Making Medicaid Better Newsletter 10.06.2011

State approves CCN contracts, provider handbooks

The Department of Health and Hospitals (DHH) has moved one step closer to implementation of Coordinated Care Networks this week with final approval from the state Division of Administration (DOA) to contract with all five entities recommended to administer CCNs.

Contracts for CCNs have now been fully executed with Amerigroup of Louisiana, Amerihealth Mercy of Louisiana and Louisiana Healthcare Connections for CCN-Prepaid plans, and Community Health Solutions of America and UnitedHealthcare of Louisiana for CCN-Shared Savings plans.

With approval of the final contracts by DOA, each CCN has moved into the readiness review phase of the implementation process. During this phase, operations will be reviewed by DHH staff and the DHH External Quality Review Organization, IPRO, and the CCNs will demonstrate network adequacy. A review of systems and financials will also be conducted by Mercer. The contracts will also be reviewed by the Centers for Medicare and Medicaid Services (CMS), the federal agency that monitors the state's Medicaid Program. Once reviews are complete and provider networks are established, CCNs can begin enrolling Medicaid recipients in their networks, with the first group in Geographic Service Area A (the greater New Orleans and Northshore areas) "going live"  Feb. 1, 2012.

Also, this week, DHH has approved and posted online provider handbooks for each of the CCNs. Handbooks serve as a written resource for health care providers regarding each CCN and their policies, procedures, services and protocols. Details on provider rights and responsibilities, prior authorization and referral processes, medical necessity standards, chronic care management programs, quality performance requirements, grievance and appeals procedures and much more are included. A link to the CCN handbooks can be found on the Making Medicaid Better Web site by clicking here.

DHH schedules provider Q & A calls

DHH will host a series of conference calls Oct. 11, 12 and 13 to answer provider questions about the implementation of CCNs. Medicaid staff directly involved in CCN development will be on the call to answer questions.

A brief introduction and update of the CCN implementation will be provided by Medicaid staff, but the bulk of the conference call will be devoted to provider questions and answers.

DHH is asking that providers participate in the call for their provider type and Geographic Service Area (GSA), as noted below, to accommodate the limited number of call-in lines and ensure the most efficient use of call time. The conference call schedule is as follows:

If you are unable to participate on your region's assigned date and call time, you may call in on another date. The call-in information for all calls is:

• Call-in line - #1-888-278-0296
• Access Code - #7299088

DHH is asking that all participants register here for the conference call of their choice by close of business Oct. 10. Due to limited call in lines, this will help ensure that all interested parties have an opportunity to participate. At the time of registration, providers will have the opportunity to submit questions or issues they would like addressed during the meeting.

DHH to release companion guides for CCN quality, systems

DHH will issue four new guides this week providing written instruction for CCNs on the quality and systems aspects of CCN implementation and ongoing management.

The Quality Companion Guide will provide CCNs with guidance on core quality improvement activities, performance improvement projects, performance measure specifications and validation processes. The Quality Companion Guide was drafted by DHH's External Quality Review Organization, IPRO.

Earlier this week, DHH issued a revision to the Shared Savings and Prepaid Systems Companion Guides (two separate guides), outlining the requirements for data exchanges and file formats. The guides address the roles of all related parties involved in data processing, including the DHH Fiscal Intermediary (Molina), the Enrollment Broker (Maximus), CCNs and DHH. The guides also include details on encounters, claims submissions, payment, reporting, coding (denials, descriptions, edits, corrections, and resubmissions), electronic data interchange testing and systems certification.

Systems issues are also addressed in DHH's recently released 834 Companion Guide, which addresses the file exchange requirements of the Enrollment Broker (Maximus) in conjunction with the CCNs, DHH and the DHH Fiscal Intermediary (Molina).

Announcements

ADVOCATE CONFERENCE REGISTRATION:  Spaces are still available for non-profit and health care advocacy groups wishing to participate in DHH's day-long, CCN Advocates' Conference. The event will take place Friday, Oct. 14 from 9 a.m. to 4 p.m. at the Holiday Inn at 9940 Airline Drive in Baton Rouge. Click here to register.

The conference is specifically designed for community-based organizations and other advocates who work with Medicaid and LaCHIP recipients. Because providers cannot assist recipients in enrolling (as they are contractors of specific plans and this presents a potential conflict of interest), this conference is not for health care providers.

There is no cost to attend and lunch will be served. Seating is limited to 300.

Provider Q and A

Q. What is the deadline for providers to sign a contract with a CCN in order to be assured inclusion in the initial printing of the CCN's provider directory?     

A. The CCN implementation schedule has been updated to adjust for the Feb. 1, 2012 go live date. For providers to be included in the initial CCN provider directory, all providers must meet the contacting deadline for their Geographic Service Area as follows:  

• GSA A - Oct. 31, 2011
• GSA B - Dec. 30, 2011
• GSA C - Feb. 27, 2012

Q. A CCN is urging me to contract with them. They have informed me that, if I do not contract with them, they will make a total of three attempts to contract with me. If I refuse all three times, they can later pay me 90% of the Medicaid fee-for-service (FFS) rate as an out-of-network provider. Is this accurate?    

A. A CCN must reimburse an out-of-network provider 100% of the Medicaid FFS rate for emergency services. For services that do not meet the definition of emergency services, a CCN is not required to reimburse non-network providers more than 90% of the published Medicaid FFS rate in effect on the date of service. The CCN must first demonstrate it has attempted to contact the provider three times with the intention to contract with the provider before reimbursing at the 90% rate. However, these three documented attempts cannot begin before October 4, 2011, the date all CCNs contracts were executed by the state.

All attempts to contract with a provider must be made in good faith, by the CCN, in writing.  This can include correspondence that outlines contract negotiations between the parties, including rate and contract term disclosure. The potential network provider has 10 calendar days to accept, reject or fail to respond to the request, verbally or in writing.

Feedback

If you have questions about Coordinated Care Networks, contact DHH's Coordinated Care Network staff at coordinatedcarenetworks@la.gov.  Learn more at MakingMedicaidBetter.com.