BCBS Secure Blue--MSHO BluePlus PMAP MN Senior Care For Kandiyohi County Public Health & Kandiyohi County Family Services----August 2006 Presented by Annette.

Case Manager: Personal Care Attendant

(PCA) Learning ModuleBCBS Secure Blue--MSHO

BluePlus PMAPMN Senior Care

For Kandiyohi County Public Health & Kandiyohi County Family Services----August 2006

Presented by Annette Sietsema, RN, BANKandiyohi County Public Health Nurse/Case Manager

BCBS Members Affected

•BluePlus PMAP Members•(population under age 65)

•Minnesota Senior Care•(PMAP over age 65)

•Secure Blue Members

Kandiyohi County Public Health & Kandiyohi County Family Services

Legislative (2005) Changes

to the PCA Program•A “Statement of Need” for PCA services•“PCA Flexible Use Agreement”•New documentation requirements*•PCA individual provider numbers required*

*The CM does not facilitate these areas


PCA Referral ProcessEach program is slightly different.

It is the FIRST step of each plan that is unique in its application.

All subsequent steps for each plan are identical thereafter.


It all begins with a phone call…

Who you gonna’ call?• No not the Ghost Busters• In fact YOU don’t have to call anyone

• It is now the responsibility of the PCA Provider to make the first contact


So who does the PCA provider call?

It is different for each type of BCBS plan…

Does the provider know that they need to make the first call?

Does the provider know who they have to call?

“I’m the case manager what am I suppose to do?”


Your new titles will be: EducatorAdvocate

Collaborator"Case Management in Hospital/Health Care Systems is a collaborative practice model including patients, nurses, social workers, physicians,

other practitioners, caregivers and the community. The Case Management process encompasses communication and facilitates care

along a continuum through effective resource coordination. The goals of Case Management include the achievement of optimal health, access to care and appropriate utilization of resources, balanced with the patient's

right to self determination.“http://www.acmaweb.org


Educating the ProviderYou will play an important role in facilitating the initiation of PCA services for your clients. Much of what you will be

doing will support and educate providers as we all begin this new (and somewhat cumbersome) process.


STEP #1We will examine Step #1 of each program separately

(With great anticipation & bated breath…)


Step #1: Blue Plus PMAPPRIOR to rendering PCA services to a BCBS MN Public Programs member

—PROVIDERS must contact the member’s individual case manager:

CALL: 651-662-5520

1-888-878-0139


Step #1: MN Senior CarePRIOR to rendering PCA services to a BCBS MN Public Programs member

—PROVIDERS must contact the member’s individual case manager.CALL SENIOR PUBLIC PROGRAMS INTAKE @

651-662-55401-800-711-9868


Step #1: Secure Blue--MSHO

PRIOR to rendering PCA services to a BCBS MN Public Programs member—PROVIDERS must contact the member’s County Care Coordinator. If the PROVIDER does not know who the County CM

is they may contact Sr. Public Programs Intake for assistance in locating the member’s county care coordinator.

CALL SENIOR PUBLIC PROGRAMS INTAKE @651-662-5540

1-800-711-9868


Steps Two, Three, Four & Five

For all three BCBS programs the subsequent steps are identical...


Step #2An assessment of the member’s need for PCA services will be completed by a PHN, EW Case Manager or County Care

Coordinator.


Step #3A BCBS Case Manager (not us!) will submit the Statement

of Need to the member’s primary care clinic after the assessment has been completed.



Step #4The members primary care provider will review and order

PCA services (a Nurse Practitioner is also qualified to do this)

The practitioner is to return the form to BCBS within 24 hours.

Step #5The BCBS Case Manager will forward a copy of the

completed Statement of Need with the determination letter issued to the PCA provider and the member


A closer look…at Secure Blue/MSHO

The County Care Manager (us) responsibility once the Provider has requested PCA services….

1. Verify the need—you may need to make a home visit2. Call Secure Blue (Bobbi Cooper)3. Remind the PCA agency about the new process for PCA

authorization of need4. Update the CSP and fax to Secure Blue5. Discuss “Flexible Use” option with client and fax

completed form to Secure Blue—remember to obtain signature

6. (if BCBS does not receive the form they will assume that the PCA hours will be flexed month to month.


Flexible Use Optionhttp://www.bluecrossmn.com/bc/wcs/groups/bcbsmn/@mbc_bluecrossmn/documents/public/post71a_080647.pdf


http://www.bluecrossmn.com/bc/wcs/groups/bcbsmn/@mbc_bluecrossmn/documents/public/post71a_080647.pdf


A few words from Deb Floren


Questions/Comments Are we in love yet?...


Closing ThoughtsAny fool can make things bigger, more

complex and more violent. It takes a touch of genius—and a lot of courage

—to move in the opposite direction.~Albert Einstein


ReferenceBCBS (2006). Legislative changes to PCA program. BCBS Provider Bulletin. As found at: http://www.bluecrossmn.com/bc/wcs/groups/bcbsmn/@mbc_bluecrossmn/documents/public/post71a_080647.pdf





BCBS Secure Blue--MSHO BluePlus PMAP MN Senior Care For Kandiyohi County Public Health & Kandiyohi County Family Services----August 2006 Presented by Annette.

Documents

pca provider

senior public programs

initiation of pca services

achievement of optimal

case management process

pca programa statement

goals of case management

mn senior careprior