Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL)
Chapter VI
Section 144-101-VI-01 - Primary Care Case Management (replaced by Section 03 on June 21, 2022)
Subsection 144-101-VI-01.08 - PCP PARTICIPATION IN PRIMARY CARE CASE MANAGEMENT

Universal Citation: 144-101-VI-01 ME Code Rules § 144-101-VI-01.08

Current through 2024-38, September 18, 2024

1.08-1 Requirements for Participation

In order to be a Primary Care Case Management PCP, providers must:

a. be a MaineCare provider, i.e. must sign or be a party to a MaineCare Provider/Supplier Agreement if appropriate to that MaineCare practice or managed care PCP practice;

b. sign or be a party to a MaineCare Primary Care Case Management Rider to the MaineCare Provider/Supplier Agreement; and

c. be a pediatrician, general practitioner, family practitioner, internist, obstetrician/ gynecologist or other physician/group specialty as approved by the OMS in either a solo or group practice; a rural health clinic, federally qualified health center, ambulatory care clinic or hospital based/affiliated outpatient clinic that employs at least one full time equivalent Primary Care Provider engaged in delivering primary care; a nurse practitioner; physician assistant; or a resident in a pediatric, family practice, internal medicine or obstetric/gynecological training program.

d. Nurse midwives and locum tenums (physicians who temporarily take the place of another) are not eligible to enroll as PCPs.

e. PCPs may practice only within the scope of their license.

1.08-2 PCP Responsibilities

Unless there is an exception set forth elsewhere in the rules, PCPs must:

a. verify a member's eligibility and managed care enrollment prior to providing services, as described in Chapter I of this Manual;

b. provide or arrange for the delivery of primary care for members enrolled in Primary Care Case Management;

c. provide or arrange twenty-four (24) hour a day, seven (7) day a week coverage as approved by the OMS. If the coverage arrangements change from that which was initially approved, the provider must request a new approval. The Office of MaineCare Services reserves the right to disapprove a new coverage arrangement;

d. not refuse an assignment or disenroll a member or otherwise discriminate against a member solely on the basis of age, gender, race, physical or mental handicap, national origin, type of illness or condition, health status, or requirements for health care services, except when an illness or condition can be better treated by another provider or the medical service is not within the scope of the provider's practice;

e. accept appropriate members who are enrolled in Primary Care Case Management who select the PCP or who are assigned to the PCP;

f. offer all appropriate immunizations to each child on his/her panel in accordance with the OMS' immunization schedule;

g. be a Prevention, Health Promotion and Optional Treatment Services' provider if treating children age twenty (20) and under;

h. assist the OMS in educating members enrolled in Primary Care Case Management;

i. keep a member who is enrolled in Primary Care Case Management on his/her panel until another PCP is selected if it is necessary for a member to change his/her PCP;

j. submit all material about Primary Care Case Management (developed by the PCP for use with MaineCare members enrolled in Primary Care Case Management) to the OMS for review and approval prior to using such materials;

k. review member utilization reports and advise the OMS of any errors, omissions or discrepancies of which the PCP is aware;

l. forward the member's medical record or a legible, complete copy to the new PCP, if a member transfers to another Primary Care Case Management PCP. The medical record(s) must be requested in writing by the member/caretaker and/or the OMS. The medical record must be provided by the PCP at no cost to the new PCP or to the member in accordance with Chapter I of this Manual and must be provided within ten (10) business days of the request being made;

m. furnish, upon request, to the OMS, at no cost to the OMS or MaineCare members, medical records pertaining to: requests for exemptions by MaineCare members, managed care enrollment, and claims;

n. complete referral forms and other necessary paperwork in accordance with the OMS' instructions, and according to Chapter I of this Manual;

o. oversee and manage a care plan for patients who have chronic conditions including but not limited to: chronic obstructive pulmonary disease (COPD), asthma, cardiovascular disease (CVD), depression and/or diabetes.

1.08-3 PCP Panel

Each full time equivalent PCP may have up to two thousand (2,000) managed care members who are enrolled in Primary Care Case Management on his or her panel. Each individual or site may serve a maximum number of MaineCare members who are enrolled in Primary Care Case Management equal to two thousand (2,000) times the number of full time equivalent Primary Care Providers in the practice or on staff. Upon mutual agreement, the OMS may waive the two thousand (2,000) member limit.

Under certain circumstances, the OMS may request that a PCP accept additional members beyond the number specified as a desired panel size. If the PCP agrees, the panel size will not be permanently altered; attrition of enrollees from the panel will be allowed until the PCP's specified panel limit has been re-established.

The PCP provider must notify the Office of MaineCare Services in writing of changes to the patient acceptance status within thirty (30) calendar days.

1.08-4 PCP Request to Disenroll a Member from His/Her Panel

The OMS must approve any PCP request to disenroll a member from his/her panel to ensure that the member's best interests are being served. PCPs may request the disenrollment of a member from their panel for the following reasons:

a. the member is in the process of being formally discharged or was previously formally discharged;

b. there is a pending lawsuit between the member and the PCP or there was a past lawsuit;

c. there is good cause, as approved by the Office of MaineCare Services. Good cause means a documented situation where there is an inability, after making a reasonable effort, to establish or maintain a satisfactory PCP/member relationship; or d. other reasons, as approved by the OMS.

A PCP who wishes to disenroll a member from his/her panel must submit a request to MaineCare's Primary Care Provider Network Services. The request must be submitted in writing or by telephone, followed up in writing.

If the request is approved, MaineCare Member Services will inform the member of the decision and assist the member in selecting a new PCP in accordance with the policies set forth in Section 1.07. The PCP must formally discharge the member from the practice in writing, by certified mail to the member. However, the PCP must state in the formal discharge letter that emergency medical care and appropriate prescription services will continue to be provided to the member for thirty (30) calendar days from the date of the letter or until the selection of a new PCP is completed. The PCP must forward a copy of the letter to MaineCare's Primary Care Provider Network Services. The change will be made within thirty (30) calendar days of the provider's notification to MaineCare's Primary Care Provider Network Services.

Emergency changes will be made within five (5) business days. Emergency means a situation where an expedited change in PCP is necessary to prevent serious and irreparable harm to the member, provider and/or staff. If the change cannot be implemented within the five (5) business day time frame, the member will be allowed to see any participating MaineCare provider for the provision and/or referral of all managed services until the disenrollment process is completed.

1.08-5 Twenty-Four Hour Coverage

The PCP must provide or arrange for the provision of medical coverage to members enrolled in Primary Care Case Management twenty-four (24) hours each day, seven (7) days each week.

The PCP must maintain a twenty-four (24) hour access telephone number that must provide members with access to the PCP or his/her covering provider. Because Members must have verbal contact with the PCP or his/her covering provider; a twenty-four (24) hour telephone number answered only by an answering machine without provision for interaction with the PCP or his/her covering provider is not acceptable. Hospital emergency rooms that do not offer phone triage or assistance in reaching the PCP cannot be utilized by PCPs for twenty-four (24) hour back-up coverage. Additionally, emergency medical technicians (EMTs) who do not offer phone triage or assistance in reaching the PCP cannot be utilized by PCPs for twenty-four (24) hour back-up coverage.

Each PCP must inform members of his/her normal office hours and explain to members the procedures that should be followed when seeking care outside of office hours. A PCP may make arrangements with another provider for coverage when he/she is unavailable.

The PCP must give the back-up provider approval to use the PCP's referral number for services rendered while providing coverage. The PCP must ensure that his/her covering provider(s) is authorized to provide all necessary referrals for services for members while providing coverage, and specifically to comply with the post-stabilization provisions described in Section 1.06.

Back-up coverage must be provided by a participating MaineCare provider.

1.08-6 Provision of Managed Services by Providers Other Than the Member's PCP

A. Referrals by PCPs PCPs agree to provide appropriate referrals for medically necessary managed services that they cannot provide. A referral must be made if the member requests a second opinion. (NOTE: PCPs are not required to provide referrals for services provided to their own Primary Care Case Management patients.) Services requiring Prior Authorization must follow policies as outlined in Chapter I Section 1.14 Prior Authorization of the MBM.

The Office of MaineCare Services' referral form or an OMS's approved referral form must be used for all referrals for managed services. The referral form must be completed in its entirety before forwarding to the OMS.

Unless otherwise specified, four legible and complete copies of the referral form must be distributed by the PCP's office as follows:

1. in the PCP's patient file;

2. to the referral provider;

3. to MaineCare's Primary Care Provider Network Services or its designee; and 4. to the member.

Referrals may be made for a specified time or for the duration of an illness but not to exceed one (1) year in either case. The PCP is responsible for managing the member's care and must maintain appropriate contact with the referred provider.

When making a referral, the PCP must provide the referral provider with his/her referral number. At the time of referral, the PCP must communicate to the referred provider all expectations, limitations and restrictions that he or she is placing on the use of the referral number.

Referred providers may not refer members for other managed services, except for services that have been authorized by the member's PCP.

B Retroactive Referrals Retroactive referrals are inappropriate except in extraordinary circumstances, when a provider is unable to obtain a referral from the member's PCP before providing the service. PCPs agree to provide twenty-four (24) hour access, therefore, retroactive referrals should be very unusual.

C. Referrals from One Primary Care Case Management PCP to another Primary Care Case Management PCP Referrals from one Primary Care Case Management PCP to another for managed services are considered inappropriate under ordinary circumstances. However, under certain circumstances, such referrals may be appropriate. Some examples are: the member is out of the area and is unable to return to his/her town of residence within a reasonable time or the referral is to a Primary Care Case Management PCP who is also a specialist for specialized treatment.

D. Requests by Providers Other than the Member's PCP for a Referral to Provide Managed Services All providers must receive a referral from the Primary Care Case Management PCP before providing managed services to a member. The PCP may choose to provide his/her referral number allowing the provider to deliver the service and bill MaineCare, or the PCP may choose to provide the necessary services themselves.

PCPs must document that they have authorized services to another provider by using the OMS' referral process. See Section 1.08-6(A).

E. Processing of Claims To ensure that payment is made for properly authorized services, providers must enter the PCP's referral number on the claim form. PCPs must authorize their own services. Providers may not use a PCP's number without specific authorization. Unauthorized use of a PCP's referral number by any other provider will be interpreted as fraud and will result in the recoupment of the unauthorized reimbursement from the billing provider and the imposition of appropriate sanctions as set forth in Chapter I of this Manual.

1.08-7 MaineCare Primary Care Case Management Rider

A. Execution of the Rider The MaineCare Primary Care Case Management Rider is a supplement to the MaineCare Provider Agreement. In the case of a partnership, all partners must sign the Rider. In the case of a corporation, the Rider must be signed by an officer of the corporation authorized to bind the corporation in such agreements.

If a practice that is a party to the MaineCare Provider Agreement contains providers who are not eligible to provide managed services because of their specific practice areas, the practice may execute the Rider, but only those members eligible to act as a Primary Care Case Management PCP may sign.

B. Termination of the MaineCare Primary Care Case Management Rider Either party may terminate the MaineCare Primary Care Case Management Rider without cause upon sixty (60) calendar days written notice to the other party. However, if a PCP voluntarily terminates his/her Rider, such termination may not be effective until all members have been transferred to another PCP or after ninety (90) calendar days, whichever occurs first.

The OMS may terminate the Rider immediately by giving written notice to the PCP if the OMS reasonably believes that conditions exist that place the health and safety of members in jeopardy.

The PCP will be provided the opportunity for an appeal (as set forth in Chapter I of this Manual) prior to the effective date of termination. The OMS reserves the right to complete the transfer of MaineCare members enrolled in Primary Care Case Management to new Primary Care Case Management PCPs prior to determination of the appeal.

The Rider automatically terminates upon the death of a PCP; termination of the MaineCare Provider Agreement; or if a PCP has suddenly left the practice site.

In the event of the sale or closing of a practice or clinic or of a change in ownership or control of a practice or clinic, the PCP must provide the OMS with a sixty (60) calendar day written notice of intent to terminate the Rider.

C. MaineCare Primary Care Case Management Rider Amendment Within thirty (30) calendar days written notice from either party, the OMS and the PCP may negotiate a revision of the Rider, to the extent allowable by law. A letter stating the revision, executed in accordance with Section 1.08-7(A), and attached to the Rider, will validate a revision of the Rider. Refusal on the part of either party to agree on the proposed amendment within thirty (30) calendar days of notice will give either party grounds to terminate the Rider.

1.08-8 Division of Program Integrity

The OMS will perform the surveillance and utilization review activities set forth in Chapter I of the MaineCare Benefits Manual.

In addition, the OMS will monitor access to care and quality of services under primary care case management. The monitoring activities will include, but are not limited to:

A.. ensuring maintenance of a toll free telephone number to receive member/PCP inquiries and/or complaints;

B. monitoring PCPs' twenty-four (24) hour access telephone numbers through random calls to PCPs during regular and after office hours;

C. tracking PCP disenrollment patterns and the reasons for those disenrollments;

D. reviewing medical records in response to complaints or significant changes in utilization patterns; and E. generating periodic utilization reports for each PCP. These reports will include, at a minimum, aggregate data on the utilization and cost experience for each PCP panel for both managed services and for those MaineCare services that are exempt. Reports will also facilitate the comparison of cost and utilization experience between panels.

1.08-9 Management Fee

The OMS will pay PCPs in private practice or those practicing in an ambulatory care clinic a monthly management fee of three dollars and fifty cents ($3.50) for each managed care member assigned to their panel as of the twenty-first (21st) day of the month. OMS also pays a PCCM management fee to rural health clinics and federally qualified health centers. No management fee is paid to hospital based physician practices that are reimbursed as part of the hospital and based upon information from the Medicare cost report. The OMS will pay the management fee in addition to any fee-for-service payment made and will pay regardless of whether the member used services in that month.

The OMS will pay PCPs the three dollar and fifty cent ($3.50) management fee the month after the service is delivered. The OMS will provide the PCP with a list of members enrolled in Primary Care Case Management for whom payment is being made.

If a member is transferred on an emergency basis from one PCP to another during the month, the PCCM management fee will be paid only to the PCP with whom the member was enrolled on the twenty-first (21st) day of the month in order to preclude the payment of two (2) PCCM management fees for the same month.

1.08-10 Interpreter Services

Providers must ensure that those members who are non-English and limited English speaking and/or deaf/hard of hearing are provided interpreter services in accordance with provisions described in Chapter I of this Manual.

Disclaimer: These regulations may not be the most recent version. Maine may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.

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