Common use of Care Management Billing Rules Clause in Contracts

Care Management Billing Rules. The Department has developed a special care management benefit for the SSI managed care population. The benefit is defined above in Article III. B., (Care Management Model for the Medicaid SSI Population). The Department will reimburse HMOs for the care management services (outlined in Article III. B.) outside of the regular capitation payment. The Department will continue to cover other care management activities as an administrative component of the capitation rate or as an integral and inseparable component of another Medicaid covered benefit, as appropriate. The Department has identified specific procedure codes to represent the Medicaid SSI care management benefit. HMOs will be required to use these procedure codes to identify SSI care management activities provided by the WICT and / or SSI care management staff. HMOs will be required to submit member-specific claims via encounter records for the SSI care management benefit. The HMO must maintain documentation for each member that supports the claimed services in their care management system. The HMO must submit member-specific claims via encounters no later than 365 days after the date of service of the claim. If an HMO encounter is denied within the Department’s Medicaid Management Information System (MMIS), the HMO has 90 days to resolve the encounter to priced status within the system.