GETTING NEEDED SERVICES FROM YOUR MANAGED CARE PLAN Workshop for Parents and Providers A Partnership...

GETTING NEEDED GETTING NEEDED SERVICES FROM YOUR SERVICES FROM YOUR MANAGED CARE PLANMANAGED CARE PLANWorkshop for Parents and Providers

A Partnership between Parents’ Place of Maryland

and Georgetown University Center for Child and Human Development

MFAI is funded by Grant No. 1 H93 MC 00072 from the Division of Services for Children with Special Health Care Needs, HRSA, U.S. DHHS

Presented by: Maryland Family Access Initiative

About Parents Place of Maryland

How do we help? Education Information Technical assistance Supportive activities

About Georgetown University Center for Child and Human Development

The Center provides research, training, policy analysis and development, and technical assistance.

Objectives

Know the services available through your MCO

Understand steps needed to access those services

Learn what to do when services are initially denied

Know methods of documentation and record keeping, and their importance

Primary Care Provider (PCP)

PCP may be Pediatrician Family Practice doctor Pediatric nurse practitioner Other

Review MCO provider panel Talk with other families Check location, hours, languages spoken,

etc.

Choosing Your Child’s PCP

Review your member handbook and roster of participating providers

Interview the doctor you are considering

Know what questions to ask Carefully choose your provider

Interpreters

Essential for some families Don’t rely on child to translate May be on staff or specially arranged May be arranged by office, MCO or

family

Knowing What Services and Providers are Covered

Carve-Outs Medical Necessity Referrals and Authorization Process

Pediatric Specialist Children with special needs require

one or more Review MCO provider panel Check hospital affiliation Determine MD’s experience with

your child’s special need Talk with other families Includes mental health provider

Therapists

Occupational therapist (OT) Physical therapist (PT) Speech and language pathologist Vision specialist Respiratory therapist (Same process as pediatric specialist

above)

Mental Health Providers

Refer to your Provider Handbook Learn if Mental Health is a Carve-out Call several Mental Health providers

listed in your handbook Ask lots of questions, I.e. Do they

treat children

Other Providers

Home health agencies Medical Supply and equipment

vendors Transportation Case managers X-ray and lab

Services your child may need and those that are covered

Prevent/primary care

Specialized treatments

After hours/emergency

In-patient X-ray/lab Home-based

Medical equipment Mental health Medication Transportation

Sources of Information - 1

Member handbook Provider directory Case managers Websites Policy documents

Sources of Information - 2

Employer summaries and human resource departments

Hotlines Contact with other families Formulary listings Other?

Steps for Obtaining Services

1. Scheduling appointments2. Keeping appointments3. Obtaining referrals and authorizations4. Filling prescriptions and obtaining refills5. Requesting assistance from your MCO

Keep Documents and Records - 1

Methods of record keeping Maintain written log Records of phone calls Create a paper trail

Keep everything and throw nothing away

Keep Documents and Records - 2

• Save copies ofReferralsApprovalsAuthorizationsDenials

Keep everything and throw nothing away

Keep Documents and Records - 3

• School records

• Test results

• Record all diagnoses

• Medical reports

Keep everything and throw nothing away

Strategies -1

Maintain open communication Establish relationship with PCP Know what is carved-in Know what is carved-out Learn conditions for approval

Strategies - 2

Communicate with referral providers Call member hotlines Understand how medical necessity

is determined Understand who determines

medical necessity

Strategies - 3

Appeal decisions Request second opinions Determine who is responsible for

mental health Learn how mental health access

differs from medical services

Questions and Discussion