Care Management

The Authorize Referral business process is responsible for referrals between providers that the State Medicaid Agency (SMA) approves for payment, based on state policy. Examples are referrals by physicians to other providers for laboratory procedures, surgery, drugs, or durable medical equipment. The SMA uses this business process primarily for Primary Care Case Management programs where additional approval controls deemed necessary by the state. Most States do not require this additional layer of control. NOTE: MITA contains three (3) different authorization business processes: 1. Authorize Service - the standard process of prior authorization of services. 2. Authorize Treatment Plan - the approval of a treatment plan prepared by a care management team in a care management setting. 3. Authorize Referral - specifically the approval of a referral to another provider, requested by a primary care physician. The Authorize Referral business process may encompass both a pre-approved and post-approved referral request, especially in the case where the member required immediate services. This business process may include, but is not limited to, referrals for specific types and numbers of visits, procedures, surgeries, tests, drugs, durable medical equipment, therapies, and institutional days of stay. The SMA evaluates requests based on urgency, state priority requirements, and type of service/taxonomy (durable medical equipment, speech, physical therapy, dental, inpatient, out-of-state). It validates key information, and ensures that the referral is appropriate and medically necessary. After review, staff approves, modifies, suspends for additional information or denies the request. This business process sends an alert to Manage Case Information business process. A post-approved referral request is an editing/auditing function that requires review of information after the referral is complete. A review may consist of verifying documentation to ensure that the referral is appropriate, and medically and/or functionally necessary, and validating provider type and specialty information to ensure alignment with agency policies and procedures. Post-approved validation typically occurs in the Process Claim or Process Encounter business processes.

The Authorize Service business process encompasses both a pre-approved and post-approved service request. This business process focuses on specific types and numbers of visits, procedures, surgeries, tests, drugs, therapies, and durable medical equipment. Its primary use is in a fee-for-services setting. Prior authorization of a service request is a care management function and begins when a care manager requests a service request by mail, facsimile, telephone, or Accredited Standards Committee (ASC) X12 278 Health Care Services Review Information request transaction. The care manager evaluates requests based on state rules for prioritization such as urgency and type of service/taxonomy (e.g., durable medical equipment, speech, physical therapy, dental, and out-of-state), validates key information, and ensures that requested service is appropriate and medically necessary. After review, staff approves, modifies, denies or suspends for additional information the service requests. The State Medicaid Agency (SMA) sends the appropriate response information for the outbound ASC X12 278 Health Care Services Review Response transaction to the provider using the Send Outbound Transaction. NOTE: MITA contains three (3) different authorization business processes: 1. Authorize Service - the standard process of prior authorization of services. 2. Authorize Treatment Plan - the approval of a treatment plan prepared by a care management team in a care management setting. 3. Authorize Referral - specifically the approval of a referral to another provider, requested by a primary care physician. A post-approved service request is an editing/auditing function that requires review of information after the service is complete. A review may consist of verifying documentation to ensure that the services were appropriate and medically necessary, and validating provider type and specialty information to ensure alignment with agency policies and procedures. Post-approved validation typically occurs in the Process Claim or Process Encounter business processes. NOTE: This business process is part of a suite that includes Service Requests for different service types and care settings including Medical, Dental, Drugs, and Off-label use of drugs, Social Service, Experimental Treatments, Out-of-State Services, and Emergencies.

The Authorize Treatment Plan business process encompasses both a prior authorization and post-approved treatment plan. The State Medicaid Agency (SMA) uses the Authorize Treatment Plans primarily in the care coordination setting where the care management team assesses the member’s needs, decides on a course of treatment, and completes the treatment plan. NOTE: MITA contains three (3) different authorization business processes: 1. Authorize Service - the standard process of prior authorization of services. 2. Authorize Treatment Plan - the approval of a treatment plan prepared by a care management team in a care management setting. 3. Authorize Referral - specifically the approval of a referral to another provider, requested by a primary care physician. A treatment plan prior-authorizes the named providers or provider types and services or category of services. The SMA prior authorizes individual providers for the service or category of services, and they do not have to submit their own prior authorizations or service requests. A treatment plan typically is a schedule of medical, therapeutic, and /or psychological procedures and appointments that spans a length of time designed to restore a patient's specific health condition. In contrast, the SMA limits an individual service request, primarily associated with fee-for-services payment, to focus on a specific visit, services, or products (e.g., a single specialist office visit, approval for a specific test or particular piece of Durable Medical Equipment (DME)). The prior authorized treatment plan generally begins with the receipt of an authorize treatment plan request from the care management team. The SMA staff then evaluates it based on urgency, state priority requirements, and type of service/taxonomy (speech, physical therapy, home health, behavioral, social), a validates key information, and ensures that requested plan of treatment is appropriate and medically or behaviorally necessary. After reviewing, staff approves, modifies, suspends for additional information or denies the request. Business process sends an alert to Manage Case Information business process. A post-approved treatment plan is an audit function that reviews suspended or paid claims to ensure the services were appropriate and in accordance with the treatment plan.

The Care Management, Establish Case business process uses criteria and rules to: • Identify target members for specific programs. • Assign a care manager. • Assess the member’s needs. • Select a program. • Establish a treatment plan. • Identify and confirm provider. • Prepare information for communication. This business process may establish a case for one individual, a family or a target population such as: • Medicaid Waiver program case management - Home and Community-Based Services (HCBS) - Other • Disease management • Catastrophic cases • Early Periodic Screening, Diagnosis, and Treatment (EPSDT) • Vaccines for children and adults • Population management This business process may initiate a case from claim processing indicators such as: • Several claims for an individual member over a time interval. • New claims close to discharge date. • Claims containing one of the with the following: - Place of Service - Certain Places of Service - Discharge Date - Admit Date - PWK - Attachments containing lab results, treatment plans, etc. - NTE - Notes containing discharge plans, goals, treatment plan - EPSDT Referral Claim - Claims containing certain types of the following information: ✓ Principle Diagnosis ✓ Admitting Diagnosis ✓ Patient Reason for Visit ✓ Other Diagnosis Information ✓ Principle Procedure ✓ Other Procedure ✓ Condition Info ✓ Treatment Code - Prescription drug claim - CLIA certification - Home Health claim - Test Result Different criteria and rules, relationships, and information define each type of health care case and require different types of external investigation. The Health Information Exchange (HIE) provides health information and clinical records for member and care coordination with provider and other agencies.

The Manage Case Information business process uses state-specific criteria and rules to ensure appropriate and cost-effective medical, medically-related social and behavioral health services are identified, planned, obtained and monitored for individuals identified as eligible for care management services under such programs as: • Medicaid Waiver program case management • Home and Community-Based Services (HCBS) • Other agency programs • Disease management • Catastrophic cases • Early Periodic Screening, Diagnosis, and Treatment (EPSDT) • Immunizations for children and adults The Establish Case business process creates each individual case and treatment plan. The Manage Case Information business process includes activities to confirm delivery of services and compliance with the plan. It also includes activities such as: • Service planning and coordination. • Facilitation of services (e.g., finding providers, or establishing limits or maximums). • Advocating for the member. • Monitoring and reassessment of services for need and cost effectiveness. - This includes assessing the member’s placement and the services received and taking necessary action to ensure that services and placement are appropriate to meet the member’s needs. The Health Information Exchange (HIE) provides health information and clinical records for member and care coordination with provider, pharmacist, and other agencies.

The Manage Population Health Outreach business process is responsible for the implementation of strategy to improve general population health. The State Medicaid Agency (SMA) identifies target populations or individuals for selection by cultural, diagnostic, or other demographic indicators. The inputs to this business process are census, vital statistics, immigration, and other information sources. This business process outputs materials for: • Campaigns to enroll new members in existing health plan or health benefit. • New health plan or health benefit offering. • Modification to existing health plan or health benefit offering. It includes production of information materials and communications to impacted members, providers, and contractors (e.g., program strategies and materials, etc.). The communication of information includes a variety of methods such as email, mail, publication, mobile device, facsimile, telephone, web or Electronic Data Interchange (EDI).

The Manage Registry business process receives a member’s health outcome information, prepares updates for a specific registry (e.g., immunizations, cancer, disease) and responds to inquiries with response information. In the context of MITA, a medical registry consolidates related records from multiple sources (e.g., intrastate, interstate or federal agencies) into one comprehensive data store. This data store may or may not reside within the Medicaid information system.

The Manage Treatment Plan and Outcomes business process uses federal and state specific criteria and rules to ensure that the providers/contractors chosen and services delivered optimizes member and member population outcomes. It includes activities to track and assess effectiveness of the services, treatment plan, providers/contractors, service planning and coordination, episodes of care, support services, and other relevant factors. It also includes ongoing monitoring, management, and reassessment of services and treatment plans for need, appropriateness, and effectiveness, and monitoring of special member populations (e.g., pregnant women and children, and HIV/intravenous drug users). Health Information Exchange (HIE) monitors a member’s health information.

The Perform Screening and Assessment business process is responsible for the evaluation of member’s health information, facilitating evaluations and recording results. This business process assesses for certain health and behavioral health conditions (e.g., chronic illness, mental health, substance abuse), lifestyle and living conditions (e.g., employment, religious affiliation, living situation) factors. This business process: • Establishes risk categories and hierarchy, severity, and level of need. • Screens for required fields. • Edits required fields. • Verifies information from external sources if available. • Establishes severity scores and diagnoses. • Associates with applicable service needs. Health Information Exchange (HIE) verifies a member’s health information.