Customer ServiceProcedureNumber:CS.343.Pro.FINAL

Title: Process Eligibility PCP Enrollment Request

Dates:Procedure Effective:02/01/2008

Date of Origin:01/17/2008

Last Review Date:01/23/2008

Last Revised Date:02/01/2008

Product Line(s): Healthy Options  Basic Health  Medicare Advantage  GAU N/A

Ownership:E. Casper, Operations Manager (signature on file)

Purpose

This policy and procedure outlines the process by which members are assigned to a Primary Care Physician (PCP).

Dependencies

The PCP Assignment policy drives the outcome of this procedure.

Data entered under this procedure is used for the Analyze and Distribute Select Option Data procedure.

Procedure

  1. PCP assignment request response guidelines:
  2. Customer Service Representative (CSR) or the Eligibility Coordinator (EC) accommodates requests for PCP assignment whenever possible.
  3. If the PCP requested has a closed states – not accepting new CHP members or is not a CHP provider CSR/EC will contact the member to identify another PCP.
  4. Requests for PCP assignment are accepted throughout the month. The member will generally be assigned to the requested PCP the first of the following month after the request has been received unless otherwise requested.
  5. Assess member eligibility history:
  6. CSR/EC reviews the member’s eligibility history on past PCP assignment requests.
  7. If the member has had eligibility in the past 12 months the CSR/EC makes a future assignment to the desired PCP.
  8. Two screens in Adaptis to complete the future PCP change request entry.
  9. Several screens in Adaptis to complete a retroactive PCP change request entry.
  10. If the member has not had eligibility in the past 12 months with CHP the CSR/EC:
  11. Enters the PCP selection for the member in the PAT System, or
  12. Files the request in the appropriate file to be worked on Manual Assignment day.
  13. If the eligibility for the member comes in on the monthly enrollment file received from the State within 12 months of the future PCP assignment the upload process will assign the member to this PCP, as long as the PCP is still a valid selection.
  14. If the future PCP assignment for the member is no longer a valid selection (e.g. closed practice, termed PCP) then the eligibility upload will assign the member to a valid PCP based on the algorithm, and report this member on the Reassigned Member Report during month end eligibility upload process.
  15. Processing PCP assignment request during eligibility upload month-end processing:
  16. The EC prints the PATReport from the PAT system and retrieves the source documents that were filed in 2.3.2.
  17. The EC reviews the member’s eligibility history:
  18. If the member is found to have eligibility for the current month the EC assigns the member to the PCP chosen by the member (unless the provider is not a valid PCP at time of assignment).
  19. If the member is not found to have eligibility for the current month the documents are re-filed to be worked after the next month end processes are complete.
  20. The EC also reviews the Reassigned Member Report and Member’s Without PCP Report on Manual Assignment Day.
  21. For members that appear on the Member’s Without PCP Report the EC reviews the member’s eligibility history, the note tab on the member’s record, and contacts.
  22. The EC assigns the member to the most recent PCP the member was assigned to or as indicated in the notes/contacts.
  23. If there is no eligibility history, notes, or contacts the EC assigns the member to the PCP based on the algorithm.
  24. The EC reviews the members on the Reassigned Member Report to determine if the PCP that the member was previously assigned to is a valid PCP to assign to. Criteria to determine if a provider is a valid for assignment is:
  25. Is there an age, and/or gender restriction however the provider has agreed to see the member?
  26. Has one location in the system for the provider termed yet another location has been established (e.g. provider moved and has another location within the same geographical area: 25 miles within the member’s zip code).
  27. Eligibility will run another PAT Report and hand deliver to Customer Service Supervisor if there were any PCP change requests entered after the initial report run.
  28. Customer Service Supervisor designates a CSR to manually enter the requests from the PAT Report into Adaptis.
  29. Retroactive PCP assignment request:
  30. Occasionally CHP receives a request to make a PCP assignment retroactive for a member. These requests are usually received in Customer Service via a phone call from the member or provider. Sometimes the retroactive PCP change is requested on the PCP selection form.
  31. The following criteria will be used for CSR and EC to authorize a retroactive PCP change:
  32. If the request is received after the 1st of the month, the request may be authorized if one of the following are true. These exceptions may be made at any time during the month, as long as the member has not been seen at the assigned PCP at the time of the call.
  33. A plan error caused the PCP to be assigned incorrectly. For example:

A PCP request has been requested previously but hasn’t been changed as documented in contacts or undocumented however caller has notes indicating date and person to whom they spoke.

Or

There has been a break in coverage and the member did not get reassigned to the same PCP.

Or

The member has not requested a PCP change, but the system shows one.

4.2.1.2.Member or provider states they have mailed or faxed in a PCP request form.

4.2.1.3.It is the first month of coverage and services have not been rendered by the assigned PCP for the current month.

4.2.1.4.A Member is at the clinic at the time of the request and services have not been rendered by the assigned PCP for the current month.

4.2.1.5.Member has moved and has not had services rendered by assigned PCP for the current month.

4.2.1.6.If the member was on open coupon or with another plan previously, was an established patient at a clinic and is being seen for the first time under CHP (no matter how many months they have been eligible).

4.2.1.7.If after reviewing notes, referrals, claims and contacts it is clear that member has not seen assigned PCP nor any action has been taken by assigned PCP (referrals or contacts) and the member is scheduled to be seen that day or sometime before the end of the month.

4.2.1.8.The request is for a Newborn. (These may be authorized regardless of the issue.)

4.2.1.9.A member feels they can’t or don’t wish to wait for the PCP change to be done for the following month (although they don’t have a scheduled appointment), but member states they might need an appointment.

4.2.1.10.The member requests the change due to a language barrier, or because the Clinic or Provider they wish to be assigned to speaks their language.

4.2.2.CSR and EC are authorized to make retroactive PCP assignments (according to the criteria listed above) up to two months.

4.2.2.1.A lead, supervisor, or manager must approve any retro requiring a change of more than two months.

4.2.2.2.If any action was taken by assigned PCP for the requested months (claims, referrals or contacts on file) the retroactive PCP assignment will not be granted.

4.3.Once a retroactive PCP assignment has been made, the CSR/EC submits a request via MACESS to reprocess ALL claims associated with the PCP change (regardless if they are PCP, specialist, hospital claims etc).

4.4.If the retroactive PCP change request does not meet the criteria, the change must be done for the following month.

4.4.1.The CSR advises the member to consult with the assigned PCP for referral.

4.4.2.The CSR may also assist the member by calling the assigned PCP’s office to request a referral.

  1. When a member has not chosen a PCP, CHP chooses a PCP for the member via a computerized algorithm. The algorithm outlines,
  2. By the member’s zip code,
  3. The assignment percentages used to allocate member assignment.
  4. The product (e.g., Basic Health Plan, Healthy Options, CHIP, or PEBB) depending upon PCP availability by product line.
  5. The assignment algorithm is modified according to the needs and limitations of the primary care network.
  6. Preferential assignment is given to the Member Health Centers with consideration given to provider capacity, member access and the needs of the community.
  7. As a general rule, the assignment distribution is divided equally among the number of PCPs with open practices in the same service area, when the PCPs are non-Member Health Centers.
  8. Examples of assignment scenarios:
  9. Ten PCPs with open practices (non-Member HealthCenter providers) serve the Centralia area; each PCP receives 10% assignment.
  10. Eleven PCPs with open practices and a MemberHealthCenter serve the Pasco area; MemberHealthCenter receives 100% assignment.
  11. Five PCPs with open practices and a MemberHealthCenter serve the SpokaneValley area; each of the providers and MemberHealthCenter receive assignment.

Timelines:

CSR are to assign members to providers the day the request is received. EC are to assign members to the provider selected by the member within 5 business days of receipt of request. The PCP assignment for the member is effective the 1st of the following month unless a retroactive assignment has been authorized. Claims request will be sent same day as retroactive change is made.

Regulatory References:

CFR Citation: / N/A
State Regulations: / N/A

Revision History:

Revision Date / Revision Description / Revision Made By
02/01/2008 / Prepare for Signature / L. North
01/23/2008 / Review comments / S. Ferrell
01/18/2008 / Initial Draft / S. Ferrell, L. North
01/14/2008 / Interview SME / S. Ferrell, E. Casper, A. Fisher

Confidentiality

In keeping with the basic tenet of medical ethics on the right to privacy, Operations Department staff members shall observe a strict confidentiality policy pertaining to information of any nature, whether it be administrative or clinical; to members and qualified dependents. All new employees of the Operations Department must sign a Statement of Confidentiality as a condition of employment.

PHI (Protected Health Information):

Individuals performing this procedure must:

Have access to and protect the confidentiality of the minimum necessary PHI needed to administer this policy;

Protected Health Information is on the weekly enrollment files received electronically from MAA, the enrollment forms received from MAA and HCA (Health Care Authority), the PCP Selection Forms received from PCPs, the Reassigned Member Report, and the Members Without PCP Report. The information on these documents may include member name, DOB (Date of Birth), SSN (Social Security Number), PCP selection, member telephone number, member address.

Does not require access to PHI.

PHI is defined as:

Member demographic information (name, address, phone number, gender, date of birth, social security number, etc.);

Correspondence and other communications from and to a member, provider or representative acting on behalf of the member;

Current and previous coverage information;

Specific medical records necessary including letters from physicians, x-rays, test results, photographs, physician notes, clinical notes, etc.;

Previous contact information with member, provider, and/or representative acting on behalf of the member (telephone records, correspondence, etc.);

Referrals, prior authorizations, hospital notifications, case management notes, claims payment information;

Encounter history and member home care support and social support information, etc.;

Correspondence related to and results from external reviews by independent review organizations.

Process Eligibility PCP Enrollment Request

Revised: 02/01/2008CS.343.Pro.FINALPage 1 of 6