What is Medipass ? Credentialing Procedures

MediPass is a primary care, case-management program designed to assure Medicaid recipients access to medical care, decrease inappropriate service utilization, and control costs.

• Developed by DHS with support from   Iowa Medical Society and Iowa  Osteopathic Medical Association
• Iowa Legislature Mandated
• Program began in 1990

MediPass Coverage

When a provider verifies a recipient’s eligibility for Medicaid, he must also verify whether the recipient is enrolled in MediPass or another managed care program.

Choosing a MediPass Primary Care Provider

Recipients choose a single primary care provider or health care clinic to be their MediPass provider. The MediPass provider becomes the recipient’s case manager and receives a monthly management fee for each enrolled recipient. The MediPass provider is responsible for providing primary care services and for providing referrals for necessary specialty services.

MediPass Primary Care Provider Reimbursement

MediPass primary care providers are paid a $3 case management fee each month for each MediPass patient assigned to them. In addition, MediPass providers receive Medicaid fee-for-service reimbursement for services that they render.

MediPass Covered Services

MediPass providers must provide or approve the following services for enrollees:
• Advanced registered nurse practitioner (ARNP) services
• Ambulatory surgical center services
• Birth center services
• Child Health Check-Up
• Chiropractic services (first ten visits per calendar year do not need
MediPass authorization)
• County health department clinic services (except dental services)
• Durable medical equipment and medical supplies
• Federally qualified health center services (except dental services)
• Home health agency services
• Hospital inpatient services
• Hospital outpatient services, except emergency room and emergency
room screening services
• Laboratory services (Independent Laboratories do not need MediPass
• Licensed midwife services
• Physician services
• Physician assistant services
• Podiatry services (first four visits per calendar year do not need MediPass
• Registered nurse first assistant services
• Rural health clinic services
• Therapy services (occupational, physical, respiratory, and speech)
• X-ray services, including portable x-rays

MediPASS Goals:

• Enhance quality and continuity of care
• Ensure appropriate access to care
•  Educate members to access medical care  from the most appropriate point

Who Can be a MediPASS Provider?

• Medical Doctor -  MD
• Doctor of Osteopathy - DO
• Nurse Practitioner - NP
• Nurse Midwife - CNM
• Federally Qualified Healthcare Center -  FQHC
• Rural Health Clinic - RHC

24 - hour Access

• A Patient Manager (PM) serves as the sole  point of access into the healthcare system  for MediPASS members 
• A single 24 - hour access phone number must  be established for scheduling appointments,  accessing information, and for use by  members when the office is closed
- This access phone number is to provide  instruction to or for members 24 hours a day

MediPASS Member Enrollment

• Members are enrolled in Managed Heath Care  (MHC) as they become eligible for Medicaid 
• Members are notified that they must choose a   MHC PM
• If a member fails to choose a Patient Manager;  one will be assigned to them
• Members may choose to change their PM  during open enrollment
• Members may change the PM during closed  enrollment by calling Member Services and  giving a “good cause” reason. 

Prior Authorization

Prior authorization is very important in Medipass.

If a service also requires prior authorization, the treating provider is responsible for obtaining that authorization in addition to the MediPass referral or the claim will deny. This includes prior authorization for out-of-state

Inpatient hospital psychiatric or substance abuse admissions must be authorized by First Health Services at 800-770-3084.

The MediPass program is a primary care case management (PCCM) program developed by Florida Medicaid in 1991 for the purpose of securing access for Medicaid recipients to adequate primary care, decreasing inappropriate utilization, and controlling program costs for individuals receiving services. Medicaid eligible persons either select  or are assigned to a Primary Care Provider (PCP). The PCP is currently paid a fee of $3.00 per month per enrolled person to manage and coordinate the enrollee’s care in addition to the customary reimbursement for Medicaid services. The goal of the MediPass program was to incorporate some of the advantages of managed care into Medicaid program administration by providing access to high quality care, ensuring that clients receive appropriate care in the proper setting, and fostering development of strong doctor-patient relationships.

Credentialing Procedures

A vital component of network management includes assuring that the quality of network providers is continually evaluated. Such levels of “quality” are often defined and assessed via a plan or network’s credentialing and re-credentialing procedures. MediPass has a comprehensive, well-defined set of credentialing policies and procedures in place to assure that its providers meet high quality standards. The current MediPass enrollment credentialing procedures are in line with industry standards as defined by NCQA. Initial site visits are done by local offices in an appropriate time frame and credentials are verified using NCQA approved sources. Upon completion of site visit and primary source verification, providers are assigned to one of five categories. The current policy identifies three of the five categories of applicants as eligible for presentation to a credentialing committee for final enrollment approval. The remaining two categories represent providers who are denied eligibility for enrollment in MediPass.

While the current MediPass credentialing policies meet the NCQA guidelines, there are some notable differences. NCQA does not quantify the acceptable or unacceptable number of paid malpractice claims to determine enrollment eligibility. The  NCQA guideline simply states that this information must be reviewed prior to enrollment approval. The current MediPass credentialing policy, provided in Appendix B, clearly identifies that “providers who have paid three or more malpractice claims within the past five years based on the date of act/omission,” will be denied enrollment. Secondly, NCQA guidelines require that network providers be re-credentialed every three years as opposed to the current MediPass re-credentialing guidelines of every two years. NCQA also requires an evaluation of member complaints and reviews of under- and overutilization during the re-credentialing process. The current MediPass policy states that the provider file, including member complaints and utilization review reports, should be forwarded to headquarters at the time of re-credentialing. However, interviews with local local area office personnel reveal that files are not routinely requested in the recredentialing process.

The above differences reveal the subtle, more stringent standards for credentialing required by MediPass, relative to NCQA guidelines. The absolute criteria of denying applicants with three or more paid malpractice claims is addressed differently by NCQA accredited health plans. Although NCQA guidelines do not give explicit  numbers, NCQA accredited health plans do look at paid malpractice claims, and do consider this in their application process. There is a high probability that an applicant to these networks would be denied enrollment with at least three paid malpractice claims in a 5-year span. Thus, in reality, MediPass credentialing has virtually the same standards as those of NCQA accredited health plans.

However, there is one practice followed by numerous health plans that is not used by the MediPass program in its initial credentialing of providers. Many NCQA accredited health plans delegate their primary source verification by accepting letters of approval from other NCQA fully accredited health plans. At the Florida Primary Care Case Management Workshop (November 2001) it was identified that ACS, the current contractor for network management and credentialing for Texas’ PCCM program, currently delegates this component of their credentialing process as well. This delegation eliminates duplication of primary source verification. Although this delegated process is provided for in the MediPass credentialing policies (Appendix B) as an option for re-credentialing of existing MediPass PCPs, the MediPass provider enrollment form or checklist does not offer the option to provide an approval or reappointment letter to serve in lieu of primary source “duplicate” verification. 

Thus, providers entering the process are not aware of this option. This primary source verification is time intensive for MediPass staff, especially in light of the current size of the MediPass network. If the option to waive initial credentials verification based on a provider’s enrollment in an approved NCQA accredited plan was more widely implemented, the MediPass credentialing process could be streamlined. This would eliminate duplicate verification, which would decrease administrative costs, resources, and the time required for a provider to become credentialed. This policy change would not result in compromised quality. This has been confirmed with the Texas PCCM program, which has already implemented this practice.

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