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

BadgerCare Plus & Medicaid SSI Provider Manual - GHC of Eau Claire May 2012
HMO Role - Health Management
The HMO’s Health Management Department identifies high risk members of childbearing age during and
following pregnancy. The team includes nurses that specialize in the area of maternal and child health and
work with members that require intensive Case Management. The HMO’s Care Management activities also
address other family needs such as providing education, newborn follow-up, encouraging HealthChecks,
providing information about transportation, and communicating issues and needs to their member’s other
health care professionals.
MEDICAL SERVICES & THERAPIES: BIRTH-TO-THREE PROGRAM
Group Health Cooperative of Eau Claire may contract for therapies (PT, OT & SLT) provided by the County.
Please refer to the Provider Services Agreement to determine if these services will be reimbursed by Group
Health Cooperative of Eau Claire.
Covered Services
Birth-to-Three services for HMO clients are reimbursed by the state on a “fee-for-service” basis, except
for medically necessary services and therapies. When contracted, the HMO reimburses the following
services for children enrolled in the Birth-to-Three Program.
Physical Therapy (PT), Occupational Therapy (OT) and Speech Language Therapy (SLT)
Certain medical services for diagnosis and evaluation purposes
Audiology testing
*Prior authorization may be required for therapies and certain medical services associated with the Birth-to-
Three Program. Please refer to the Authorization Guidelines section of this Handbook for more information.
Non-Covered Services
The following services are not reimbursed by the HMO:
Special instruction, family training, counseling and home visits
Social work
Non-emergency medical transportation
Targeted case management
[90]