Transition Period for New PrimeWest Health Members

Document Sample
Transition Period for New PrimeWest Health Members Powered By Docstoc
					                            PRIMEWEEKLY                           FOR CASE MANAGERS


           Volume 2, Issue 29                                                                    August 18 – 24, 2008


               Transition Period for New PrimeWest Health Members
                                Chris Hagen, PharmD RPh, Utilization Management & Pharmacy Manager
           Understanding all of the benefit and coverage policies of PrimeWest Health can be a daunting
           task, even for members and providers who are familiar with our programs. Because of this,
           PrimeWest Health offers a transitional period for members new to our programs, which allows
           them to continue accessing established therapies and services while they become acclimated to
           our benefit set. Any member new to PrimeWest Health who identifies him/herself as requiring
PAGE ONE




           special consideration for services established prior to enrollment will be given these transitional
           rights. Members may apply for transitional care consideration by doing any of the following:
            1. Contacting Member Services at 1-866-431-0801 (toll free)
            2. Contacting his/her county worker and filling out a Transition of Care form
            3. Filling out a Health Risk Assessment


           In addition, the PrimeWest Health Care Coordination team actively searches for members who
           require transitional assistance.


           During the transition into PrimeWest Health’s programs, our Care Coordination team considers
           each member’s individual health concerns and existing services at the time of enrollment.
           These may include, but are not limited to, orthodontia, behavioral health, chemical dependency,
           high-risk pregnancy, pharmacy utilization, and other conditions or services. The process is
           designed to transition new members to contracted network providers and covered services
           as seamlessly as possible. New members are required to make the transition from an
           out-of-network provider to a participating provider if such a transition will not create undue
           hardship on the member and is clinically appropriate.


           PrimeWest Health is responsible for ongoing care and will authorize services as needed to
           meet the member’s needs. We will not authorize coverage for services that are not part of the
           member’s benefits set (as described in the Certificate of Coverage) or services that are excluded
           by laws governing Medicaid coverage. Typically, members in transition are granted 120 days of
           continuation for the following, unless otherwise noted:
            •	 Continued payment of all eligible drugs the member is taking under a current prescription.
               Payment shall continue until a formulary exception is submitted or for 90 days, whichever
               occurs first, and will apply to all those members who have been identified as requiring

                                                                                                         page 1 of 3
              a continuation. This applies to established medications only; new prescriptions require
              formulary adherence.
           •	 An acute condition where the member is engaged in a current course of treatment
           •	 Pregnancy beyond the first trimester. Services will be authorized through the 6-week
              postpartum check.
           •	 A life-threatening mental or physical illness
           •	 A physical or mental disability constituting an inability to engage in one or more major life
              activities, provided that the disability has lasted or can be expected to last for at least one
              year, or can be expected to result in death
           •	 A disabling or chronic condition that is in an acute phase
           •	 Presence of a terminal illness where life expectancy is less than 180 days. Authorization will
              be extended until the member expires, even if it exceeds the 120-day window.


           If new members need transitional assistance for established services—already authorized
PAGE TWO




           by a prior Managed Care Organization (MCO) or the State before enrollment in PrimeWest
           Health—please help our Care Coordination team steer them to the proper channels so
           continuity of care can be preserved. Please keep in mind that not all services are subject
           to transition rights. For questions regarding this policy please contact Chris Hagen,
           Utilization Management & Pharmacy Manager, at chris.hagen@primewest.org.


                                        Questions and Answers
                                    Elaine Carlquist, BSN, PHN, CCP, Senior Care Coordinator
                                        Beth Pries, MSW, LGSW, Senior Care Coordinator
           PrimeWest Health continues to receive great questions from our county case managers. We hope
           this periodic question and answer section of PrimeWeekly is a helpful way to share not only the
           questions, but also their answers with all of our county partners.

           Question
           When completing the Skilled Nursing Facility (SNF) Minimum Data Set (MDS) risk assessment,
           nursing home staff are asked to use the most recent MDS assessment to answer the questions.
           However, answers to some of the questions on the risk assessment are only found on the annual
           MDS assessment, which may not be the most current. In this situation, is it okay to use the most
           recent as well as the annual MDS assessment to answer the questions?


           Answer
           Yes, is okay to use both of the MDS assessments; however, the most current MDS assessment
           should be used whenever possible.


           Question
           If a county case manager helps a member apply for alternative housing, such as an apartment,
           and accompanies the member on a visit to see the facility, can the county case manager bill for
           the site visit?                                                                    page 2 of 3
             Answer
             If a county case manager spends time with a member to help him/her obtain safe and suitable
             housing, that time is considered case management time and is billable. Whenever possible,
             family or friends should be involved with helping the member find alternative housing, but
             if no one else is able to help the member, a county case manager may offer this type of billable
             assistance.


             Question
             If a resident of a nursing home requests a private room, to whom do we send the request?


             Answer
             For members who reside in Beltrami, Clearwater, and Hubbard counties, direct the
             request to Beth Pries, MSW, LGSW, Senior Care Coordinator, at 1-218-308-2807 or
             beth.pries@primewest.org. For members of all other PrimeWest Health counties, requests
PAGE THREE




             should be directed to Becki Pender, RN, CCP, Senior Care Manager, at 1-320-335-5204,
             1-888-588-4420 ext. 5204, or becki.pender@primewest.org.

                                           Important 2008 Dates
             9 Public Health and Human Services Supervisor meetings
                 August 28, 10 a.m. – 3 p.m.*         October 23, 10:30 a.m. – 2:30 p.m.
                 September 25, 10:30 a.m. – 2:30 p.m. December 11, 10:30 a.m. – 2:30 p.m.


             *Due to a full agenda, the Public Health and Human Services Supervisor meeting on
             August 28 will start earlier and end later than usual. The time scheduled for the meeting is
             10 a.m. – 3 p.m. The meeting agenda will be sent to supervisors by August 22.


             All meetings will be held at the PrimeWest Health office in Alexandria unless otherwise
             indicated.


             The county case manager educational session will be October 24, 9 a.m. – 12 p.m. The location of
             the county case manager session will be announced.




                     You can find a PDF copy of PrimeWeekly for Case Managers by going
               to our website and clicking on Partners & Providers>Resources> Forms, Letters, and
                                           Miscellaneous Documents.




                                                  Main Office       Northern Office
                                           2209 Jefferson St, Ste 101 3124 Hannah Ave NW
                                             Alexandria, MN 56308 Bemidji, MN 56601
                                                           www.primewest.org