Provider not participated with Medicaid MCO - Would he get reimbursement?

Payments to Managed Care Organizations

Recipients are linked by their MCO to a primary care physician or clinic. All MCO-enrolled recipients are provided an identification card by their respective MCO. As a result, recipients must obtain all services except services excluded (see page 4 for a list of excluded services) through their MCO. The recipient’s primary care physician or clinic will give referrals for specialty care.

If you are not part of an MCO and a recipient identified by EVS as an MCO recipient seeks services from you for which an MCO is responsible, you may contact that MCO to determine if it will approve payment for rendered services. Otherwise, the MCO has no obligation to reimburse you except in the case of providing routine family planning services, or in some instances reimbursement for pregnancy related services.

NOTE: If the recipient-required services are emergency services, you may provide the appropriate services and expect to be reimbursed by the MCO upon billing the MCO directly. If you provide non-emergency services without MCO authorization, Medical Assistance will not reimburse you.

Recipient Protection

DHMH understands the importance of protecting the recipient’s choice of MCOs under this program. Providers who want to provide Medicaid services may notify their Medicaid patients of the MCO’s which they have joined or intend to join. However, providers must disclose the names of all MCO’s in which they expect to participate under HealthChoice and may not steer a recipient to a particular MCO by furnishing opinions or unbalanced information about networks.

In order to communicate HealthChoice information, it is imperative that DHMH has current addresses of recipients. As providers, you are in a unique position to inform recipients of the importance to pass on any new address information to DHMH. When possible, please inform recipients that they must give their correct address to their Department of Social Services. If recipients receive SSI, they will need to change their address with the Social Security office.

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