final tpa presentation pco 21210

8/6/2019 Final TPA Presentation PCO 21210

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Welcome

Thank you for taking time out of your busy schedule!


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Molina Healthcare of New Mexico, Inc. Third Party Assessor

(Molina Healthcare TPA) Introductions

OUR MOLINA HEALTHCARE TEAM

Provider Services:

Karen Bounds, Director, Provider Services

Denise Henry, Manager, Provider Services

Aracely Pena, Provider Services Representative

Diego Gutierrez, Provider Services Representative

Launa Markel, Provider Services Representative

LaDawnaKing, Provider Services Representative

Utilization Management:

Patty Kehoe RN, Director, Healthcare Services

Gina Burttram RN, TPA Manager

Kim Shipman, Supervisor, Mi Via , EMSA & PCO


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Who Is Molina? Founded more than 20 years ago by C. David Molina, MD. Since 1980 Molina Healthcare

has been a leader in providing quality healthcare to those who depend on government

assistance. Our commitment to our consumers has made us a national leader in providing

affordable healthcare to families and individuals. During this time, weve become one of the

most experienced managed healthcare companies in the country.

Molina Healthcare Inc., is among the most experienced managed healthcare companies

serving patients who have traditionally faced barriers to quality healthcareincluding

individuals covered under Medicaid, the Healthy Families Program, the State Childrens Health

Insurance Program (SCHIP) and other government-sponsored health insurance programs.

Molina has health plans in California, Florida, Michigan, Missouri, New Mexico, Ohio, Texas,

Utah and Washington as well as 21 primary care clinics located in Northern and Southern

California and additional clinics in Virginia. The companys corporate headquarters are in Long

Beach, California.

Serving approximately 96,000 (Salud, SCI & SCI/UNMCI) consumers in New Mexico.

Serving as the Medicaid Third-Party Assessor for certain fee-for-service, home and

community-based and long-term care programs.


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What We Do

Molina Healthcares mission is to serve low-income

populations and those who have traditionally faced

barriers to quality of health care.

Molina Healthcares Utilization Management Department:

Performs utilization review and third-party assessment functions under the

Third-Party Assessor contract with the New Mexico Human Services

Department/Medical Assistance Division (HSD/MAD)

Participates in provider training sessions. Offers customer service assistance.

Participates in development of clinically-based criteria.

Makes recommendations to HSD/MAD for enhancements to programs.

Serves as a resource to providers throughout New Mexico.


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Who To Contact Molina Healthcare TPA Fax Requests

Monday through Friday (except holidays): 8:00 a.m. 5:00 p.m.

Dedicated fax lines: Toll Free Fax: (866)553-9359 (866)553-9268 and (866)553-9272.

Please provide specific information on waiver type (i.e. DD, Mi Via, etc.) with review request.

Molina Customer Service Check status of review requests

Monday through Friday (except holidays): 8:00 a.m. 5:00 p.m. Telephone: (505) 348-0311

Toll Free Telephone: (866) 916-3250

ACS Verify consumer Eligibility & Claim Status Telephone: (505) 246-2056

Toll Free Telephone: (800) 705-4452

Molina Healthcare TPA Website UR Instructions, Training Materials & Frequently AskedQuestions www.MolinaHealthcare.com


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What is Personal Care Option (PCO)?

This is a program designed to assist Medicaid eligible consumers

age 21 and older to obtain non-skilled assistance at home with

activities of daily living (ADLs.) The need for assistance is

reviewed by Molina Healthcare TPA using medical criteria. The

applicant must meet the criteria for low or high nursing facilitylevel of care. PCO services provide an alternative to being placed

in a nursing facility.

The PCO program offers a range of services to consumers who are

unable to perform some or all activities of daily living because of a

disability or functional limitation(s). POC Services include: Individualized bowel and bladder services,

meal preparation and assistance, support services,

hygiene/grooming, minor maintenance of assistive devices,

mobility assistance, eating, assisting with self-administered

medication, skin care, cognitive assistance and household services.


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Option because consumers have an option of two

different service delivery models:

Consumer-Delegated

Consumer-Directed


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Consumer-Delegated: This model is ideal for consumers who do not want to or are

not able to direct their own care.

The Consumer:

Delegates the delivery of services to the Medicaid approvedprovider PCO Agency.

PCO Agency Is Responsible for: Advertising and recruiting prospective attendants,

interviewing, hiring, firing and training according to programregulation. (See MAD Regulation 8.315.4.11, Section B)

Quality assurance and is expected to closely monitor theconsumers services through monthly supervisory home visits.

PCO Directory:http://www.nmaging.state.nm.us/PCO_Program.html


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Consumer-Directed: This model is ideal for consumers want to and are able to

direct their own care.

The Consumer: Advertises and recruits prospective attendant(s), interviews,

hires, fires and trains according to program regulation. (SeeMAD Regulation 8.3154.10, Section A for specifics onConsumer Directed Personal Care)

PCO Agency Is Responsible for: Working with the consumer and acting as the fiscal

intermediary. PCO Directory:

http://www.nmaging.state.nm.us/PCO_Program.html

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Consumer Eligibility Requirements

Must have full Medicaid benefits

Must be 21 years of age and over If not yet 21, submit a Medical Assessment Form (MAD 075)

90 days prior to the birthday of turning 21.

Must meet the medical criteria requirements.


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Molina Healthcare TPA Process for New

PCO Consumers Not in CoLTS:

Consumer calls Molina Healthcare TPA at 1-866-

916-3250.

Consumer receives packet in the mail with Molina

Healthcare TPAs contact information/instructions

& a blank MAD 075.

Consumer takes MAD 075 to physician to complete;mails/faxes MAD 075 to Molina Healthcare TPA.

Molina Healthcare TPA staff review the MAD 075

for completeness.13


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Molina Healthcare TPA Process for NewPCO Consumers Not in CoLTS-cont.

If the MAD 075 is incomplete, Molina Healthcare

TPA will fax it back to the physician indicating

what sections need to be completed.

If the MAD 075 indicates that the consumer meets

initial criteria, Molina Healthcare TPA will assign

an independent assessor to perform an in-homeassessment.

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If the MAD 075 indicates consumer does not meet

criteria, Molina Healthcare TPA will issue a denial

letter to the consumer (and send a copy to PCO

agency, if known).

At the in-home assessment, the assessor explains

the program and both service delivery models toconsumer.

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Molina Healthcare TPA Process for New PCOConsumers Not in CoLTS-cont.

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Molina Healthcare TPA staff reviews the results of

the independent assessment to determine if theconsumer meets nursing facility level of care (LOC).

If the consumer does meet the level of care, Molina

Healthcare TPA will issue an eligibility letter to theconsumer and will fax back to the PCO agency the

MAD 075 approving a 75 day temporary

authorization.


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The MAD 075 will include the authorization

number from Omnicaid, the time period, andUnits/Hrs approved (dependent on whether

delegated or directed).

If the consumer does not meet LOC, Molina

Healthcare TPA will issue a denial letter to the

consumer (and send a copy to PCO agency, if

known).

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Molina Healthcare TPA Process for NewPCO Consumers In CoLTS

MCO sends MAD 075 and in-home assessment to

Molina Healthcare TPA. Molina Healthcare TPA reviews submission of the

assessment and MAD 075 and determines LOC.

If the consumer does not meet LOC, Molina Healthcare

TPA will issue a denial letter to the MCO, consumer(and PCO agency, if known).

If the consumer does meet LOC, Molina Healthcare

TPA notifies MCO of approval by faxing MAD 075

with the authorization number and LOC span. 18


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Molina Healthcare TPA Process for NewPCO Consumers In CoLTS-cont.

MCO assigns number of hours and sends

authorization information to PCO Agency andconsumer.

PCO Agency develops service plan with the

consumer.

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The completed MAD 075 will be sent to

Molina Healthcare TPA by the MCO. Molina Healthcare TPA will return the

MAD 075 form if received directly from a

PCO agency for a consumer enrolled with

an MCO.


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Annual Re-assessments

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Re-assessment Process

Consumer receives a letter from the MCO contactwith information and blank MAD 075.

Consumer mails/faxes completed MAD 075 toMCO to review within 30 days of receiving MAD075.

MCO contacts consumer to schedule in-homeassessment.

MCO conducts in-home assessment. MCO sends MAD 075 and assessment to Molina

Healthcare TPA.

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Re-assessment Process-cont. Molina Healthcare TPA reviews submission of the

assessment and MAD 075 and determines LOC.

If the consumer does not meet LOC, Molina Healthcare

TPA will issue a denial letter to the MCO, consumerand PCO agency.

If the consumer does meet LOC, Molina Healthcare

TPA notifies MCO of approval by faxing MAD 075

with the authorization number and LOC span. MCO authorizes services and informs the PCO Agency and

consumer.

PCO Agency receives prior authorization from the MCO and

uses the information received to create a service plan with the

consumer. 23


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Re-review

Reconsideration

Fair Hearing


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Re-review

The request must be received by Molina Healthcare TPA

within 10 calendar days from the date on the denial letter.

No additional medical/clinical information is required.

For non-CoLTS consumers, the request must be made

by the physician.

For CoLTS enrollees, the request must be made by the

MCO.

Molina Healthcare TPA has 15 days to reply to the Re-review request.


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Reconsideration

The request must be received by Molina

Healthcare TPA within 30 calendar days from the

date of the initial or re-review denial.

The request must have additional medical/clinical

information (that is different from the initialinformation submitted) in order to meet the

requirements for the reconsideration.


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Fair Hearing

This request is administered through the HSD Fair

Hearings Bureau.

This is the appeal process that an applicant orrecipient may utilize either after the re-review and

reconsideration processes have been exhausted, or

in lieu of the re-review or reconsideration process.

Consumer has 13 days from date of denial letter tonotify Molina Healthcare TPA of request for

continuation of care.


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Continuation of Benefits

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If you are now receiving services that have been denied, in order

to continue to receive the same Medicaid services while the

hearing process goes forward, the request for a Fair Hearing

must be received by the HSD Hearings Bureau, your local

Income Support Division office or the Medical Assistance

Division no later than the close of business on the thirteenth

(13th) calendar day from the date on this notice.

If you ask for a hearing within the thirteen (13) calendar daysand continue to receive the same Medicaid services but the final

hearing decision favors HSD or the contractor, you will have to

repay HSD for the cost of those services (8.352.2.13 (B) (2)

NMAC).


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Q. What information should I have ready when I

call Molina Healthcare TPA Customer Services

regarding status of a prior authorization request?A. You will need to provide:

FAQS

Recipient number, name and date of birth;

Your provider name and number or NPI;

The date the request was sent to us; and Item(s) or service(s) requested.


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FAQS Cont.

Q. How will I be notified when my request for

prior approval has been completed?

A. The form you submitted for the Prior Approval

Review Request will be faxed back to you with

Molina Healthcare TPAs PA number.

Q. Can a consumer in a nursing home transfer to

Medicaid Personal Care Options viaCommunity Integration?

A. Yes, if they are eligible for full Medicaid and

have received a community integration

allocation.


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FAQS Cont.

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Q. If a consumer is not 21 years of age what

alternatives are there?A. The New Mexico Medicaid program (Medicaid) pays

for medically necessary personal care servicesfurnished to eligible recipients under 21 years of ageas part of the Early and periodic Screening, Diagnosticand Treatment (EPSDT) program. (NMAC 8.323.2

EPSDT PERSONAL CARE SERVICES)


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FAQS Cont.

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Q. If a consumer is receiving Medicare can they

receive Medicaid Personal Care?A. Yes, if they are on an eligible full MedicaidCategory

Q. Can a Personal Care Attendant be the

consumers spouse?A. No


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final tpa presentation pco 21210

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