GETTING NEEDED GETTING NEEDED SERVICES FROM YOUR SERVICES FROM YOUR MANAGED CARE PLANMANAGED CARE PLANWorkshop for Parents and Providers
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
Presented by: Maryland Family Access Initiative
About Parents Place of Maryland
How do we help? Education Information Technical assistance Supportive activities
About Georgetown University Center for Child and Human Development
The Center provides research, training, policy analysis and development, and technical assistance.
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
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.
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
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
Knowing What Services and Providers are Covered
Carve-Outs Medical Necessity Referrals and Authorization Process
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
Therapists
Occupational therapist (OT) Physical therapist (PT) Speech and language pathologist Vision specialist Respiratory therapist (Same process as pediatric specialist
above)
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
Other Providers
Home health agencies Medical Supply and equipment
vendors Transportation Case managers X-ray and lab
Services your child may need and those that are covered
Prevent/primary care
Specialized treatments
After hours/emergency
In-patient X-ray/lab Home-based
Medical equipment Mental health Medication Transportation
Sources of Information - 1
Member handbook Provider directory Case managers Websites Policy documents
Sources of Information - 2
Employer summaries and human resource departments
Hotlines Contact with other families Formulary listings Other?
Steps for Obtaining Services
1. Scheduling appointments2. Keeping appointments3. Obtaining referrals and authorizations4. Filling prescriptions and obtaining refills5. Requesting assistance from your MCO
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
Keep Documents and Records - 2
• Save copies ofReferralsApprovalsAuthorizationsDenials
Keep everything and throw nothing away
Keep Documents and Records - 3
• School records
• Test results
• Record all diagnoses
• Medical reports
Keep everything and throw nothing away
Strategies -1
Maintain open communication Establish relationship with PCP Know what is carved-in Know what is carved-out Learn conditions for approval
Strategies - 2
Communicate with referral providers Call member hotlines Understand how medical necessity
is determined Understand who determines
medical necessity
Strategies - 3
Appeal decisions Request second opinions Determine who is responsible for
mental health Learn how mental health access
differs from medical services
Questions and Discussion