CCME Asks for Your Help In Updating Contact Data for Recipients

CCME posted a notice November 2, 2010 asking providers to help update contact data for recipients. Our guess is that they are finding out, the hard way, about yet another challenge which providers handle every day in providing services to their consumers. Here is the text of the announcement on QiReport:

11/2/2010 - When CCME is conducting annual assessments for recipients, we have found that many recipients have had changes to their demographic information. We may ask for your assistance to get updated recipient addresses or phone numbers. Without this information CCME may not be able to complete the annual assessments. Medicaid recipients have signed releases allowing DMA and its contractors access to their health information. CCME already has access to the recipient's personal health information, so providing addresses or phone numbers over the phone does not constitute a HIPAA violation. CCME employees who may be calling you for this information will be the Independent Assessment field nurses or our IA schedulers. They will identify themselves as CCME employees prior to requesting this updated information. If CCME is unable to contact the recipient to schedule the annual assessment the recipient will not be able to continue to receive PCS. Thanks for your cooperation.

DMA Publishes New Clinical Coverage Policies

On October 29, 2010 North Carolina Division of Medical Assistance published two new proposed Clinical Coverage Policies for In Home Care Adults (IHCA) and In Home Care Children (IHCC), which are intended to replace the existing PCS/PCS Plus program. DMA is looking to close down the existing PCS and PCS Plus programs as soon as possible after January 1, 2011. The new replacement Policies have a 45 day comment period.

The most important aspect of the new proposed policies would be the change in the minimum requirements for PCS eligibility. Under current Policy 3C, a recipient must have two ADLs assessed as needing at least limited assistance. Under the proposed new IHCA policy, recipients must have at a minimum two ADLs, of which one must be at least rated as needing extensive assistance, or a minimum of three ADLs rated as needing at least limited assistance.

The new policies may be accessed here: http://www.ncdhhs.gov/dma/mpproposed/index.htm

Fax Errors by CCME

CCME finally admitted today what providers have been saying for weeks- that fax transmissions which CCME thought it had sent to providers may not have been received due to a “fax failure”.  Also, when the provider who was supposed to have gotten the referral did not respond in 48 hours, CCME apparently did not in all cases refer the consumer to another agency.  Providers in such cases who were selected by the consumer are getting a “second chance” to accept the consumer.  The effective date that governs is the effective date stated in the most recent letter which the provider receives.
Here is the text of CCME’s announcement:

8/10/2010 - If you receive a "Second Attempt" fax from CCME, this indicates that CCME has attempted to make a referral to your agency and has not received a response. The provider agency should fax back the referral form with a response indicating whether the provider accepts or declines the PCS referral. This response must be returned to CCME within 2 business days. In some cases, providers may not have received CCME's first attempt due to a fax failure. Currently, CCME is faxing "Second Attempt" letters to providers for whom referral responses have not been received. This is to ensure that agencies have every opportunity to accept a referral before CCME forwards it to the recipient's second choice provider.
The effective date of the authorization is indicated near the bottom of the referral letter. This date varies depending on the type of independent assessment conducted (Admission, Change of Provider, etc.) and on the results of the assessment. The "Second Attempt" referral letter does not change the 10-day service authorization start period that is listed on the authorization letter. If the provider accepts the referral on the "Second Attempt" letter, the 10-day start period is effective based on the date of the authorization letter (not the referral letter). In cases where the referral letter indicates that the service authorization is effective on "the first business day following CCME's receipt of your acceptance...", this will be based on the date of the "Second Attempt" referral letter.

Important Notice for PCS Providers About CCME Errors and Fixes

DMA confirmed today that, prior to this week,  the “end dates” for Medicaid benefits from PCS recipients were calculated wrong by CCME due to a miss-communication with the programmer about what the effective end dates should be.  This error affected 100% of the 1,089 individuals who were sent cut-off letters, and was brought to DMA’s and CCME’s attention by SembraCare.

A fix has been devised and will be implemented this week, so that end dates will henceforth occur on the correct date, and not before.  SembraCare clients do not need to take further action, as we will re-bill these items for you until they pay properly.

A second and separate problem has arisen from CCME’s failure to properly note the recipients’ rights to continuance of service even though they take appeals from CCME reductions or denials of benefits.

We recently demonstrated this error to DMA and CCME as well.  In response, DMA and CCME have now established a method of restoring coverage for PCS recipients who take appeals.  According to the CCME website, authorizations will be restored by CCME without the need for further action by providers or recipients for those PCS recipients who appeal within about ten days after the appeal is lodged.  CCME is unable to get copies of recipient appeal notices in time to adjust the end dates properly and prevent a cut off, and so is having to go back and make the adjustment after the fact.  Again, SembraCare customers will not have to take action to address this issue, as we will re-bill the time for you.