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DEDICATED TO THE HEALTH OF ALL CHILDREN Winner of Outstanding Chapter Award 1966, 1996, 2000 & 2004 |
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DEDICATED TO THE HEALTH OF ALL CHILDREN Winner of Outstanding Chapter Award 1966, 1996, 2000 & 2004 |
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Medicaid
Medicaid Managed Care (CMO's)
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Medicaid
General Medicaid News
What is PeachCare for Kids PeachCare for Kids began covering children in 1999, providing comprehensive health care to children through the age of 18 who do not qualify for Medicaid and live in households with incomes at or below 235% of the federal poverty level. Applying for PeachCare for Kids If you are aware of children who do not have health insurance, they may be eligible for coverage under this program. Families may call 1-877-427-3224 to request an application or complete the application online at www.peachcare.org. Physician's offices may request copies of PeachCare for Kids applications by calling the toll free number as well. Eligibility and Requirements
Visit www.peachcare.org for more information on eligibility and requirements. How much does it cost? There is no cost for children under age six. Currently, the cost per month for PeachCare for Kids coverage over age six, is $10 to $35 for one child and a maximum of $70 for two or more children living in the same household. There are no co-payments or deductibles required for benefits covered by PeachCare for Kids. If you have any questions, please call PeachCare for Kids at 1-877-427-3224. Application Assistance for Spanish Speaking Families Spanish speaking families can apply online in their native language. Information on PeachCare for Kids in Spanish is accessible at www.peachcare.org. Three Month Lock Out Peach Care for Kids members are subject to a three-month waiting period for eligibility coverage if their premiums are not received by the 1st of the following month. Example:
Also note, the waiting period for PeachCare for Kids coverage for parents who voluntarily terminate coverage of private insurance is six months. Payment Options for PeachCare for Kids There are now additional payment options available to parents of PeachCare for Kids to ensure their premiums are received timely. Members can begin paying their premiums via the following methods: 1. Telephone or Internet access using a credit or debit card 2. Automatic account withdrawal 3. Premium payment booklets for mail service Members log onto the password protected "my account" of www.peachcare.org to view their account information, pay premiums, update their contact information, check the status of premium payments and verify monthly payments. Members can also use their credit or debit cards for payment by calling (877) 427-3224.
Medicaid Managed Care - CMO's
October 1, 2009: In an effort to diminish any confusion involved in obtaining prior authorizations and referrals for out-of–network providers or access to pediatric subspecialists, the Georgia Chapter has provided its members with Medicaid CMO escalation contacts. The first list was published in August 2007 and was updated and republished October 1, 2009. Click here to view the updated document, Medicaid CMO Medical Management Escalation Process. Many members continue to have problems and issues with the Medicaid CMOs, who are entering their third year of handling the Medicaid and PeachCare programs in Georgia. While we don't have a staffer at the Chapter office dedicated solely to helping with Medicaid issues, we want to do our best to help members with these critical issues. We would ask that you email your questions/issues to medicaidquestions@gaaap.org and we will respond to them via that route. We have some of your physician leaders who can answer these questions and Chapter staff can assist in certain areas, especially on immunization or Health Check questions. The Chapter completed, in 2007, a report on Access to care for Children in the Medicaid and PeachCare programs. Both of these programs have undergone significant changes in the past two years and as such, in many instances, access to care has diminished. The study includes a survey of several Georgia communities on the availability of pediatric providers. Click here for a complete copy of the report.
Who are the Managed Care Organizations?
Centene Corporation DBA Peach State Health Plan With corporate headquarters in St. Louis, they currently operate in Indiana, Kansas, Missouri, New Jersey, Ohio, Texas and Wisconsin. You can find more information on their website at www.pshpgeorgia.com. To identify the local provider representative for your area, contact Provider Services at 1-866-874-0633.
Amerigroup Corporation Based in Virginia Beach, Virginia they operate as a Medicaid only managed care organization. They currently operate in the District of Columbia, Florida, Illinois, Maryland, New Jersey, New York and Texas. You can find more information on their website at www.amerigroupcorp.com . To identify the local provider representative for your area, contact Provider Services at 1-800-454-3730.
WellCare of Georgia, Inc. They are a provider of only government sponsored health products. They are based in Tampa, Florida and currently operate in Connecticut, Illinois, Indiana, Florida, Louisiana and New York. You can find more information on their website at www.wellcare.com. To identify the local provider representative for your area, contact Provider Services at 1-866-231-1821.
CMO Credentialing Escalation Process:
In the even you are experiencing credentialing concerns with the CMO, you can utilize the below escalation process. Please remember this should not be your first line of defense. You should always contact your CMOs area Field Representative first.
WellCare requests that you to contact your specific Regional Area Director:
Marla Gould, Regional Director (SE) 912-233-2112, ext 3601 Beth Nunnally, Regional Director (SW) 229-888-9627 Kimberly Hall, Provider Regional Manager (North) 770-532-6334, ext 3563 Doug Rodgers, Regional Director (Central) 706-324-0824, ext 0824 Tracy Smith, Provider Relation Manager (Atlanta) 678-327-0952 James Johnson, Provider Relations Manager (Atlanta) 678-327-0953
Peach State: Contact the Credentialing Coordinator at 678-556-2332
Amerigroup: contact Kiya Harrison at kharri4@amerigroupcorp.com
Checking Medicaid CMO Eligibility:
With the implementation of HB 1234 in 2008, there have been some changes to the way you verify member eligibility. Previously, you would go to the CMOs websites to determine eligibility by plan affiliation; however, due to the bill the only acceptable verification of plan affiliation for a member is via the GHP web portal. You may notice that all the CMOs have a link to the GHP web port for plan affiliation verification. You may still utilize the CMO eligibility verification for PCP assignment. The link to GHP web portal is www.ghp.georgia.gov.
Recoupment of Claims by CMOs:
Pediatricians have reported experiencing recoupment from CMOs, in some cases up to 12 months after the date of services. This may occur for a number of reasons, but the most common is the CMO that paid the claim was not the responsible payor. One of two things may occur:
1. The incorrect CMO is listed on either the GHP web portal or the CMO portal. DCH has worked diligently to minimize this problem and you should seldom see this occurrence. The CMOs have agreed to waive timely filing in these cases and are working together to ensure proper payment to providers.
2. The member has primary insurance that was not discovered until after the date of service. In these instances where the CMO is unaware of a members other insurance at the date of service and discovers other insurance after services have been rendered, DCH has instructed the CMOs to cease and decease recoupment from the provider and utilize pay and chase methods with the primary insurance. This change in policy went into effect September 2008. If you have recoupment prior to September 2008 relating to Third Party Liability, you are encouraged to appeal the claims with the primary insurance. If the denial is upheld you can utilize the individual CMOs appeals process.
Who is eligible for the Georgia Families Managed Care Program?
In June 2006 Georgia Families transitioned low-income families, children, and pregnant women, women eligible for Medicaid due to cervical cancer and PeachCare for Kids to managed care. Aged, Blind and Disabled (ABD) population and Foster Care children are not included in the managed care program at this time.
How can your patients can enroll in Georgia Families?
Maximus, the enrollment broker for GA Families, works with Medicaid members who are eligible to participate in the GF program. Members are encouraged to do the following to enroll:
1. By calling 1-888-GA-ENROLL (1-888-423-6765) 2. On line at www.georgia-families.com 3. By completing an enrollment packet and mailing it to GF 4. Attending an assisted enrollment session
Once a member has enrolled into a plan, they will have 90 calendar days to change their health plan or PCP. After the 90-day period, they will not be able to make any changes to their health plan affiliation without cause until the open enrollment period begins the following year.
To assist you and your patient in the enrollment process, there are a few thing you should know:
· Maximus has also developed a brochure and CMO comparison sheet that you can download from their website (www.georgia-families.com) for distribution to your patients in the office. · Providers can tell their patients which plans(s) they are participating with, but they cannot advise their patients’ which plan to choose. The patients need to chose a plan based on their own decision making process.
Please be reminded that CMO Medicaid members have the option during their open enrollment period (once per year) to change their CMO and PCP assignment. Open enrollment is continuous, based on the individual member’s enrollment date. Members will receive a letter from Georgia Families 30 days prior to their enrollment anniversary date. If the member does not make a choice during the 30-day window they will remain in their CMO.
Georgia Health Partnership – Fee-for-Service (FFS) Medicaid
Affiliated Computer Services (ACS) is an electronic healthcare administrative system. ACS still functions as the DCHs third party administrator for Georgia Medicaid and PeachCare for Kids that are excluded from the Georgia Families (GF) program.
GHP WebEx Trainings
For your convenience ACS offers provider trainings via the GHP web portal. Courses include, but are not limited to, Claim Voids and Adjustments, Crossover and Secondary Claims, Facility Setting Prior Authorizations, Physician Office Prior Authorizations, Understanding Provider Enrollment, the Basics of Georgia Medicaid Member Eligibility and Easy use of the GHP Web Portal. Simply click the Provider Training Information link located in the Georgia Health Partnership News section of the GHP home page (www.ghp.georgia.gov).
Your ACS field representatives are still available to assist you. Click Here to contact information for the field rep assigned to your area.
The following Manuals can be found on the GHP website:
Medicaid Provider Manual Medicaid Preferred Drug Injectable Drug List
The Medicaid Health Check (formerly EPSDT) program is Georgia’s well child preventive health care program for Medicaid-eligible children birth to 21 years of age and PeachCare-eligible children birth to 18 years of age. It is the Early and Periodic Screening, EPS component of Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program. Georgia Medicaid provides and reimburses the Diagnostic and Treatment aspect of EPSDT services under other programs (such as Laboratory, Children Intervention Services (CIS), Physicians, Hospitals, Home Health, etc).
Health Check Program is HIPAA compliant
The following are tips to guide you when billing for Health Check Services with FFS. The April 1, 2008 Health Check manual is available on the web at www.ghp.georgia.gov.
EPSDT Referral Codes- Listed below are the acronyms and descriptions of the Health Check referral codes.
In box 19 of the CMS 1500 form, document if a referral was made by indicating "N" for no or "Y" for yes. Then document one of the following:
Lead Assessment All children are required to have a blood lead test at both 12 months and 24 months of age. Lead Risk Assessments are no longer required until 3 years of age. Click here for the new lead assessment form. For Spanish version of the Lead Questionnaire, click here.
TB Risk Assessment
Please click here to view the TB Risk Assessment Form. For Spanish version of the TB Risk Assessment, click here.
Reviewing your Health Check Record Although Health Check Record Reviews are currently not available as a service through the Chapter, it is important to periodically review your charts for Health Check accuracy. The goal of the Health Check program is to make certain a child’s health needs are met through initial and periodic exams and evaluations, so that health problems are found, diagnosed and treated early.
Medicaid and PeachCare for Kids Enrollment
The quickest and easiest way to become a Medicaid and PeachCare provider would be to apply online at www.ghp.georgia.gov. Start by accessing the Provider Information Tab, under the "Enroll as an Individual" link. Once you've completed the online application, you will receive a confirmation number. Be sure to attach this confirmation number to the requested documents and mail them via certified mail to GHP.
Georgia Health
Partnership (GHP)
Each provider must enroll separately. The Effective date of enrollment will be the first day of the month in which the completed application is received by GHP or the effective date of any required license, whichever is later. If you would like an application mailed to you, call the Provider Enrollment unit at GHP, 404-298-1228, or 1-800-766-4456.
Helpful Hint: If you are mailing your application to GHP, Click Here for a Physician Services checklist, to ensure you have all the required documentation.
When adding an additional location, completing an entire application is not necessary. An abbreviated coversheet entitled "Additional Location for Individual Practitioner" is available. Click Here to print a copy of the abbreviated form.
When adding a provider to an existing group, as long as the provider already has a Georgia Medicaid number, you will only need to complete an "Additional Location (DMA-005)" form. Click Here to print a copy of this form. Be sure to write the payee number on the cover sheet. This will help link the new provider number to the group. (You will also avoid the need for and FTE or W9)
When starting your own practice, as long as the provider already has a Georgia Medicaid number, you will only need to complete an "Additional Location (DMA-005)" form. A power of attorney is also needed.
When changing information, such as telephone numbers, EPO status, etc. you will need to complete a "Change of Information Form". Click Here to print a copy of the form and instruction sheet.
Enrolling into Georgia Better Health Care (GBHC)
Enrolling into GBHC will allow a FFS member to choose you as their primary care provider. You can find application online at www.ghp.georgia.gov under the Provider Information Tab, under the "enroll as a GBHC group" link. NOTE: This process can take up to 180 days.
Enrolling into Health Check COS
In order to be a Health Check provider, you will need to first enroll into Vaccine for Children (VFC) program. You can contact them directly at (404) 657-5013 or (800) 848-3868 and ask that an enrollment package be mailed to you.
Next, you will need to enroll in Health Check category of service in order to perform well child exams. Click Here for the equipment verification form. Mail this form, along with your acceptance letter, into the VFC program to GHP.
Georgia Health
Partnership (GHP)
NOTE: Your Health Check effective date can be retro-active back to the same effective date as your VFC if necessary.
Click Here for the most Frequently Asked Questions regarding Enrollment. For questions or concerns call (404) 881-5089.
Enrolling into Care Management Organizations (CMO)
Each CMO has their own criteria for contracting and credentialing with their plan. You can go to their websites for further information on contracting with their plan. Remember…a Medicaid ID number is required to participate in the CMOs network. Medicaid ID numbers are location specific. You can obtain a Medicaid ID number by going to the GHP web portal. Once you’ve completed the application you will receive a temporary Medicaid ID number. You can simultaneously begin the credentialing process with the CMOs using the temporary Medicaid ID number. Credentialing with the CMOs can take up to 180 days, but typically only take 60.
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