Medical Services

Managed Care

State Plan Amendment - Title XIX of the Social Security Act

Supplement 8 - Provider Notifications and Information

Provider Information

The State informs providers on program specifics and requirements through billing manuals, the Managed Care Provider Manual or provider handbook, and through the Provider Agreement and Addendum to the Provider Agreement. PCPs receive a variety of other notices and correspondence on an unscheduled basis providing them with both general managed care information (updates, reminders and etc.) and correspondence related to specific beneficiaries. The State also provides information on current projects and studies concerning statewide data as well as caseload specific data.

The Managed Care Provider Manual or provider handbook provides detailed information on requirements of the PCP, State responsibilities (administration of beneficiary enrollment, mediation, complaint resolution, billing assistance, and etc), suggested practices, and other information intended to assist providers in their participation of the program.

Caseload Lists

A list of beneficiaries is sent to PCPs at the beginning of each month showing currently enrolled beneficiaries. In addition to specific identifying information for each beneficiary, the list also provides EPSDT information for children. Indicators for services due such as well-child screens and immunizations are included. The child’s birth date and the periodicity schedule of target services trigger these indicators.

Paid Claims Report

A report is sent to PCPs at the beginning of each month showing all managed care and all pharmacy claims that were adjudicated in the previous month for beneficiaries under the PCPs caseload.

Remittance Advice

A roster of beneficiaries is sent at the end of each month (around the 25th) to PCPs with their monthly case management payment. The list includes all beneficiaries that the PCP received a case management fee for the month.

Other Correspondence

PCPs receive a variety of other notices and correspondence on an unscheduled basis providing them with both general managed care information and correspondence related to specific beneficiaries. The State also provides information on current projects and studies concerning statewide data as well as caseload specific data.