BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...

BadgerCare Plus & Medicaid SSI Provider Manual - GHC of Eau Claire May 2012
Out-of-Network: The group of non-contracted physicians, providers, clinics, and facilities outside the GHC
service area.
Practice Group: An organized group of physicians that have joined together in a defined structure to facilitate the
care of members between primary care and specialty care.
Primary Care Clinic: A clinic contracted to provide primary care services to BadgerCare Plus and Medicaid SSI
members. The member must choose a primary care clinic for their care. A member may change their primary
care clinic up to two (2) times per year. Each family member may have a different primary care clinic. A member
may see any primary care provider in their primary care clinic.
Primary Care Provider: A Wisconsin Medicaid Certified network provider who is contracted to provide primary
care services to members. The contracted physician evaluates the member’s total health needs and provides
personal medical care in one or more medical fields. When medically needed, he/she preserves continuity of care.
He/she is also in charge of coordinating other provider health services and refers the member to other contracted
BadgerCare Plus and Medicaid SSI providers as appropriate to the member. Primary care providers include the
following: Family Practice, Internal Medicine, Pediatric, and OB/GYN physicians in addition to Nurse Practitioners
and Nurse Midwives.
Receipt Date: Determined by the date marked as received by the Health Management Department when
received by mail or by the date received and date stamped by fax in the Health Management Department.
INPATIENT MANAGEMENT FACILITIES
All hospital admissions, inpatient rehabilitation facility admissions (including inpatient pulmonary rehabilitation
admissions), non-emergent intra-facility admissions (transfers), and long term care and skilled nursing facility care
(including out-of-network 1 admissions) are reviewed for medical appropriateness of admission and continued
stay. 2 Notification of an inpatient admission by the hospital can serve as a trigger for the Health Management
nurse consultant to assess, in partnership with the contracted facility, the need for discharge planning or case
management.
Concurrent Review of inpatient management is a collaborative process with hospital staff and/or attending
physicians to provide concurrent review by telephone or fax. On-site review may be necessary in some situations
where the anticipated length of stay for the patient’s diagnosis is lengthened. The concurrent review process
includes, but is not limited to, the following components:
GHC nurse consultants provide concurrent review of medical records and are available to assist
with members’ care management or discharge planning needs;
When appropriate, the nurse consultant will work with members and families to explain health
management decisions and facilitate discharge planning.
Nurse Consultants use clinical decision support criteria to evaluate medical necessity and
appropriateness of care;
Potential quality issues identified during concurrent review are reported to the Group Health
Medical Director and if found to be significant, to the Group Health Quality Improvement
Committee.
1
Out-of-network is defined as the group of non-contracted physicians, providers, clinics, and facilities outside the GHC
service area.
2
Authorization for services does not guarantee payment for services. Payment for services is dependent on other nonmedical
criteria such as the benefits associated with a member’s specific plan and eligibility issues.
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