Provider Orientation 2012 - STAR, STAR+PLUS, and CHIP

1. Provider Orientation 2012 - STAR, STAR+PLUS, and CHIP MHTPS006052012.02

2. Headline Goes Here Agenda • Molina Story • Programs • Texas Programs • Service Area • Program Overview • Members • Enrollment • Who Must Enroll • Eligibility • Program ID Cards • Benefits • Cost Sharing • Medical Transportation • Value Added Services • Rights & Responsibilities • Claims & Billing • Claims Submission • Claims Submission Requirements • LTSS Submission Requirements • Coding Edits • Newborn Claims Submission • Claims Submission Tips • Claims Payment • Electronic Fund Transfers • Providers • Contract Requirements • Provider Access & Availability • Cultural Competency • Provider Web Portal • Roles & Responsibilities • Support • Health Services • Prior Authorizations • Requesting Prior Authorizations • Prior Authorization Requirements • Case Management • Service Coordination • Pharmacy Services • Behavioral Health Services • Complaints & Appeals • Quality Improvement Program • Texas Health Steps (THSteps) • FREW Overview • Questions • Item 1 • Item 2 • Item 3

3. Headline Goes Here The Molina Healthcare Story • The Molina Story - Video • Item 1 • Item 2 • Item 3

4. Headline Goes Here • Item 1 • Item 2 • Item 3 Programs

5. Headline Goes Here Texas Programs • Item 1 • Item 2 • Item 3

6. Headline Goes Here Service Areas • Item 1 • Item 2 • Item 3 Active Molina Service Areas.

7. Headline Goes Here Program Overview • STAR – State of Texas Access Reform • The STAR program offers Medicaid services to members through a managed care system.  • STAR+PLUS • is a Texas Medicaid managed care program designed to provide health care, acute and long-term services and support through a managed care system. • CHIP • Provides low-cost insurance for children under the age of 19 whose families earn too much to qualify for Medicaid, but cannot afford private insurance. • CHIP Perinate • Is a state and federally funded CHIP program: Non-Medicaid eligible pregnant women and their Medicaid/Non-Medicaid • eligible newborns. • Item 1 • Item 2 • Item 3

8. Headline Goes Here • Item 1 • Item 2 • Item 3 Members

9. Headline Goes Here Enrollment • Item 1 • Item 2 • Item 3

10. Headline Goes Here Who Qualifies? • STAR – State of Texas Access Reform • TANF/TANF-related recipients • Pregnant Women • Children receiving Medicaid assistance only • STAR+PLUS • Mandatory • Supplemental Security Income (SSI) consumers age 21 or older • Medicaid Buy-In (MBI) • Community Based Alternatives (CBA) waiver consumers • Consumers eligible because they are in a Social Security exclusion program such as: • -Disabled Adult Children Program, and • -Widow/Widower Program. • Voluntary • SSI-eligible children (under age 21) • SSI children that do not volunteer, will be in traditional Medicaid. • Item 1 • Item 2 • Item 3

11. Headline Goes Here Who Qualifies? Continued • CHIP • Eligibility is determined by the state administrative services contractor and members are enrolled in CHIP for a continuous 12-enrollment period. During the 10th month, the member must initiate the renewal process to ensure continued enrollment. Members are encouraged to ensure that the application is successfully processed. • CHIP Perinate • The unborn children of uninsured pregnant women who are Texas residents and • Have a household income greater than 185% FPL, and at or below 200% FPL • Have a household income at or below 200% FPL, but do not qualify for Medicaid because of immigration status. • Item 1 • Item 2 • Item 3

12. Headline Goes Here Eligibility • Providers should verify eligibility before each service • Ways to verify eligibility • Molina Provider Web Portal • Molina’s Interactive Voice Response System (IVR) • 1-866-449-6849 • Monthly PCP Roster • AIS line/TXMedConnect • Calling Customer Services at: • STAR/STAR+PLUS for Bexar, Harris, Dallas, Jefferson, • El Paso, & Hidalgo1-866-449-6849 • CHIP Rural Service Area 1-877-319-6826 • Item 1 • Item 2 • Item 3

13. Headline Goes Here STAR Member ID Card • STAR Members receive two ID Cards : State issues Medicaid ID Card and Molina issues Member ID Card • Item 1 • Item 2 • Item 3

14. Headline Goes Here STAR+PLUS Member ID Card • STAR+PLUS Members receive two ID Cards: State issues Medicaid ID Card and Molina issues Member ID Card • Item 1 • Item 2 • Item 3

15. Headline Goes Here CHIP Member ID Card • CHIP Members only receive one ID Card from Molina Healthcare • Item 1 • Item 2 • Item 3

16. Headline Goes Here CHIP Perinate Member ID Card • CHIP Perinate Members only receive one ID Card from Molina Healthcare • Item 1 • Item 2 • Item 3

17. Headline Goes Here STAR Covered Services • Covered Services include, but are not limited to, Medically Necessary: • Ambulance services • Audiology services • Behavioral Health Services • Birthing services provided by a physician or Advanced Practice Nurse in a licensed birthing center • Birthing services provided by a licensed birthing center • Chiropractic services • Dialysis • Durable medical equipment and supplies • Early Childhood Intervention (ECI) services • Emergency Services • Family planning services • Home health care services • Hospital services, including inpatient and outpatient • Laboratory • Mastectomy, breast reconstruction, and related follow-up procedures • Medical checkups and Comprehensive Care Program (CCP) Services for children (birth through age 20) through the Texas Health Steps Program • Oral evaluation and fluoride varnish in the Medical Home in conjunction with Texas Health Steps • Outpatient drugs and biologicals; administered by CareMark • Drugs and biologicals provided in an inpatient setting • Podiatry • Prenatal care • Primary care services • Preventive services • Radiology, imaging, and X-rays • Specialty physician services • Therapies – physical, occupational and speech • Transplants • Vision • Item 1 • Item 2 • Item 3

18. STAR+PLUS Covered Medical Services Headline Goes Here • Covered Services include, but are not limited to, Medically Necessary: • Ambulance services • Audiology services • Behavioral Health Services • Birthing services provided by a physician or Advanced Practice Nurse in a licensed birthing center • Birthing services provided by a licensed birthing center • Cancer screening, diagnostic, and treatment • Chiropractic services • Dialysis • Durable medical equipment and supplies • Early Childhood Intervention (ECI) services • Emergency Services • Family planning services • Home health care services • Hospital services, including inpatient and outpatient • Laboratory • Mastectomy, breast reconstruction, and related follow-up procedures • Medical checkups and Comprehensive Care Program (CCP) Services for children (birth through age 20) • Oral evaluation and fluoride varnish in the Medical Home in conjunction with Texas Health Steps • Optometry, glasses, & contact lenses • Outpatient drugs and biologicals; administered by CareMark • Drugs and biologicals provided in an inpatient setting • Podiatry • Prenatal care • Primary care services • Preventive services • Radiology, imaging, and X-rays • Specialty physician services • Therapies – physical, occupational and speech • Transplants • Vision • Item 1 • Item 2 • Item 3

19. STAR+PLUS Covered Long Term Care Services Headline Goes Here • Covered Services include, but are not limited to, Medically Necessary: • Day Activity and Health Services (DAHS) • Personal Assistance Services (PAS) • Home Delivery Meals • Adaptive Aids • Adult Foster Care Home Services • Adult Day Care Services • Assisted Living • Emergency Response Services • Medical Supplies • Minor Home Modifications • Nursing Services • Respite Care (short-term supervision) • Therapies (occupational, physical and speech) • Item 1 • Item 2 • Item 3

20. Headline Goes Here CHIP Covered Services • Covered Services include, but are not limited to, Medically Necessary: • Inpatient General Acute and Inpatient Rehabilitation Hospital Services • Skilled Nursing Facilities (Including Rehabilitation Hospitals) • Outpatient Hospital, Comprehensive Rehabilitation Hospital, Clinic and Ambulatory Health Care Center • Physician / Physician Extenders Professional Services • Durable Medical Equipment (DME), Prosthetic Devices and Disposable Medical Supplies • Home and Community Health Services • Inpatient Mental Health Services • Outpatient Mental Health Services • Inpatient Substance Abuse Treatment Services • Outpatient Substance Abuse Treatment Services • Rehabilitation Services • Hospice Care Services • Emergency Services, including Emergency Hospitals, and Ambulance Services • Transplants • Vision Benefits • Chiropractic Services • Tobacco Cessation Program • Case Management and Care Coordination Services • Drug Benefits, administered by CareMark • There is no lifetime maximum on benefits; however, 12-month period or lifetime limitations do apply to certain services. Co-pays apply until a family reaches its specific cost-sharing maximum. • Item 1 • Item 2 • Item 3

21. Headline Goes Here CHIP Perinate Covered Services • Covered Services include, but are not limited to, Medically Necessary: • Inpatient General Acute and Inpatient Rehabilitation Hospital Services • Outpatient Hospital, Comprehensive Rehabilitation Hospital, Clinic and Ambulatory Health Care Center • Physician / Physician Extenders Professional Services • Prenatal Care and Pre-Pregnancy Family Services and Supplies • Emergency Services, including Emergency Hospitals, and Ambulance Services • Case Management and Care Coordination Services • There is no lifetime maximum on benefits; however, 12-month enrollment period or lifetime limitations do apply to certain services. Co-pays do not apply to CHIP Perinate Members. CHIP Perinate Newborns are eligible for 12-months continuous coverage, beginning with the month of enrollment as a CHIP Perinate. • Item 1 • Item 2 • Item 3

22. Headline Goes Here CHIP Cost Sharing • Co-pay amounts vary from $0 to $100 based on Federal Poverty Levels (FPL) and type of service • Co-pay amounts can be found: • On Member’s ID Card • By contacting Customer Service • Upon meeting cost-sharing limits the Member must contact Maximus to report they have reached their maximum out of pocket • Maximus will notify Molina Healthcare of cost-sharing limit being met. • Molina Healthcare will re-issue the Member a new Member ID Card, indicating no co-pay amount ($0) • Federal law prohibits charging premiums, deductibles, coinsurance, copayments, or any other cost-sharing to Native American or Alaskan Natives Members. • Item 1 • Item 2 • Item 3

23. Headline Goes Here Medical Transportation • The Medical Transportation Program (MTP) is provided by HHSC • To get a ride or learn more call: (Monday – Friday, 8 a.m. to 5 p.m.) • 1-877-633-8747; 1-877-MED-TRIP • TTY: 1-800-735-2989 • Medicaid and Children with Special Health Care Needs (CSHCN) Services Program can receive transportation services to get to and from a provider, dentist, hospital or pharmacy. HHSC will: • Help coordinate a ride or assist • Pay for a bus ride or ride sharing service • Pay a friend or relative by the mile for the round trip • Provide gas money directly to the Member/parent /guardian • Item 1 • Item 2 • Item 3

24. Value Added Services Effective September 1, 2012 Headline Goes Here • Item 1 • Item 2 • Item 3

25. Value Added Services Continued Effective September 1, 2012 Headline Goes Here • Item 1 • Item 2 • Item 3

26. Value Added Services Continued Effective September 1, 2012 Headline Goes Here • Item 1 • Item 2 • Item 3

27. Headline Goes Here Member Rights • You have the right to respect, dignity, privacy, confidentiality and nondiscrimination. That includes the right to: • Be treated fairly and with respect. • Know that your medical records and discussions with your providers will be kept private and confidential. • You have the right to a reasonable opportunity to choose a health care plan and primary care provider. This is the doctor or health care provider you will see most of the time and who will coordinate your care. You have the right to change to another plan or provider in a reasonably easy manner. That includes the right to: • Be told how to choose and change your health plan and your primary care provider. • Choose any health plan you want that is available in your area and choose your primary care provider from that plan. • Change your primary care provider. • Change your health plan without penalty. • Be told how to change your health plan or your primary care provider. • You have the right to ask questions and get answers about anything you do not understand. That includes the right to: • Have your provider explain your health care needs to you and talk to you about the different ways your health care problems can be treated. • Be told why care or services were denied and not given. • You have the right to agree to or refuse treatment and actively participate in treatment decisions. That includes the right to: • Work as part of a team with your provider in deciding what health care is best for you. • Say yes or no to the care recommended by your provider. • Item 1 • Item 2 • Item 3

28. Headline Goes Here Member Rights Continued • You have the right to use each complaint and appeal process available through the managed care organization and through Medicaid, and get a timely response to complaints, appeals and fair hearings. That includes the right to: • Make a complaint to your health plan or to the state Medicaid program about your health care, your provider or your health plan. • Get a timely answer to your complaint. • Use the plan’s appeal process and be told how to use it. • Ask for a fair hearing from the state Medicaid program and get information about how that process works. • You have the right to timely access to care that does not have any communication or physical access barriers. That includes the right to: • Have telephone access to a medical professional 24 hours a day, 7 days a week to get any emergency or urgent care you need. • Get medical care in a timely manner. • Be able to get in and out of a health care provider’s office. This includes barrier free access for people with disabilities or other conditions that limit mobility, in accordance with the Americans with Disabilities Act. • Have interpreters, if needed, during appointments with your providers and when talking to your health plan. Interpreters include people who can speak in your native language, help someone with a disability, or help you understand the information. • Be given information you can understand about your health plan rules, including the health care services you can get and how to get them. • You have the right to not be restrained or secluded when it is for someone else’s convenience, or is meant to force you to do something you do not want to do, or is to punish you. • You have a right to know that doctors, hospitals, and others who care for you can advise you about your health status, medical care, and treatment.  Your health plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service. • You have a right to know that you are not responsible for paying for covered services.  Doctors, hospitals, and others cannot require you to pay copayments or any other amounts for covered services. • Item 1 • Item 2 • Item 3

29. Headline Goes Here Member Responsibilities • You must learn and understand each right you have under the Medicaid program. That includes the responsibility to: • Learn and understand your rights under the Medicaid program. • Ask questions if you do not understand your rights. • Learn what choices of health plans are available in your area. • You must abide by the health plan’s and Medicaid’s policies and procedures. That includes the responsibility to: • Learn and follow your health plan’s rules and Medicaid rules. • Choose your health plan and a primary care provider quickly. • Make any changes in your health plan and primary care provider in the ways established by Medicaid and by the health plan. • Keep your scheduled appointments. • Cancel appointments in advance when you cannot keep them. • Always contact your primary care provider first for your non-emergency medical needs. • Be sure you have approval from your primary care provider before going to a specialist. • Understand when you should and should not go to the emergency room. • You must share information about your health with your primary care provider and learn about service and treatment options. That includes the responsibility to: • Tell your primary care provider about your health. • Talk to your providers about your health care needs and ask questions about the different ways your health care problems can be treated. • Help your providers get your medical records. • Item 1 • Item 2 • Item 3

30. Headline Goes Here Member Responsibilities Continued • You must be involved in decisions relating to service and treatment options, make personal choices, and take action to keep yourself healthy. That includes the responsibility to: • Work as a team with your provider in deciding what health care is best for you. • Understand how the things you do can affect your health. • Do the best you can to stay healthy. • Treat providers and staff with respect. • Talk to your provider about all of your medications. • Item 1 • Item 2 • Item 3

31. Headline Goes Here • Item 1 • Item 2 • Item 3 Claims & Billing

32. Headline Goes Here Claims Submission • Timely filing of claims is 95 days from the date of service • Methods for submitting claims: • Electronic Submission • Approved vendors: • EMDEON • Payor ID for all - 20554 • Molina Provider Web Portal • Paper - P.O. Box 22719 ∙ Long Beach, CA 90801 • TMHP Single Source Portal • A request for correction or adjustment must be submitted within 120 days from denial date shown on original Explanation of Payment (EOP) or Remittance Advise (RA) • Members may not be balance billed for any Covered Services • May collect any Member Co-pays, or • Payment for non-covered services, only with Member acknowledgement statement • Item 1 • Item 2 • Item 3

33. Headline Goes Here Claims Submission Requirements • Use standard, nationally recognized codes: • CPT Codes • HCPCS • Revenue Code • Modifiers when appropriate • ICD-9 • NDC as required by TMHP http://www.tmhp.com/Pages/Topics/NDC.aspx • POA as required by TMHP http://www.tmhp.com/News_Items/2010/08-13-10%20Present%20on%20Admission%20Reporting.pdf • Covered Services and codes our outlined in Texas Medicaid Provider Manual • Claims must contain following provider identification numbers: • National Provider Identification (NPI) attested on the TMHP Master Provider File • EPSDT Texas Provider Identification (TPI) when billing THStep services • LTSS provider may have an API • Both billing provider NPI and rendering provider’s NPI are required on claims • Item 1 • Item 2 • Item 3

34. Headline Goes Here LTSS Submission Requirements • LTSS Payment Matrix – • Item 1 • Item 2 • Item 3

35. Verisk Health fka HealthCare Insight (HCI) Headline Goes Here • Molina’s Claims editing service partner through September 4, 2012: • The code editing rules used by HCI are industry standard rules and guidelines as published and defined in CPT and by CMS, such as National Correct Coding Initiative edits. These edits are used by most, if not all health care claims payers in the United States. • HCI coding edits help identify: • Nationally recognized Fraud, Waste and Abuse billing patterns • Unbundled and fragmented billings • Other common billing errors such as duplicate billings • Benefits of using HCI: • Control healthcare costs in CMS Medicare/Medicaid programs • Creates consistent and equitable reimbursement for all billing providers • Edits applied: • Currently applied post payment • Effective July 1, 2012 edits will be applied pre-payment • Effective September 4, 2012 Molina Healthcare will manage all coding edits • Item 1 • Item 2 • Item 3

36. Headline Goes Here Billing Maternity Claims • Delivery charges should be billed with the appropriate CPT codes: • 59409 & 59410 = Vaginal Delivery • 59514 & 59515 = C-Section • Delivery Codes must be billed with one of the following modifiers (59409, 59410, 59514, 59515, 59612,59614, 59620, or 59622): • U1 – Medically necessary delivery prior to 39 weeks of gestation • U2 – Delivery at 39 weeks of gestation or later • U3 – Non-medically necessary delivery prior to 39 weeks of gestation • 59430-TH = Postpartum Care after discharge • Item 1 • Item 2 • Item 3

37. Headline Goes Here Newborn Claims Submission • Routine Newborn Care - STAR: • Initial care should be billed under the Mother’s Medicaid Number (PCN), or identification number, for the first 90 calendar days • Routine Newborn Care - CHIP: • Newborns are not automatically eligible • Mother must apply for baby’s coverage • Routine Newborn Care - CHIP Perinate: • Newborns are automatically eligible • Issued their own Medicaid identification number • Item 1 • Item 2 • Item 3

38. Headline Goes Here Claims Submission Tips • Report services performed correctly • Reporting the most comprehensive CPT code that describes the services performed – do not unbundle and do not fragment a procedure into component parts. • Use appropriate modifiers and condition indicators, when appropriate • Use age and gender appropriate codes. • Report units correctly • Avoid downcoding or up coding • Make sure you are billing with the correct NPI/Tax ID/TPI combination that is attested to with Medicaid/TMHP. • Claims must contain following provider identification numbers: • National Provider Identification (NPI) attested on the TMHP Master Provider File • EPSDT Texas Provider Identification (TPI) when billing THStep services • LTSS provider may have an API • Claims billed with a Group or Clinic NPI should also include the rendering provider’s NPI • Item 1 • Item 2 • Item 3

39. Claims Payment Headline Goes Here • Claims Payment Timeline: • Molina has up to 30 days to pay all clean claims • Claim is submitted in the correct format and contains all of the elements required to adjudicate the claim. • On average claims submitted electronically are paid in 9 days • On average paper claims are paid in 14 days • Payment Methods • Paper or Live Check • Electronic Fund Transfers (EFT) • Item 1 • Item 2 • Item 3

40. Electronic Fund Transfers (EFT) Headline Goes Here • FIS ProviderNet • To Register, go to: • https://providernet.adminisource.com/ • Customer Service during registration process • Provider.Services@fisglobal.com or • 1-877-389-1160 • Elements required to Register for EFT/ERA (Electronic Funds Transfer and Electronic Remit Advice) • Internet access • Valid email address • NPI • Tax ID • Mailing address as reflected on recent EOP (Explanation of Payment) • Recent Molina Healthcare Check Number • Bank information, including account and routing numbers • Item 1 • Item 2 • Item 3

41. Electronic Fund Transfers (EFT) Contact Information Headline Goes Here • Molina ERA/EFT Contact information: • Customer Service Phone Number: (866) 409-2935 • Customer Service email: EDI-eraeft@MolinaHealthcare.com • Website, direct link to EDI page: • http://www.molinahealthcare.com/medicaid/providers/common/edi/Pages/home.aspx • Item 1 • Item 2 • Item 3

42. Headline Goes Here • Item 1 • Item 2 • Item 3 Providers

43. Contract Requirements – Behavioral Health Headline Goes Here • To the extent Provider is a primary care physician: • Provider shall have screening and evaluation procedures for detection and treatment of, or referral for, any known or suspected behavioral health problems and disorders. (UMCC Att. B-1, §8.1.15.4.) • To the extent Provider provides inpatient psychiatric services: Provider shall schedule Members for outpatient follow-up and/or continuing treatment prior to discharge. The outpatient treatment must occur within seven days from the date of discharge. Behavioral health providers must contact Members who have missed appointments within twenty-four (24) hours to reschedule appointments. (UMCC Att. B-1,§8.1.15.5.) • Item 1 • Item 2 • Item 3

44. Contract Requirements – Early Childhood Intervention (ECI) Headline Goes Here • Providers must cooperate and coordinate with local Early Childhood Intervention (ECI) programs to comply with federal and state requirements relating to the development, review and evaluation of Individual Family Service Plans (IFSP). • Provider understands and agrees that any Medically Necessary health and behavioral health services contained in an IFSP must be provided to the Member in the amount, duration, scope and setting established in the IFSP. (UMCC Att. B-1, §8.1.9.) • Item 1 • Item 2 • Item 3

45. Contract Requirements – Family Planning Headline Goes Here • If a Member requests contraceptive services or family planning services, Provider must also provide the Member counseling and education about family planning and available family planning services. • Provider shall not require parental consent for Members who are minors to receive family planning services. • Provider shall comply with state and federal laws and regulations governing Member confidentiality (including minors) when providing information on family planning services to Members. (UMCC Att. B-1, §8.2.2.2.) • Item 1 • Item 2 • Item 3

46. Contract Requirements – Liability Headline Goes Here • In the event Health Plan becomes insolvent or ceases operations, Provider understands and agrees that its sole recourse against Health Plan will be through the Health Plan’s bankruptcy, conservatorship, or receivership estate. (UMCC Att. A, §4.05(f).) • Provider understands and agrees that the Health Plan’s Members may not be held liable for the Health Plan’s debts in the event of the entity’s insolvency. (UMCM, Ch 8.1, 37) • Provider understands and agrees that HHSC does not assume liability for the actions of, or judgments rendered against, Health Plan, its employees, agents or subcontractors. Further, Provider understands and agrees that there is no right of subrogation, contribution, or indemnification against HHSC for any duty owed to Provider by the Health Plan or any judgment rendered against the Health Plan. HHSC’s liability to Provider, if any, will be governed by the Texas Tort Claims Act, as amended or modified (Tex. Civ. Pract. & Rem. Code §101.001 et seq.). (UMCC Att. A, §4.05(f).) • Item 1 • Item 2 • Item 3

47. Contract Requirements – Marketing Headline Goes Here • Marketing. Provider agrees to comply with HHSC’s marketing policies and procedures, as set forth in the UMCC (which includes UMCM). (UMCC Att. B-1, §8.1.6, UMCM, Ch. 4.) • Provider is prohibited from engaging in direct marketing to enrollees that is designed to increase enrollment in a particular health plan. The prohibition should not constrain Providers from engaging in permissible marketing activities consistent with broad outreach objectives and application assistance. (UMCC Att. B-1, §8.1.6, UMCM Ch. 4.) • Item 1 • Item 2 • Item 3

48. Contract Requirements – Medicaid Provider Agreement Headline Goes Here • Acute care providers serving Medicaid Members must enter into and maintain a Medicaid provider agreement with HHSC or its agent to participate in the Medicaid Program, and must have a Texas Provider Identification Number (TPIN). • All Providers, both CHIP and Medicaid, must have a National Provider Identifier (NPI) in accordance with the timelines established in 45 C.F.R. Part 162, Subpart D (for most Providers, the NPI must be in place by May 23, 2007.) (UMCC Att. B-1, §8.1.4.) • Item 1 • Item 2 • Item 3

49. Contract Requirements – Member Communications Headline Goes Here • Health Plan is prohibited from imposing restrictions upon Provider’s free communication with a Member about the Member’s medical conditions, treatment options, Health Plan referral policies, and other Health Plan policies, including financial incentives or arrangements and all managed care plans with whom Provider contracts. (UMCC Att. A, §7.02, and BBA §438.102.) • Item 1 • Item 2 • Item 3

50. Contract Requirements – Primary Care Physicians(PCPs) Headline Goes Here • To the extent Provider is a primary care physician: • Provider shall be accessible to Members 24 hours per day, 7 days per week. (UMCC Att. B-1, §8.1.4.) • Provider shall provide preventative care • to children under age 21 in accordance with AAP recommendations for CHIP Members and the THSteps periodicity schedule published in the THSteps Manual for Medicaid Members; and • (ii) to adults in accordance with the U.S. Preventative Task Force requirements. (UMCC Att. B-1, §8.1.4.2.) • Provider shall assess the medical needs and behavioral health needs of Members for referral to specialty care providers and provide referrals as needed. PCPs must coordinate Members’ care with specialty care providers after referral. (UMCC Att. B-1, §8.1.4.2.) • Item 1 • Item 2 • Item 3