Provider Management

The Manage Provider Communication business process receives requests for information, provides publications, and assistance from prospective and current providers’ communications (e.g., inquiries related to eligibility of provider, covered services, reimbursement, enrollment requirements). The State Medicaid Agency (SMA) may communicate information using a variety of methods such as email, mail, publication, mobile device, facsimile, telephone, web or Electronic Data Interchange (EDI). This business process includes the log, research, development, approval and delivery of routine or ad hoc messages. NOTE: Manage Provider Communication business process handles inquiry from prospective and current providers by providing assistance and responses to individual entities (i.e., bi-directional communication). Also included are scheduled communications such as program memorandum, notifications of pending expired provider eligibility, or formal program notifications such as the disposition of appeals. The Perform Provider Outreach business process targets both prospective and current provider populations for distribution of information about programs, policies, and health care issues.

The Manage Provider Grievance and Appeal business process handles provider* appeals of adverse decisions or communications of a grievance. The Manage Provider Communication business process initiates a grievance or appeal from a provider. The State Medicaid Agency (SMA) logs and tracks the grievance or appeal, triages it, and sends it to appropriate reviewers. Staff researches or requests additional information. The SMA may schedule a hearing, conduct actions in accordance with legal requirements, and make a ruling based upon the evidence presented. Staff documents and distributes results of the hearings, and adds relevant documents to the provider’s information. SMA formally notifies provider of the decision. This business process supports the Manage Performance Measures business process by providing information about the types of grievances and appeals it handles, grievance and appeals issues, parties that file or are the target of the grievances and appeals, and the dispositions. The SMA uses information to discern program improvement opportunities, which may reduce the issues that give rise to grievances and appeals. Based on the appeal business process, if a provider wins an appeal that affects or clarifies a Medicaid State Plan, health plan, or health benefit, this process sends that information to Maintain State Plan, Manage Health Plan Information or Manage Health Benefit Information business processes to modify the relevant policy or procedure. Disposition could result in legislative change requirements that the SMA will communicate to lawmakers. NOTE: States may define grievance and appeal differently, depending on state laws. States may involve multiple agencies in the Manage Provider Grievance and Appeal business process. *This business process supports grievances and appeals for both prospective providers and current providers. A non-enrolled provider can file a grievance or appeal, for example, when SMA denies an application for enrollment.

The Perform Provider Outreach business process originates internally within the State Medicaid Agency (SMA) in response to multiple activities (e.g., identified gaps in medical service coverage, public health alerts, provider complaints, medical breakthroughs, modifications in the Medicaid Program policies and procedures). SMA may develop prospective Provider outreach information, also referred to as Provider Recruiting information, for targeted providers identified by analyzing program information (for example, not enough dentists to serve a population, new immigrants need language-compatible providers). Enrolled Provider outreach information may relate to corrections in billing practices, public health alerts, public service announcements, drive to sign up more Primary Care Physicians, and other objectives. The State Medicaid Agency develops outreach information for target populations identified by analyzing member information. The State Medicaid Agency may communicate information in a variety of methods such as email, mail, publication, mobile device, facsimile, telephone, web or Electronic Data Interchange (EDI). The State Medicaid Agency produces, distributes, tracks and archives all contractor outreach communications according to state rules. The Manage Performance Measures business process defines benchmarks and measures outreach efficacy. NOTE: The Perform Provider Outreach business process targets both prospective and current provider populations for distribution of information about programs, policies, and health issues. Manage Provider Communication business process handles inquiry from applicants, prospective and current providers by providing assistance and responses to individuals (i.e., bi-directional communication).

The Manage Provider Information business process is responsible for managing all operational aspects of the Provider data store, which is the source of comprehensive information about prospective and contracted providers and their interactions with the State Medicaid Agency (SMA). The Provider data store is the SMA Source of Record (SOR) for provider demographic, business, credentialing, enumeration, performance profiles, payment processing, and tax information. The data store includes contractual terms (e.g., the services the provider is to provide) related performance measures, and the reimbursement rates for those services. In addition, the Provider data store contains records about and tracks the processing of provider enrollment applications, credentialing and enumeration verification, and all communications with or about the provider, including provider verification requests and responses, and interactions related to any grievance/appeal. The Provider data store may store records or pointers to records for services requested and services provided, performance, utilization, and program integrity reviews, and participation in member care management. Business processes that generate prospective or contracted provider information send requests to the Member data store to add, delete, or modify information. The Provider data store validates information upload requests, applies instructions, and tracks activity. The Provider data store provides access to provider records to applications and staff via batch record transfers, responses to queries, and subscription services.

The Terminate Provider business process is responsible for the termination of provider agreement to participate in the Medicaid Program. The basis for termination can be: • Centers for Medicare & Medicaid Services (CMS) and the State Medicaid Agency (SMA) terminate a provider agreement if an individual provider: - Is not in substantial compliance with the requirements of participation, regardless of whether immediate jeopardy is present; - Provider does not meet the eligibility criteria for continuation of payment as set forth in 42 CFR 488.412(a)(1). • CMS and the state may terminate a facility's provider agreement if a facility: - Is not in substantial compliance with the requirements of participation, regardless of whether immediate jeopardy is present; or - Facility fails to submit an acceptable Corrective Action Plan (CAP) within the timeframe specified by CMS or the SMA. • CMS and the SMA terminate a facility's provider agreement if a facility: - Fails to relinquish control to the temporary manager, if CMS or the SMA imposes that remedy; or - Facility does not meet the eligibility criteria for continuation of payment as set forth in 42 CFR 488.412(a)(1). The effect of termination of the provider agreement ends: (1) payment to the facility, and (2) any alternative remedy.