Medical Services

Managed Care

State Plan Amendment - Title XIX of the Social Security Act

Supplement 5 - PCP Requirements

Providers are notified of their requirements through the South Dakota Medical Assistance Provider Agreement, Addendum to the Provider Agreement or through the South Dakota Medical Assistance Managed Care Provider Manual.

Primary care case managers must:

  • Be Medicaid qualified providers and agree to comply with all applicable federal statutory and regulatory requirements, including those in Section 1932 of the Act, 42CFR §438 and any other applicable Federal and State laws including all anti-discriminatory laws and Acts.
  • Must agree to comply with all State plan standards regarding access to care and quality of service.
  • Sign a contract or addendum for enrollment as a primary care case manager which explains the primary care case managers responsibilities and which complies with the PCCM contract requirements in Section 1905(t)(3) of the Act.
  • Provides for reasonable and adequate hours of operation and make available 24-hour, 7 days per week access by telephone for information, referral, and treatment needs during non-office hours.
  • Provide comprehensive primary health care services to all eligible Medical Assistance beneficiaries who choose or are assigned to the primary care case manager's practice.
  • Refer or have arrangements for sufficient numbers of physicians and other appropriate health care professionals to ensure that services under the contract can be furnished to enrollees promptly and without compromise to quality of care.
  • Not refuse an assignment or dis-enroll an enrollee or otherwise discriminate against an enrollee solely on the basis of age, sex, color, race, physical or mental handicap, national origin, service utilization, or health status or need for health services, except when that illness or condition can be better treated by another provider type.
  • Provider agrees to refer recipients for specialty care, hospital care, and other services when medically necessary and sign and document referrals.
  • Provider agrees to comply with any applicable Federal and State laws that pertain to enrollee rights, and ensure that its staff and affiliated providers take those rights into account when furnishing services to enrollees. Provider agrees to adhere to “Enrollee Rights” as described in Supplement 4.
  • Provider agrees to make oral interpretation services available free of charge to each potential enrollee and enrollee for all non-English languages
  • Provider agrees to notify the recipient and OMS in a direct and timely manner of the desire to remove the recipient from the caseload because the recipient/provider relationship is not mutually acceptable. All dis-enrollment requests must be considered “good cause” reasons and approved by OMS in accordance with 42CFR §438.56
  • Provider agrees not to conduct direct or indirect marketing activities specifically intended to attract beneficiary enrollment or dis-enrollment with a specific PCP.
  • Provider agrees to keep the recipient as a patient until another provider is assigned.
  • Provider agrees to accept the established monthly case management fee for each eligible recipient under his or her caseload. Recipients who select primary care providers which are enrolled as rural health clinics, federally qualified health centers or Indian Health Services facilities are not “eligible recipients” for purposes of receiving such case management fee only.
  • Provider agrees not to have a caseload that exceeds 750 recipients and to accept beneficiaries in the order in which they enroll with the primary care case manager.
  • Provider agrees to be dis-enrolled as a Provider for failure to comply with Provider requirements.
  • In accordance with requirements of 45 CFR Part 74, providers must agree to retain medical and financial records for at least three years after the final payment is made and all pending matters closed. Additional time is required if an audit, litigation, or other legal action involving the records is started before or during the original three-year period ends. These requirements are fully described in the State’s Provider Billing Manual and State Administrative Rules.
  • Each PCP entity must make oral interpretation services available free of charge to each potential enrollee and enrollee. This requirement is described in the PCP Handbook or Managed Care Provider Manual.
  • Each PCP must pursue third party liability resources as specified in State Plan Attachments 4.22 A