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Primary Care Provider (PCP) EnrollmentCan I decide how many Carolina ACCESS (CA) patients we would like to enroll?Yes. You can set an enrollment limit. The maximum allowed is 2000 enrollees per physician or physician extender. How do I change my enrollment limit?You may make changes to your enrollment limit or restrictions by completing a Medicaid Provider Change Form. Carolina ACCESS (CA) EnrolleeHow can I tell if a patient is enrolled with Carolina ACCESS?Carolina ACCESS enrollment can be verified by:
What should I do if a patient does not bring their Medicaid Identification Card for appointment?Providers have a few options to verify eligibility and CA enrollment when patients present without their Medicaid Card:
Can enrollees change primary care providers?Yes. Carolina ACCESS enrollees may request a change by contacting their caseworker or the Medicaid supervisor at their county Department of Social Services (DSS). Under normal circumstances the change will take approximately 30 days. Changes are effective the first day of the month. Until the change is made by the DSS, your practice must either provide services or refer the enrollee to another PCP for service. What should be done if a patient is enrolled with the wrong PCP?Advise the patient to contact his caseworker or the Medicaid supervisor at the DSS to enroll with the correct PCP immediately. If the patient does not request the change in a timely manner, contact your regional Managed Care Consultant for assistance. ReferralsWhat if my Carolina ACCESS panel members need specialized health care services that my office cannot provide?Primary Care Providers (PCPs) are responsible for referring Carolina ACCESS enrollees to specialists and other health services as needed. Medicaid will only pay for Medicaid covered services if the PCP authorizes treatment, except for the exempt services. A list of these exempt services can be found in the Managed Care Provider Information section of the Basic Medicaid Billing Guide. When authorizing treatment, the PCP must give the treating specialist or provider his NPI number. CA enrollees may be referred to any specialist who accepts Medicaid. Be sure to identify your patient as a CA enrollee when making the referral. In most situations, authorization should be given prior to services being rendered. However, authorization may be granted in other situations at the PCP's discretion. Authorization for referrals may be given by telephone or in writing. It is recommended that PCP's store documentation on all CA referrals for internal tracking purposes and quality of care issues. This can be done in the patient's record or on a comprehensive referral log. Office referral documentation can be cross-referenced to the Carolina ACCESS Monthly Referral Report. CA PCPs should specify the number of visits and length of time that an authorization is valid in order to eliminate unnecessary phone calls or misunderstandings. It is important for the PCP to be specific when authorizing care. Does the doctor to whom we refer a patient have to be participating with Carolina ACCESS (CA)?No. Carolina ACCESS does not have a network of specialists so you may refer your patients to any provider who accepts Medicaid. What if we receive a request for a referral for a patient we have never seen before?PCPs may, but are not required to, authorize specialty care for patients they have not seen. If your practice chooses not to authorize in this situation, refer the patient to his caseworker or the Medicaid supervisor or refer the specialist to the regional Managed Care Consultant for assistance. Your monthly enrollment report identifies new enrollees to your practice; you are strongly encouraged to make contact with the new enrollees to schedule a visit to establish a record. Is PCP authorization required each time a Specialist sees a CA enrollee?Unless the service you are providing is an exempt service as listed in the Managed Care Provider Information section of the Basic Medicaid Billing Guide, you must obtain authorization from the PCP. The length and scope of the authorization is at the discretion of the PCP. Can referrals be made by telephone?Yes. PCPs may make referrals by telephone or in writing. Carolina ACCESS does not dictate how the referral process takes place. However, it is important to obtain authorization to treat a CA enrollee prior to services being rendered. For more information, please read the Managed Care Provider Information section of the Basic Medicaid Billing Guide. What if a CA Enrollee 'self refers' to our office?CA enrollees must get PCP authorization before seeing another doctor,
unless the service is exempt from authorization. A list of exempt services
can be found in the Managed Care Provider Information section of the Basic
Medicaid Billing Guide. BillingAre CA enrollees responsible for co-payments?All Medicaid co-payment rules apply to Carolina ACCESS enrollees. What if the patient has a Third Party Insurance?Medicaid will always be the payor of last resort. If the patient has private insurance this must be billed before billing Medicaid. If there is no private insurance data on the Medicaid Identification Card and the patient states they have other insurance you should contact the local DSS or complete a DMA 2057 form. For additional information about thirdy party insurance, refer to the Third Party Insurance section of the Basic Medicaid Billing Guide. How should claims be filed when a PCP refers a CA Enrollee to our office?When a PCP refers a CA enrollee to your office, you should be given the PCP's NPI authorization number. When filing your claim, you must put the referring PCP's NPI authorization number in block 17b of the CMS-1500 claim form. Clarify with the PCP what time or treatment limitations are placed on the authorization; e.g., good for the full course of treatment, good for one visit, etc. Since CA enrollees can change PCPs monthly, you must check the card each month to verify the PCP. If my office has questions concerning claims who should we contact?You should make contact with the Provider Service Section of EDS at 1-800-688-6696. To check on the status of a claim, contact the Automated Voice Response System at 1-800-723-4337. Emergency DepartmentDo CA Enrollees admitted through the Emergency Department require PCP authorization?No. However, physician services provided following admission from the Emergency Department billed on the CMS-1500 will require authorization from the CA enrollee's PCP listed on the current month's Medicaid card. Is the Emergency Department required to obtain referral authorization from the PCP listed on the Medicaid Identification Card?No. Services provided in the Emergency Department do not require authorization by the member's CA PCP. Refer to the Managed Care Provider Information section of the Basic Medicaid Billing Guide for more additional information. OtherDo all Medicaid covered services require authorization?No. There are some services that do not require the primary care provider's authorization. A list of these exempt services is published in the Managed Care Provider Information section of the Basic Medicaid Billing Guide. What is NCHC Insurance?North Carolina Health Choice is a state and federally funded health insurance for children under the age of 19 whose family cannot afford private insurance and who do not qualify for Medicaid. NCHC is administered by the North Carolina State Health Plan. Who do I contact for additional questions or information?Contact your Regional Managed Care Consultant. If you are unable to reach the consultant, you may contact the state Managed Care office at (919) 647-8170. Updated August 29, 2008 |