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

BadgerCare Plus & Medicaid SSI Provider Manual - GHC of Eau Claire May 2012
If the individual is enrolled in a Medicaid HMO at the time of admission, the HMO is responsible for care
provided during the first 72 hours (three business days plus any intervening weekend days and/or legal
holidays) when there is a statement of Emergency Detention (ED) or detention order. During this period of
time, care is deemed medically necessary. The HMO is responsible for court-ordered treatment beyond the
mandatory 72 hours and any intervening weekend days or holidays, if they are involved in the discharge
planning at an out-of-network facility, or if additional care is provided at a network facility.
If the individual is not enrolled in a Medicaid Program at the time of admission, the admitting facility will submit
a Medicaid application regardless of expected length of stay. Medicaid fee-for-service remains the payer for
the duration of the stay, even if the individual subsequently enrolls in the HMO.
PRENATAL CARE COORDINATION – MEDICALLY NECESSARY SERVICES
Prenatal Care Coordination (PNCC) services are reimbursed by the Medicaid fee-for-service Program for all
clients, including those enrolled in HMOs. The PNCC Agency is responsible for services that include outreach,
risk assessment, care planning, care coordination, and follow up to support high-risk pregnant women. The
HMOs are responsible for coordinating care and managing medically necessary services.
The successful provision of services to clients requires cooperation, coordination, and communication between
the HMO and the PNCC Agency.
Fee-for-Service
The following services are not reimbursed by the HMO, but are submitted to the state for reimbursement as feefor-service:
• Outreach
• Assessments
• Care plan development and Case management
• Health education and nutrition counseling
• Care coordination and monitoring
Coordination of Care between the County and HMO
It is important for Counties and HMOs to coordinate care and work together to ensure healthy outcomes for their
clients and members. The successful provision of services requires cooperation, coordination and
communication between the HMO and the PNCC. Coordination of care can improve communication between all
members of the health care team; encourage the timely sharing of information; avoid duplication of services;
support care plans; and offer resources to each other.
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