SembraCare

Providers have noted in recent weeks that CCME authorizations of continued services during Medicaid appeals appeared to be getting further and further behind, resulting in excessive delays in getting paid for MOS claims during appeals.  Our investigation has determined that this occurred due to a breakdown of the MOS procedure for a period of time, because a staff member of a vendor company – whose job it was to handle appeals – went on leave, and no one was assigned to cover those responsibilities.  According to DMA, this situation has now been corrected and the backlog of work is caught up, which should mean shorter delays for MOS authorizations in the new year.

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.

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.