Frequently Asked Questions
- General Managed Care
- Utilization Management
- Home and Community Based Services
- Outcomes and Analytics
What consideration will there be for complexity and comorbidity in the capitation formula?
Complexity of co-occurring and chronic conditions for children are being taken into account when determining rates and program design.
Can providers bill retroactively (i.e., "back bill")?
Plan eligibility is not retroactive. Accordingly, bill Managed Care Organizations (MCOs) fee-for-service (FFS) for 2-3 months. Refer to the guidance found in this presentation.
Are clinicians mandated to code their own sessions?
Yes, clinicians are mandated to code their own sessions.
Can billing departments or billing systems automate codes based on keywords?
No, billing departments or billing systems cannot automate codes based on keywords.
What are the billing codes and where are they located?
A draft manual is available here. All plans and providers will use the same coding construct which will crosswalk procedure code and modifier code combinations back to fee-for-service (FFS) rate codes.
Are we moving towards a Per-Month-Per-Member (PMPM) environment or a Fee-for-Service (FFS) environment?
We are moving towards a PMPM environment. Managed Care Organizations (MCOs) receive a fixed monthly payment for each member which covers a defined set of services, or benefits. Please refer to slide 16, "How Managed Care is Paid," found here.