Medicaid Waiver: This is the Procedure to Get Paid by WHN LME for Outpatient MH Services for Out-Of-Network (OON) Providers: Prior to the Medicaid Waiver, everything was Seamless
Can we please have our old system back...you know....the efficient one that allowed Medicare and Medicaid to automatically wrap around to each other? This is bullocks. This is correspondence between myself and Ms Donna Baker Oliver, working in Provider Relations at WHN LME in Asheville, NC. She's a nice lady. But I have a lot of questions. Here is Ms. Oliver's response to earlier general questions I had re: the OON Provider payment and authorization system: ____________________________________________________________________________ On Thu, Jul 12, 2012 at 9:13 AM, Donna Baker Oliver
> I was forwarded this question from our enrollement phone line. Here is
> my understanding:
> 1. A separate client specific application needs to be submitted for
> each of the three enrollees referenced in the July 4 letter from Melissa
> 2. Even if one of the enrolless has Mcare/Mcaid, in order to receive
> reimbursment for the secondary Mcaid you would need to submit that
> client specific application for that enrollee.
> 3. You only though need to submit one credentialing application (not
> I don't know if this helps, when we use the word managed that often
> refers to authorization...you are correct in that Mcare/Mcaid enrollees
> services do not need to be authorized.
> Thank you,
> Donna Baker Oliver, LCSW
> Western Highlands LME
> Outpatient Provider Network Specialist
> 1-800-671-6560 (toll free)
> 828-225-2785 ext 2977 (Buncombe)
> 828-225-2784 (fax)
Thanks for your reply, Ms. Oliver.
This is being posted on my blog so that other providers can organize themselves, if they even choose to, re: this OON (Out of Network) Provider status.
I have some subsequent questions as I want to be very very clear what you are requiring here re: this OON (Out of Network) Provider information that you need on a client by client basis, something that has taken place automatically for over 10 years but whic his now supplanted by this Medicaid Waiver which has created all this work:
1. am I going to have to recreate a separate 9 page specific application each time I ask for a group of authorizations . If the answer is yes, I will simply copy each one and change the date and signature page.
2. how many authorizations are commonly given and is there any basis on the past rate at which I have been seeing the client that has any relationship to the number of authorizations that are permitted? In other words, does WHN LME have the capability to SEE the medicaid utilization from the past years?
3. Is there any other paperwork that has to be processed in order for me to be paid to continue to see the clients I have been seeing? I note that the WHN LME paperwork indicates that the matter will be processed "within 10 days." Will I receive notice via e mail or how that this has taken place?
4. Who do I speak to when the 10 business days is up and it has not been processed?
5. If I see the client WITHIN THE MONTH e.g., July, that the paperwork was received by WHN LME, am I going to be able to be paid, for example, for July visits or do I have to wait until everything has been processed to bepaid as an OON?
6. OK, you seem to be saying that the dually eligible clients do not have to be MANAGED OR AUTHORIZED but you do need the 9 page form in order that I BE PAID. Am I correct about this? And the tiresome procedure as associated with that, versus the seamless wrap around that was in place re: Medicare automatically wrapping around to Medicaid, is no longer, and I will have to take the Medicare payment information, send it to you, and then wait for what...a check? an automatic deposit into my bank account----which was the way it was done before?
7. What is the additional paperwork for the non dually eligible client-----one with Medicaid only? Is this going to include a Person Centered Plan? If so, he'll need to find another therapist. I just want to know how extensive the paperwork is for the Medicaid only client so I can choose whether to refer him out or not. He is calling me and asking for appointments.
8. When you say that I only need to do only 1 credentialing application not 3, you are referring, I assume, to the : a. tax return of mine you received b. attestation re: emergency contact procedures 3. certification of my expertise (which doesn't seem to matter) 4. W-9. Correct?