Policy Title: Coordination With Managed Care Organizations (MCO)

Transcription

1 Policy Title: Coordination With Managed Care Organizations (MCO) Number: TD-QMP-7045 Subject: Coordinating services for children with the MCO for services that are not covered by TennDent Primary Department: Operations Effective Date of Policy: 6/22/12 Last Reviewed by TennDent Quality Monitoring/Improvement Committee: Secondary Department: Prior Policy or Cross Reference(s): Date Policy Last Revised: Review Frequency: Annually Next Scheduled Review: Annually by 12/31 TennDent Quality Monitoring/Improvement Committee Approval: on file Approval Date: Scope: TennDent Staff, Managed Care Organizations, TennCare Members and TennDent Network Providers Purpose: To describe the process for coordinating services with the MCOs to make arrangements for services that are not covered by TennDent or to resolve any problems or issues between the MCO and TennDent. Authoritative Reference: Contract between Bureau of TennCare and Delta Dental A.37 and A.37.b Policy: As indicated in the TENNderCare (EPSDT) Medically Necessary Services Policy, TennDent Dentists will provide dental treatment or appropriate medical referrals for TENNderCare members under the age of 21. Treatment or referrals will be made for necessary health care,

2 diagnostic services, treatment and other measures to correct, ameliorate, or prevent from worsening defects and mental illnesses and conditions discovered by the screening services, regardless of whether the medical services are covered under TennDent. The dentist will make the patient and/or parent or guardian aware of any medical service that is needed. Information regarding the TENNderCare services are included in the Provider Office Reference Manual, during provider training, through electronic media and provided to members upon enrollment, through outreach activities and at least annually. Dentists should contact the patient s MCO to coordinate appointments and/or transportation for medical treatment identified during a dental visit. The Manager of TennDent is also available to assist the dental office in coordinating with the MCO for appropriate medical care. TennCare enrollees will receive treatment that is medically necessary. There are two specific services that are commonly coordinated with the MCO s that relate to dental services. The MCO is responsible for providing transportation to and from dental services and anesthesia services for dental procedures performed by a dentist in an inpatient/outpatient hospital facility or an ambulatory surgical center. The TennDent Customer Service Representatives provide the dentists and members transportation assistance information for dental appointments. The caller is given the MCO transportation services number. A TennDent Transportation Coordinator is available to assist with emergency needs and coordination with the MCO contact as defined in the TENNderCare (EPSDT) Outreach Member Transportation Procedure. When dental services are required to be performed in an Inpatient/Outpatient Hospital Facility or in an Ambulatory Surgical Center (ASC), dental providers are required to request prior authorization unless the dental treatment constitutes an emergency. A completed TennCare Inpatient and Outpatient Hospital Readiness Pre-Admission Form is required to be submitted by the treating provider to TennDent with the treatment plan documentation required as outlined in Section 13 of the TennDent Provider Office Reference Manual. The form must evidence that the requesting dental provider attempted to treat the patient in-office and where appropriate, referred the patient to a pediatric dentist or other specialist. The dental provider requesting prior authorization must obtain authorization from the patients TennCare MCO. The TennDent explanation of benefits with the approval indicating that treatment is approved to be completed in a hospital/asc setting serves as TennDent authorization to the MCO. The provider must ensure the following: 1. That the selected hospital/ambulatory surgery center is participates in the TennCare patient s MCO network. 2. The requisite medical staff, anesthesiologists, etc. are participants in the TennCare patient s MCO network. 3. The dental provider has consulted with the patient s primary care physician concerning the dental care to be conferred in the hospital/asc.

3 4. The The patients s primary care physician has examined the patient and supplied the dental provider with the patient s up-to-date medical evaluation. 5. The patient s medical evaluation has been supplied to TennDent, if requested. MCO contact information is provided in the Provider Office Reference Manual, section Providers may also contact the Manager of TennDent for assistance with coordination with an MCO. TennDent will work closely and cooperatively with the MCOs to deliver dental services and identified medical services to TennCare members. To accomplish this goal The Manager of TennDent will serve as the lead for coordination of services with each MCO. The Manager of TennDent will contact each of the MCO Coordinators and provide direct access information in the event that coordination of services is needed. The Coordinators are responsible for resolving any services or problems. If the MCO and TennDent cannot resolve the issues or problems the MCO and TennDent will meet with TennCare to reach final resolution of the matters involved. Final resolution shall occur within ninety days from referral to TennCare. Coordination of a prior authorization between the MCO and TennDent will not cause a denial, delay, reduction, termination or suspension of any appropriate service to a member. The Care Coordinators will resolve any issues related to requests for authorizations within the fourteen day timeframe for standard prior authorizations and three calendar days for expedited prior authorizations. When either party receives a disputed claim for payment from a provider for an enrollee or the party believes care is the responsibility of the other party, the Claims Coordinator for that party will contact the respective Claims Coordinator of the other party with four business days of receiving such claim for payment. If the Claims coordinators are unable to reach agreement on which party is responsible for payment of the claims, the claim shall be referred to the Claims Coordination Committee for review. The Claims Coordination Committee for TennDent will consist of the Manager of TennDent and a Dental Consultant. The Claims Coordination Committee of TennDent will meet with the two members of the Claims Coordination Committee of the MCO within ten calendar days of receipt of the initial disputed claim or request from the provider. If resolution of the claim results in the party who assumed responsibility for authorization and payment having no liability, the other party will reimburse and abide by the prior decision of that party. Reimbursement will be made within ten business days of the Claims Coordination Committee s decision. If the Claim Coordination Committee cannot reach an agreement as to the prior division of financial responsibility within ten business days of the initial referral to the Claim Coordination Committee, said claim shall be referred to the Chief Executive Officers (CEO) or the CEO s designee, of both TennDent and the MCO for resolution immediately. A meeting shall be held among the CEOs or their designee(s),

4 of the parties within ten calendar days after the meeting of the Claim Coordination Committee, unless the parties agree to meet sooner. If the meeting between the CEO s or their designee(s) do not successfully resolve the dispute with ten calendar days, the parties will within fourteen days after the meeting among the CEOs or their designee(s), submit a request for resolution of the dispute to the State or the State s designee for a decision on responsibility after the service has been delivered. The process shall be completed within thirty days of receiving the claim for payment. In the event the parties cannot agree with thirty days of receiving the claim for payment, both parties will be responsible for enforcing hold harmless protection for the member and the party who first received the request or claim from the provider will be responsible for authorization and payment to the provider with the following time frames designated by the Bureau of TennCare: claims must be processed in accordance with the requirements of the MCO and TennDent s respective agreements with the State of Tennessee. The party that first received the request or claim from the provider must also make written request of all requisite documentation for payment and must provide written reasons for any denial. The Request for Resolution shall contain a concise description of the facts regarding the dispute, the applicable contract provisions, and position of the party making the request. A copy of the Request for Resolution shall also be delivered to the other party. The other party shall then submit a Response to the Request for Resolution within fifteen (15) calendar days of the date of the Request for Resolution. The Response shall contain the same information required of the Request for Resolution. Failure to timely file a Response or obtain an extension from the state shall be deemed a waiver of any objections to the Request for Resolution. The state, or its designee, shall make a decision in writing regarding who is responsible for the payment of services within ten (10) days of the receipt of the required information. The decision may reflect a split payment responsibility that will designate specific proportions to be shared by the MCO and TennDent which shall be determined solely by the State, or its designee based on specific circumstances regarding each individual case. Within five (5) business days of receipt of the Decision, the nonsuccessful party shall reimburse any payments made by the successful party for the services. The nonsuccessful party shall also pay to the state, within thirty (30) calendar days of the Decision, an administrative fee equal to ten percent (10%) of the value of the claims paid, not to exceed onethousand dollars ($1000) for each request for resolution. The amount of the Contractor s payment responsibility shall be contained in the state s Decision. These payments may be made with reservation of rights regarding any such judicial resolution. If a party fails to pay the state for the Contractor s payment responsibility as described in this section within thirty (30) calendar days of the date of the state s Decision, the state may deduct amounts of the Contractor s payment responsibility from any current or future amount owed the party. Denial, Delay, Reduction, Termination or Suspension - The parties agree that any claims payment dispute or request for authorization shall not cause a denial, delay, reduction, termination or suspension of any appropriate services to an eligible TennCare enrollee under age 21. In the event there is a claim

5 for emergency services, the party receiving a request for authorization to treat any enrollee shall insure that the enrollee is treated immediately and payment for the claim must be approved or disapproved based on the definition of emergency medical condition specified in the Provider Office Reference Manual. Emergencies - Prior authorization shall not be required for emergency services prior to stabilization. Federal law requires the emergency screenings be provided at the Emergency Department. The enrollee s MCO is responsible for payment for the screening or any medical care required to stabilize the patient. If the screening reveals that a dental problem exists, TennDent shall be notified and is responsible for providing any necessary emergency services. Services provided in accordance with the following requirements that are outside of the scope of TennDent s Contract shall be considered an MCO responsibility. Related Policies and Procedures: Coordination with Managed Care Organizations Procedure Related Documents: Coordination with Managed Care Organization Tracking Tool TennDent Provider Office Reference Manual TennCare Inpatient and Outpatient Hospital Readiness Pre-Admission Form