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GETTING NEEDED SERVICES FROM YOUR MANAGED CARE PLAN

GETTING NEEDED SERVICES FROM YOUR MANAGED CARE PLAN. Workshop for Parents and Providers. Presented by: Maryland Family Access Initiative. A Partnership between Parents’ Place of Maryland and Georgetown University Center for Child and Human Development.

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GETTING NEEDED SERVICES FROM YOUR MANAGED CARE PLAN

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  1. GETTING NEEDED SERVICES FROM YOUR MANAGED CARE PLAN Workshop for Parents and Providers Presented by: Maryland Family AccessInitiative A Partnership between Parents’ Place of Maryland and Georgetown University Center for Child and Human Development MFAI is funded by Grant No. 1 H93 MC 00072 from the Division of Services for Children with Special Health Care Needs, HRSA, U.S. DHHS

  2. About Parents Place of Maryland • How do we help? • Education • Information • Technical assistance • Supportive activities

  3. About Georgetown University Center for Child and Human Development • The Center provides • research, • training, • policy analysis and development, • and technical assistance.

  4. Objectives • Know the services available through your MCO • Understand steps needed to access those services • Learn what to do when services are initially denied • Know methods of documentation and record keeping, and their importance

  5. Primary Care Provider (PCP) • PCP may be • Pediatrician • Family Practice doctor • Pediatric nurse practitioner • Other • Review MCO provider panel • Talk with other families • Check location, hours, languages spoken, etc.

  6. Choosing Your Child’s PCP • Review your member handbook and roster of participating providers • Interview the doctor you are considering • Know what questions to ask • Carefully choose your provider

  7. Interpreters • Essential for some families • Don’t rely on child to translate • May be on staff or specially arranged • May be arranged by office, MCO or family

  8. Knowing What Services and Providers are Covered • Carve-Outs • Medical Necessity • Referrals and Authorization Process

  9. Pediatric Specialist • Children with special needs require one or more • Review MCO provider panel • Check hospital affiliation • Determine MD’s experience with your child’s special need • Talk with other families • Includes mental health provider

  10. Therapists • Occupational therapist (OT) • Physical therapist (PT) • Speech and language pathologist • Vision specialist • Respiratory therapist • (Same process as pediatric specialist above)

  11. Mental Health Providers • Refer to your Provider Handbook • Learn if Mental Health is a Carve-out • Call several Mental Health providers listed in your handbook • Ask lots of questions, I.e. Do they treat children

  12. Other Providers • Home health agencies • Medical Supply and equipment vendors • Transportation • Case managers • X-ray and lab

  13. Prevent/primary care Specialized treatments After hours/emergency In-patient X-ray/lab Home-based Medical equipment Mental health Medication Transportation Services your child may need and those that are covered

  14. Sources of Information - 1 • Member handbook • Provider directory • Case managers • Websites • Policy documents

  15. Sources of Information - 2 • Employer summaries and human resource departments • Hotlines • Contact with other families • Formulary listings • Other?

  16. Steps for Obtaining Services • Scheduling appointments • Keeping appointments • Obtaining referrals and authorizations • Filling prescriptions and obtaining refills • Requesting assistance from your MCO

  17. Keep Documents and Records - 1 • Methods of record keeping • Maintain written log • Records of phone calls • Create a paper trail Keep everything and throw nothing away

  18. Keep Documents and Records - 2 • Save copies of • Referrals • Approvals • Authorizations • Denials • Keep everything and throw nothing away

  19. Keep Documents and Records - 3 • School records • Test results • Record all diagnoses • Medical reports • Keep everything and throw nothing away

  20. Strategies -1 • Maintain open communication • Establish relationship with PCP • Know what is carved-in • Know what is carved-out • Learn conditions for approval

  21. Strategies - 2 • Communicate with referral providers • Call member hotlines • Understand how medical necessity is determined • Understand who determines medical necessity

  22. Strategies - 3 • Appeal decisions • Request second opinions • Determine who is responsible for mental health • Learn how mental health access differs from medical services

  23. Questions and Discussion

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