehensive and reasonably accessible
health insurance. In addition, children whose parents have
access to the State group health insurance plan are also not
eligible.
• A premium between $20 and $75 is required for families with
income above 150% of the federal poverty level.
Covered Behavioral Health Services
•
•
•
•
•
•
•
•
•
Diagnostic Evaluation
Psychological Testing
Medication Management
Traditional Outpatient Services
Group Therapy
Inpatient Hospitalization
Partial Hospitalization Program
(PHP)
Intensive Outpatient Program
(IOP)
Residential Treatment
Value Added Services:
• Community Psychiatric
Supportive Treatment
• Psychosocial Rehabilitation
Group
• Child and Adolescent
Psychosocial Group
HealthWave 21 Provider Network
•
•
•
•
•
Community Mental Health Centers – 27
Facilities/Hospitals – 18 in 47 locations
Substance Abuse Treatment – 23 in 62 locations
Groups – 59 contracted groups
Group/Solo Providers –
•
•
•
•
70 MD level
118 PHD level
29 ARNP level
392 Master’s level
HealthWave 21 Provider Network
• Facility Providers
• Group Providers
• Solo/Individual Providers
Joining the Network
• Credentialing
–
–
–
–
–
Application (or CAQH)
Demographic Profile
Insurance
W9
Attachments
• Contract
– Obligations
– Specific Kansas Requirements
– Compensation Schedule
Commitment and Involvement
• Kansas Mental Health Coalition
• KAMU Annual Conference
• Governor’s Advisory Commission on Children with Special Health
Care Needs
• Governor’s Mental Health Planning Council
• Iroquois Center for Human Development
• NAMI Kansas
• Mental Health Association of South Central Kansas
• Coordination of Care Team
Debra Whited Burnham
Kansas Network Manager
Cenpatico
534 S. Kansas Ave., Ste. 305
Topeka, KS 66603
785-633-5746 Cell
800-989-1655, ext. 1 Office
785-354-4206 Fax
www.cenpatico.com
Medical Assistance
Cash
Assistance
Food Assist &
Nut Program
Title XXI
Title XIX
(CHIP)
(Medicaid)
(Medical Health)
Unicare
(Medical Health)
Cenpatico
(Behavioral Health
& Substance
Abuse)
Children’s
Mercy Family
Health Partners
(Medical Health)
Unicare
(Medical Health)
Kansas Health
Solutions
(Behavioral
Health)
Value Options
(Substance
Abuse)
Disabled adults and
Fee-For-Service
Children’s
Mercy Family
Health Partners
HealthWave 19
HealthWave 21
Managed Care
Medical
Transportation
Management
(MTM)
Kansas Health
Solutions
(Behavioral
Health)
Value Options
(Substance
Abuse)
Presented by
Michele Johnson
Director of Provider Network Development
Kansas Health
Solutions is…
• A not-for-profit limited liability corporation (LLC) that administers
managed behavioral health care.
• A company established by the 27 Community Mental Health
Centers across the State of Kansas to provide quality outpatient
mental health services to Members in all 105 counties.
• The corporation was formed in January 2007 for the initial purpose
of contracting with the State of Kansas Department of Social and
Rehabilitation Services to provide a Prepaid Ambulatory Health
Plan (PAHP) for the mental health needs of Medicaid enrollees.
• Contract was signed on March 1, 2007.
136
Mission
To promote a system of efficient,
effective and accountable behavioral
healthcare accessible to all Kansans
through a responsive provider
network.
137
Vision
Together, with its Providers, KHS strives to
set the standards for progressive, high
quality, cost effective care, with
sensitivity to its Members. KHS will
deliver services that are driven by
consumer and family needs, recoveryfocused, innovative and accessible.
138
KHS Values
• Encourage Member participation,
inclusion, involvement and treatment in
the least restrictive environment possible
• Effective steward of public funds
• Accountable for delivering services and
performing its mission in as effective and
efficient manner as possible
139
General Information
Centers for Medicare
and Medicaid Services
Kansas Health
Policy Authority
Social and Rehabilitative
Services
Kansas Health Solutions, LLC
Funding Stream from
CMS through KHPA.
Providers
SRS contracts with KHS
to provide mental health benefits
to Kansas Medicaid recipients through a network of Providers.
Members
140
Medicaid Overview
“Title XIX of the Social Security Act, a Federal/State
entitlement program, pays for medical assistance for
certain individuals and families with low incomes. This
program, known as Medicaid, became law in 1965 as a
cooperative venture jointly funded by the Federal and State
governments (including the District of Columbia and the
Territories) to furnish medical assistance to eligible needy
persons. Medicaid represents the largest source of funding
for medical and health-related services for America's
poorest people.”
www.srskansas.org
141
KHS Information
Eligibility Groups
• Medicaid – general eligibility group, additional services if meet
functional needs
• Group 1: Eligible for all services
• Group 2: Eligible for all services; could have an unmet
Spenddown
• MediKan – “Benefits” equal to Medicaid – however NOT part
of Medicaid, Kan-Be-Healthy (KBH) or Severe Emotional
Disturbance Waiver (SED)
• Kan-Be-Healthy – Always Medicaid; when identified by
KHPA/SRS as KBH, Providers can bill 3 additional assessment
codes
142
KHS Information
Documents that define the relationship between KHS
and the Provider
• Provider Agreement
• Provider Manual
• Severe Emotional Disturbance Waiver Manual
(SED Waiver)
• Psychiatric Rehabilitation Treatment Facility Community
Based Alternatives Grant Manual (PRTF CBA Grant)
• Provider Credentialing Application
• Provider Billing Manual
• Provider Notices
• Provider Dispatches
143
KHS Goals
Meet or exceed standards of:
• Accessibility: Plan Members are aware of, seek and are
connected to the right service at the right time in the right
location.
• Acceptability: Plan Members are satisfied with the
processes and outcomes of the health care services they
receive.
• Value: Plan Members experience improvements in their
quality of life, their symptoms and their functioning.
144
KHS Goals
Meet or exceed standards of:
• Impact: Stakeholders, SRS, the community, and taxpayers
benefit from the positive gains in individual and population
health that are achieved.
• Cultural Sensitivity: Providers and the services they
render are sensitive to the Member’s cultural heritage,
values and beliefs. All Members receive linguistically
understandable and culturally competent services.
145
KHS Board of
Managers
Makeup:
• 8 representatives of the State’s Community
Mental Health Centers (CMHCs)
• 1 consumer
• 1 family member of a consumer
• 5 members at large
146
Consumer, Family, Community
Committee
Kansas Health Solutions will use Advisory
Councils to remain in touch with consumers,
families, other stakeholders and providers
Councils will be made of:
Consumers
Family of enrolled Members
Input directly into KHS Board
Meet at least quarterly
147
KHS Ombudsman
An ombudsman is someone who helps with concerns
The ombudsman’s primary job is to help Members
understand the mental health care system, especially if
there are problems
The ombudsman will:
Help when Members have an issue with services
Assist Members in filing grievances or appeals
Refer Members to advocacy organizations for help and support
The ombudsman can be reached at:
1-866-547-0222
148
KHS Provider Network
Approximately 2600 Practitioners between
Kansas, Missouri, and Oklahoma
144 Group Agreements
27 Community Mental Health Centers
10 Federally Qualified Healthcare Centers
6 Child Welfare Contractors
101 Private Agencies
346 Solo Provider Agreements
149
To Locate a Provider
• Call Member Services at 888.547.2878
• Ask for a Provider Directory
• KHS Website
https://www.kansashealthsolutions.
org/providers/index/provider_direc
tory
• Current Provider can also assist
150
KHS Enrollment
To Enroll as a KHS Provider contact:
Michele Johnson
Phone: 785.575.9356
Email: [email protected]
Website:
https://www.kansashealthsolutions.org/pr
oviders/index/network_join
151
Credentialing Process
• New Provider/Practitioner must enroll with
the Kansas Medical Assistance Program
(KMAP)
• Kansas Health Solutions Provider Agreement
• Credentialing application
• Supporting documents
Once enrolled you will receive the opportunity
for a provider orientation visit.
152
Responsibilities
Kansas Health Solutions is responsible for:

Developing a network of doctors and therapists to
provide Member care
Assuring quality services are provided to our Members
Ensuring access to care for all Members
Paying doctors/therapists for care given to Members
Utilization Management and Quality Management
functions
Customer service
Data Management and reporting
153
General Provider
Responsibilities
Provider Coverage
• Provider shall be responsible for arranging 24 hour crisis
coverage for Members
• Alternative Provider arrangements need to be in place to
respond to services for Members when the primary
provider is unavailable
• Information about these arrangements need to be available
in writing to KHS at any time
Regulatory Compliance
• Providers are expected to be familiar and compliant with all
154
laws and regulations
General Provider
Responsibilities
KHS Care Coordination can assist with
coordinating care for Members with
multiple providers or systems involved.
This is the case for many members with
Special Health Care Needs.
Coordination of care beyond that provided
at the practitioner level may be necessary.
155
Goals of KHS Services
•
•
•
•
•
•
•
Provide the right mix of services
Delivered in the right amount
To the right person
At the right time
Be accessible
Provided by competent practitioners and
Conducive to family involvement when
possible
156
Medical Necessity
• Authority: Intervention recommended by treating Provider
and deemed necessary by the Secretary of the Kansas
Department of Social and Rehabilitative Services or his/her
designee
• Purpose: Intervention is for treating a medical
condition/mental illness
• Scope: Intervention provides most appropriate level of
service, considering benefits or harm to Member
• Evidence: Scientific evidence will be the basis; if no
evidence, then professional standards of care will be
considered
• Value: Cost-effective, not necessarily lowest price, compared
to alternative treatment
157
Sharing Member Rights and
Responsibilities
•
•
•
•
•
•
•
•
•
•
Receive information
Dignity and Privacy
Receive information on available treatment options
Participate in decisions
Free from restraint or seclusion
Copy of medical records
Free exercise of rights
Freedom to change Providers
Choose their Provider
Ask for a therapist who knows their language/culture
158
Responsibilities
•
•
•
•
•
•
•
•
•
•
•
•
Receive services at convenient times/places
Obtain services within the specified access standards
Treat others with consideration/respect
Be at appointments on time
Call if they must cancel
Be an active part of the treatment team by reporting symptoms and
asking questions
Tell doctor if they do not agree with recommendations
Tell doctor if they want to end treatment
Take medication as prescribed and report any problems
Carry/show their insurance card
Tell Provider if they have other insurance
Follow plans and instructions as agreed upon
159
Responsibilities
Member Rights and Responsibilities continued:
Second Opinions
• KHS Members have the right to a second opinion from
another licensed Provider
• Provider needs to inform Members of this right
• KHS will provide alternate professional within or outside
of network at no additional charge (if no alternative
Provider available in network)
160
Claims Overview
Claims outlined in Biller’s Manual
www.kansashealthsolutions.org
Or Call
1-866-547-6457
To Request A Biller’s Manual
161
Claims Overview
Core Requirements for Claims Submission
All Services:
• The Practitioner who is providing services has obtained a
KMAP number, is credentialed through KHS, and has
completed all required trainings;
• The Practitioner providing the service has the correct
credentials and training to provide the service billed;
• The Outpatient Registration Form has been completed and
submitted;
• At least one of the diagnoses for the Member is a KHS
covered diagnosis, and has to be line referenced;
162
Claims Overview
• The Clinical Update Form is to be completed no later than 18
months post initial Outpatient Registration Form;
• If there has been no claim activity for 6 months, a Clinical
Update must be completed;
• Additional Clinical Updates need to be completed when a
significant clinical change has occurred;
• Original claims must be submitted within 365 days from the
date of service to meet Timely Filing Requirements.
163
KHS Enrollment
To Enroll as a KHS Provider contact:
Michele Johnson
Phone: 785.575.9356
Email: [email protected]
Website:
https://www.kansashealthsolutions.org/pr
oviders/index/network_join
164
534 S. Kansas Ave., Suite 510
Topeka, Kansas 66603
Toll Free: 866-547-0222
Fax: 785-234-2410
Afternoon
Break
Medical Assistance
Cash
Assistance
Food Assist &
Nut Program
Title XXI
Title XIX
(CHIP)
(Medicaid)
(Medical Health)
Unicare
(Medical Health)
Cenpatico
(Behavioral Health
& Substance
Abuse)
Children’s
Mercy Family
Health Partners
(Medical Health)
Unicare
(Medical Health)
Kansas Health
Solutions
(Behavioral
Health)
Value Options
(Substance
Abuse)
Disabled adults and
Fee-For-Service
Children’s
Mercy Family
Health Partners
HealthWave 19
HealthWave 21
Managed Care
Medical
Transportation
Management
(MTM)
Kansas Health
Solutions
(Behavioral
Health)
Value Options
(Substance
Abuse)
MCO Overview
Organizational Overview
• National Office: Norfolk, Virginia
• Behavioral/Substance Abuse
Specialty Company with 30 years
experience
• Over 22 million covered lives
nationally
169
National Focus
National Office
National Support Centers
Regional Service Centers
Serving:
1 to 3 Million Lives
500,000 to 1 Million Lives
250,000 to 500,000 Lives
Under 250,000 Lives
170
Web Services
NETWORKCONNECT
PROVIDERCONNECT
Robust network management
and provider relations
Secure, online administrative
self-service for providers
CARECONNECT
TELECONNECT
Superior clinical case management
and data collection
Easy-to-access telephonic self-service
for providers and members
SERVICECONNECT
MEMBERCONNECT
Industry-best customer service
and issue resolution
Online self-service and award-winning
content for members
Technology + Innovation + Service + Access
171
ValueOptions Public Sector Division
ValueOptions of California
manages eligibility and
authorizes behavioral health
services for children and
adolescents in more than 30
counties across the state.
Managing Medicaid behavioral
health services in 40 Colorado
counties, Colorado Health Networks
won national recognition for its
transition to a recovery-based
model of care.
ValueOptions of Kansas
implemented a statewide
program designed to
enhance substance abuse
services provided through
federal block grant and
Medicaid dollars.
Value Behavioral Health of
Pennsylvania serves Medicaid
consumers in 14 counties,
customizing operations to meet
the unique needs of each
county.
The Massachusetts Behavioral Health
Partnership is a statewide entity that
focuses on consumer-led initiatives,
performance-based contracting, and
behavioral health integration with primary
care services.
Reflecting a growing national
trend of braiding state child
welfare funding with Medicaid
dollars, the Connecticut
Behavioral Health Partnership
manages services statewide for
children and families.
ValueOptions of
Illinois recently
implemented a
statewide Behavioral
Health program
ValueOptions New Jersey
manages an innovative
statewide system of behavioral
care for at-risk children and
their families.
Blending 17 funding streams to
serve the state’s Medicaid and
uninsured populations,
ValueOptions New Mexico
provides an integrated system
of mental health and substance
abuse services.
Serving the Dallas metropolitan
area and seven surrounding
counties, ValueOptions
NorthSTAR blends funding
streams to improve service
delivery integration and
manages an innovative
pharmacy program.
172
Delivering Medicaid behavioral
health services for children and
adults across central Florida,
Florida Health Partners
received a national award of
excellence for being an
effective, efficient provider
organization.
In North Carolina,
ValueOptions conducts
statewide behavioral health
utilization management and
review of ten distinct levels
of care.
National Crisis Response Teams
Provided crisis management, disaster
resources and resilience and stress
management services
• 9/11 World Trade Center bombing
• April, 2007 Virginia Tech shootings
• BP oil spill
173
VO-Kansas Overview
Kansas Substance Abuse Prepaid
Inpatient Health Plan (SA-PIHP)
• Clients: Kansas Department of Social
and Rehabilitation Services
• Contract start date: July 1, 2007
• Approximately 85 substance abuse
providers statewide
175
Kansas SA-PIHP (continued)
• Covered lives: Estimated 240,000
• Medicaid beneficiaries and individuals covered
by other programs such as federal Substance
Abuse Prevention and Treatment block grant
funds for indigent consumers
• ValueOptions also manages Kansas Senate
Bill 67/4th time Driving Under the Influence
funds
176
Services Provided
• Outpatient Individual and Group
Counseling
• Intensive Outpatient Services
• Residential Reintegration, Intermediate and
Social Detoxification Services
• Medically Managed Intensive Inpatient
Acute Detoxification and Inpatient
Treatment
177
Services Provided (continued)
• Medically Managed Intensive Inpatient Acute
Detoxification and Inpatient Treatment
• Auxiliary Services including:
- Assessment/Referral
- Case Management
- Person-Centered Case Management (PCCM)
- Support Services
- Dependent Children – Overnight Boarding
178
VO-KS Services
by Location
Claims Payment (National)
Customer Service (KS & NY)
Finance (KS)
IT/Reporting (KS & TX)
NCQA Compliant Provider Credentialing
(KS & National)
• Provider Relations and Contracting (KS &
National)
• Quality Improvement and Fraud and Abuse
Monitoring (KS)
• Utilization Management (KS & TX)
•
•
•
•
•
179
VO-KS Quality Improvement
Department
• Member Prevention, Education and Outreach (PE&O)
• Critical Incident Investigation and Reporting
• Clinical Record Audits
• Grievances, Denials and Appeals
• State and Federal Compliance (including Fraud and Abuse)
• Performance Improvement Projects
• Monitoring indicators such as access, availability and
member safety
• Provider and Enrollee satisfaction
180
VO-KS Provider Relations
Department
•
Assist providers in the credentialing process
•
Help answer provider questions regarding claims and
billing
•
Coordinate provider licensure with the State
•
Identify service gaps and release requests for
proposals accordingly
•
Verify accuracy of provider fee schedules
•
Provide important information regarding system and
contract changes
181
VO-KS Clinical
Department
• Utilize ASAM criteria to determine the
medical necessity of certifications
• Identify high risk members in need of
Intensive Case Management
• Facilitate coordination of care and
placement to improve member outcomes
• Assist member transition through the
continuum of care
• Ensure confidentiality of substance abuse
information through verification of
Releases of Information
182
Questions?
To refer a client for Substance Abuse
Assessment and Treatment
1-866-645-8216 (24 hours a day)
To become a ValueOptions Provider
1-800-397-1630
Website
www.ValueOptions.com/kansas
183
Kansas Contact
Frances Breyne, J.D.
Director of Provider Relations
ValueOptions – Kansas
785-338-9012
[email protected]
184
Medical Assistance
Cash
Assistance
Food Assist &
Nut Program
Title XXI
Title XIX
(CHIP)
(Medicaid)
(Medical Health)
Unicare
(Medical Health)
Cenpatico
(Behavioral Health
& Substance
Abuse)
Children’s
Mercy Family
Health Partners
(Medical Health)
Unicare
(Medical Health)
Kansas Health
Solutions
(Behavioral
Health)
Value Options
(Substance
Abuse)
Disabled adults and
Fee-For-Service
Children’s
Mercy Family
Health Partners
HealthWave 19
HealthWave 21
Managed Care
Medical
Transportation
Management
(MTM)
Kansas Health
Solutions
(Behavioral
Health)
Value Options
(Substance
Abuse)
Contract No. RC100261JW
Proposal for
Lift Eligibility Assessment Services
Tri-County Metropolitan Transportation
District of Oregon
September 17, 2009
by
Medicaid
Transportation Management
Sondra Megrail,
Education, Training, and Outreach
Coordinator
186
Agenda
What are MTM's duties as a broker?
When do you contact MTM?
How is a trip assigned?
What happens after a trip is
scheduled?
Question and answer session
187
www.mtm-inc.net/kansas/
188
MTM’s duties as a Broker
Arrange rides through the Customer
Service Center
Routine scheduling of trips at least 48 hours in advance
is available Monday through Friday, 8 am to 5 pm
Urgent/next day scheduling available 24 hours a day/ 7
days a week
Call Center contact number:
1-888-240-6497
189
Contract and credential transportation
providers
Require vehicle inspections, insurance, and
driver motor vehicle and KBI background
checks
100% coverage of Kansas
Two types of transportation providers
Commercial
Sole Source
190
Monitor service quality
Formal complaint and grievance process
Grievance hotline # 1-866-436-0457
On-time performance
Reduce fraud, waste and abuse
Verification of service through driver’s manifest
Attendance verification
191
A dedicated Care Management Coordinator
Serves as a single point of contact for facilities and sole
source providers
Determines the level of need when public transportation
or sedan service is not enough
Ensures medically appropriate transportation for special
needs groups
Sets recurring trips
Prior authorizes trips that 50+ miles, out-of-state
(requires State approval), and require meals and
lodging (revised prior authorization form)
192
Contact Care Management
To request transportation for routine
recurring appointments
To submit medical transportation expenses
to reduce members’ spend down amounts
(please see spend down form)
To troubleshoot with the Care Manager
193
Setting a Trip
Call MTM at 1-888-240-6497 at least 48 hours
before the appointment.
A friendly customer service representative will ask
for the following information:
Member’s full name, current address, and phone number
Medicaid ID
The date the member wants to ride
The name, address, and phone number of where the
member is going
The medical reason for the transportation request
The type of appointment (doctor, dentist, therapy, etc.)
The trip can not be set without all of this information.
194
Setting a Trip
Transportation can only be set for a Medicaid
covered service going to an enrolled Medicaid
provider
Covered Services (included in your handout)
Children 5 to 16 traveling alone will be required
to have a signed Parental Authorization Form
(included in handout).
195
How Trip is Assigned
Public Transit assigned
If the member lives within ¾ of a mile of a fixed
bus route and is physically and mentally able to do
so.
If a member states they cannot ride the bus, the
Care Manager will verify via Level of Need or LON
form through the member’s physician (a revised
form is included in your handout).
196
Ambulatory/Sedan vehicle assigned
If the member can transfer from a wheelchair to
vehicle seat, and the wheelchair fits in the trunk
This category includes sedans, cabs, vans and
minibuses without wheelchair lifts
197
Wheelchair lift-equipped vehicle assigned if
sedan is not appropriate
Stretcher vehicle assigned for members who
must lay prone, but do not require medical
attention/monitoring
198
After Trip is Scheduled
The transportation provider will call the member to
tell them the time of pickup and their phone
number.
The Member should be ready 60 minutes before the
pickup time.
If the Member has a scheduled ride back, the
transportation provider should pick them up less than
30 minutes after the appointment is over.
If the Member must call the transportation provider
for pick up after the appointment, the transportation
provider arrive within less than 60 minutes of the call.
199
Late or No Shows
The member should call MTM right away if
they need to cancel their ride.
Members should call MTM at 1-888-240-6497
if their ride does not show up.
200
Website Information
Website: www.mtm-inc.net
Instructions:
1. Scroll to the bottom of the page and click on
National Map.
2. A map of the U.S. will appear, click on Kansas.
3. The Kansas Homepage will come up (included in
your handout), click on the Facilities and Agencies
tab at the right.
4. www.mtm-inc.net/kansas/
201
www.mtm-inc.net/kansas/
202
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