patient annual pcp report mmm

What is the PCMH annual reporting process?

You will attest to continuing to meet PCMH criteria and submit data and some documentation. This process is not as involved as initial recognition, but it maintains a practice’s recognition and encourages continuous improvement. When Does Annual Reporting Begin? Your PCMH Annual Reporting date is 30 days prior to your recognition anniversary date.

What is the role of an MMP in Medicaid eligibility recovery?

MMPs are encouraged to work with the individual and the state to assist the individual with regaining Medicaid eligibility during the period of deemed continued eligibility.

What does it mean to be fully informed about the MMP?

, §30.4.1 and §30.4.2 regarding what information must be provided to the individual during the enrollment process).“Fully informed” means that the individual must be provided the applicable rules of the MMP, as described in §30.5 of this guidance and in the state-specific Demonstration Marketing Guidelines.

When does the state have to inform the beneficiary of MMP?

The state must inform the beneficiary that he or she is a member of the MMP as of the given effective date (as prescribed in §20.1), and must be instructed to continue to use plan services until the disenrollment goes into effect.

What are the requirements for PCMH?

Practices must submit data and documentation that cover the 6 PCMH concepts. Practices must meet the minimum number of requirements for each category. The 6 areas include: 1 Patient-Centered Access 2 Team-Based Care 3 Population Health Management 4 Care Management 5 Care Coordination and Care Transitions 6 Performance Measurement and Quality Improvement

How does PCMH maintain recognition?

As part of maintaining your PCMH recognition, each year your practice will undergo an Annual Reporting process. You will attest to continuing to meet PCMH criteria and submit data and some documentation. This process is not as involved as initial recognition, but it maintains a practice’s recognition and encourages continuous improvement.

When Does Annual Reporting Begin?

Your PCMH Annual Reporting date is 30 days prior to your recognition anniversary date. All Annual Reporting data and documentation must be submitted no later than 30 days prior to your recognition expiration date. Practices that are a part of a multi-site organization share the same Annual Reporting date, unless otherwise requested. The Annual Reporting date is based on the date the first practice achieves recognition.

What to do after PCMH recognition?

After you earn recognition, continue to follow the PCMH model and activities. Continue with your quality improvement and performance measurement efforts. This will help during next year’s Annual Reporting.

What Information Will I Need to Show NCQA?

Practices must submit data and documentation that cover the 6 PCMH concepts. Practices must meet the minimum number of requirements for each category. The 6 areas include:

What is Medicare Part 50.3?

50.3 - Reinstatements for Invalid Disenrollments ................................................ 79 50.3.1 - Reinstatements for Disenrollment Due to Erroneous Death Indicator or Due to Errone ous Loss of Medicare Part A or Part B, Erroneous Incarceration Information, or Erroneous Unlawful Presence Information ....................................................................................................... 79

What is the responsibility of MMPs?

While states will have primary responsibility for initiating enrollments , disenrollment , cancellations , and opt-out requests , MMPs will still be responsible for other required data exchanges required by Medicare, including updates to Medicare Part D Low Income Subsidy (LIS) status. Please refer to the CMS Plan Communications User Guide (PCUG) for related information on files that must be exchanged, including:

What is dual eligible Medicare?

serves people who are enrolled in both Medicare and Medicaid , also known as dual eligible beneficiaries. The goal of the Initiative is to ensure dual eligible beneficiaries have full access to seamless, high quality integrated health care. Through demonstrations under the capitated financial alignment model, integrated Medicare-Medicaid Plans (MMPs) enter into three-way contracts with CMS and states. The demonstrations also strive to simplify the processes for dual eligible individuals to access the care and services they are entitled to under Medicare and Medicaid programs. This includes providing beneficiaries with a seamless enrollment and disenrollment process as well as clear communication about that process. States play a critical role in this process by working with both CMS and MMPs to ensure that beneficiaries receive information about the demonstrations in clear and timely manner and are appropriately enrolled or disenrolled.

How far in advance do you have to submit a passive enrollment to CMS?

The passive enrollment transactions from the state must be submitted to CMS between 63 and 90 days in advance of the MMP enrollment effective date, but no later than the 63rd day before the MMP enrollment effective date. The beneficiary must receive a passive enrollment notice at least 60 days in advance.

When did Medicare start sending MBI?

Beginning in April 2018 , CMS started sending the new Medicare cards with the MBI to all Medicare beneficiaries. As of April 1, 2018, CMS is only sending the MBI on enrollment related reports and files. States and MMPs will need to be prepared to process enrollment related transactions using the MBI as of April 2018.

When was the MMP updated?

The National MMP Enrollment Guidance has been updated in several key areas since last issued in 2016. The changes provide additional clarity, reduce burden for states and beneficiaries, and incorporates changes in Medicare regulations:

What is the exhibit 10 of CMS?

Exhibit 10: Model Notice for CMS Rejection of Enrollment............................ 148 Exhibit 11: Acknowledgement of Request to Cancel Enrollment ..................... 149

What is the role of ASES in determining eligibility for public employees?

ASES   do   not   play   a   role   in   determining   the   eligibility   for   public   employees   and pensioners. 1.3 Termination of Eligibility A  Medicaid,   CHIP,   Commonwealth,   ELA   Employee   or   Pensioner   enrollee   who   is determined   ineligible   for   MMM   Multi   Health   after   a   redetermination   conducted   by   the Puerto   Rico   Medicaid   Program   will  remain   eligible   for   services   under   MMM   Multi Health   until   the   date   specified   in   a   negative   redetermination   decision   on   the   MA-10 issued   by   the   Puerto   Rico   Medicaid   Program.   An   enrollee   who   is   a   public   employee   or pensioner   will  remain   eligible   until   disenrolled   from   MMM   Multi   Health   by   the applicable Commonwealth agency. 1.4 The duty to verify eligibility All  contracted   providers   under   MMM   Multi   Health   can   validate   a   patient’s   eligibility   with their   enrollee   ID.   It   also   provides   the   patients   coverage   history   and   access   to   print   the Certificate   of   Eligibility.   The   verification   of   eligibility   warrants   that   all   of   its   network providers   will  verify   the   eligibility   of   enrollees   before   the   provider   provides   covered services.   This   verification   of   eligibility   is   a   condition   of   receiving   payment.   It’s   required that   the   provider   verify   the   enrollee’s   eligibility   before   providing   services   or   making   a referral. The systems that support the eligibility verification process are: InnovaMD Access​ – (​ www.innovamd.com​ ) MSO Provider Call Center Telephones​ : 787-993-2317 (Metro Area) 1-866-676-6060 (toll free) Monday through Friday, 7:00 a.m. to 7:00 p.m. 2. Enrollment and disenrollment 2.1   Effective date of enrollment With   the   exception   of   the   example   provided   below,   enrollment,   whether   chosen   or automatic,   will   be   effective   the   same   date   as   the   effective   date   of   eligibility​ .   A  newborn

What is a pharmacy technician?

certified   pharmacy   technicians highly   trained   to   handle   clinical   interventions   and   to effectively   establish   communication   with   providers   involved   in   charge   of   health   care. The   MMM   Multi   Health   Pharmacy   Operations   team   consists   on   the   Clinical   Unit   and the Rejects Monitoring Unit ● Clinical   Pharmacy   Unit​ :   responsible   for   the   evaluation   and   resolution   of received coverage determination requests. ● Rejects   Monitoring   Unit​ :   performs   the   rejected   claims   monitoring process,   to   ensure   that   claims   are   not   inappropriately   rejected   at   the point   of   service,   based   on   the   ​MI   Salud   ​Formulary   of   Covered   Medications (FMC by its Spanish acronym) and Protocols approved by ASES. MMM   Multi   Health   has   a   pharmacy   drug   utilization   specialist   dedicated   to   continuously review   the   Drug   Utilization   in   order   to   coordinate   with   the   PBM   topics   to   be   discussed with   medical   groups   in   educational   activities   through   the   PBM   Academic   Detailing program   and   MMM   Multi   Health   visits   to   physician   offices   by   its   Clinical   Practice Consultants   (CPC).   In   these   activities   topics   as   polypharmacy   and   its   implications   and appropriate   use   of   medicines   are   discussed.   The   drug   utilization   analysis   also   allow   us to   establish   programs   for   the   optimum   treatment   of   patients   conditions   such   as asthma,   depression,   diabetes   and   cholesterol   among   others,   and   to   identify opportunities   for   establishing   a   discipline   that   allows   us   to   offer   our   beneficiaries   a Pharmacy   Benefit   Program   that   assures   the   quality   and   effectiveness   of   the   drug therapy. 5.1.   Pharmacy Covered Services MMM Multi Health provides pharmacy services, including the following: ● All  costs   related   to   prescribed   medications   for   Enrollees,   excluding   the enrollee’s Copayment where applicable. ● Drugs   on   the   Formulary   of   Covered   Medications   of   the   ​MI   Salud   (FMC,   for its   Spanish   acronym)   Drugs   on   the   ASES   Formulary   that   are   not   included in   the   FMC,   but   that   have   been   evaluated   and   approved   by   ASES

How long does a MMM have to respond to an appeal?

no   longer than   seventy-two   (72)   hours after   the   MMM   receives   the   appeal and makes reasonable efforts to provide oral notice.

What is a supporting statement for a prescription?

The   physician’s   supporting   statement   must   indicate   that the   requested prescription drug should be approved based on: o The drug does not have any bioequivalent on the market; and o The drug is clinically indicated because of: o Contra-indication   with   all   drugs   that   are   in   the   FMC   that   the   Enrollee   is already   taking,   and   scientific   literature’s   indication   of   the   possibility   of serious adverse health effects related to the taking the drug; o History   of   adverse   reaction   by   the   Enrollee   to   some   drugs   that   are   on   the FMC; o Therapeutic failure of all available alternatives on the FMC o If   the   drug   prescribed   is   not   part   of   the   FMC   or   the   LME   at   the   point   of sale the pharmacy will receive the following reject message: ▪ Non-   FMC/LME   Drug:   Exception   request   required.   Validate   other alternatives in FMC/LME before proceeding. o If   after   validation   the   pharmacy   decides   to   proceed   with   the   evaluation   of the prescribed drug, it must contain the following standard information: ▪ Prescription ▪ A  supporting   statement   setting   forth   the   clinical   justification   and medical necessity for the prescribed medication ▪ Expected duration, as required by the protocol for the medication. o The   prescribing   physician   must   provide   a   written   supporting   statement based   on   clinical   evidence   that   the   requested   prescription   drug   is medically   necessary   to   treat   the   member’s   disease   or   medical   condition. The   physician’s   supporting   statement   must   indicate   that   the   requested prescription drug should be approved based on:

What is a QAPi?

6.1 Quality Assessment Performance Improvement Program The Quality   Assessment   Performance   Improvement (QAPI)   Program   was   established specifying   quality   measurements   and   performance   improvement   activities   based   on clinically   sound,   nationally   developed   and   accepted   criteria   standards,   and   taking   into consideration   the   latest   available   research   in   the   area   of   quality   assurance.   Some   of the   elements   that   comprise   the   QAPI   Program   will   be   described   in   the   subsequent sections. 6.2 Advisory Board The   Advisory   Board   is   an   open   discussion   forum   available   to   representatives   of   the Government   Health   Plan,   such   as,   enrollees,   family   members,   providers,   among   others, from   MMM   Multi   Health.   The   stated   forum   convenes   on   a   quarterly   basis.   The participants   of   the   Advisory   Board   shall   contribute   in   the   resolution   of   situations related   to   the   healthcare   delivery   system,   the   quality   of   covered   services   (for   example, physical   health   and   mental   health)   enrollees   rights   and   responsibilities,   resolution   of enrollees   grievances   and   appeals,   and   needs   of   the   groups   represented   by   the participants   of   the   Advisory   Board   pertaining   to   the   Puerto   Rico   Medicaid   program. MMM   Multi   Health   will  promote   an   equitable   representation   of   the   Advisory   Board’s participants   in   terms   of   race,   gender,   special   populations,   and   Puerto   Rico’s   geographic areas   in   the   Government   Health   Plan.   MMM   Multi   Health   will  maintain   a   record   of   the attendees   and   of   the   activities   discussed   during   the   Advisory   Board   meetings.   The Advisory   Board’s   participants   shall   actively   contribute   to   the   discussions;   none   shall dominate proceedings, in order to foster an inclusive and participative environment. 6.3 Performance Improvement Projects The   Performance   Improvements   Projects   (PIPs)   are   consistent   with   the   statutes   of   the Federal   and   State   government,   the   regulations   and   the   requirements   of   Quality Assessment   and   Performance   Improvement   Program   pursuant   to   42   CFR   438.330.   The main   purpose   of   the   PIPs   is   to   achieve   a   favorable   and   positive   effect   on   health outcomes   and   satisfaction   of   the   enrollee.   The   projects   are   designed   to   achieve,

What is quality improvement program?

The   Quality   Improvement   and   Performance   Program   provides a   structure   for   the delivery   of   quality   care   to   all   enrollees   with   the   primary   goal   of   improving   health   status or,   in   instances   where   the enrollee’s   health   is not   amenable   to   improvement, maintaining   the   enrollee's   current   health   status   by   implementing   measures   to   prevent any further deterioration of his or her health status. Objectives: 1) Measurable   compliance   and   detailed   goal   setting   for   quality   improvement activities and performance improvement projects. 2) Continuous   quality   assessment   and   probing   to   promote   tangible   and   required performance improvement. 3) Targeted   efforts   to   minimize   encountered   barriers   that   impede   full   continuum of care, in order to drive improved healthcare outcomes for our population. 4) Maintain   partnerships   with   stakeholders   that   will  maximize   the   plan’s   capability to provide adequate healthcare services and benefits.

What is P&T in pharmacy?

Pharmacy   and   Therapeutic   Committee (P&T)   to   be   covered   only   through an exception process if certain clinical criteria are met. ● An   exception   request   may   be   used   for   (i)   Non-FMC   drugs,   or   (ii) medications   covered   with   utilization   management   edits   under   the   FMC (such   as   step   therapy,   quantity   or   dose   limits,   or   prior   authorization requirements),   when   the   prescriber   wishes   to   bypass   such   restrictions.   In those   cases,   MMM   Multi   Health   must   suggest   that   the   prescriber   first consider   using   drugs   listed   on   the   List   of   Medications   by   Exception   (LME). If   the   prescriber   demonstrates   that   none   of   the   alternatives   in   the   LME are   clinically   viable   for   the   patient,   then   MMM   Multi   Health   can   consider approving coverage for drugs outside of the LME. ● If   a   drug   outside   of   the   FMC   but   inside   the   LME   is   prescribed,   the   drug will   be   managed   as   an   exception   request.   All   evaluations   will   have   to evidence   medical   necessity   and   will   have   to   be   justified   by   the   patients prescribing physician. o Prescribing   physician   will   have   to   evidence   contraindication   for   all for   the   alternatives   within   the   FMC.   The   MCO   will   request   a   copy of   the   patient’s   medical   history   that   validates   the   presented contraindication   to   all   the   FMC   alternatives   or   physician   should provide   scientific   evidence   that   substantiates   that   the   utilization   of one   of   the   FMC   alternatives   would   represent   serious   health repercussion to the patients’ health. o Patient   has   experienced   serious   adverse   reactions   to   all   the alternatives of the FMC. o Patient   has   failed   experienced   therapeutic   failure   to   all   the alternatives   in   the   FMC   due   to   ineffectiveness   of   therapy   or because it has severely worsen the patient’s condition or illness. ● If   a   drug   outside   of   the   FMC   and   the   LME   is   prescribed,   the   drug   will   be managed   as   an   exception   request.   All  evaluations   will  have   to   evidence

What is the number to call Vital Plan?

Listed below are the services that Vital Plan covers. Some services may have limits. Call your Insurer at 1-844-336-3331 (toll free), TTY 787-999-4411 (for the hearing impaired) if you want more information. Routine doctor office visits, checkups, and sick visits. Well-baby visits, well-child visits, and immunizations.

How often do you have to pay for a generic medicine?

This way, you only have to pay for the medicine once instead of paying three times (1 payment per month).

What is the phone number for a mental health insurance company?

If you need help finding mental health, alcohol and substance abuse services, call your Insurer at 1-844-336-3331 (toll free), TTY 787-999-4411 (for the hearing impaired).

What is the fee for a Puerto Rico health certificate?

The Puerto Rico Department of Health charges a nominal fee up to $5.00 for the emission of the certificate.

What is Vital Plan?

Vital Plan offers services to keep you healthy. Vital Plan works with Insurers, who coordinate with you and your doctors to help you access services you need. You can start getting services as soon as your Medicaid Office tells that you are eligible for the Government Health Program. You don’t have to wait.

Who is responsible for copaying for a health certificate?

Any applicable copayment for procedures or laboratories for the emission of a Health Certificate will be the sole responsibility of the beneficiary.

Does Vital Plan require a PCP?

Vital Plan offers mental health, alcohol and substances abuse services. You do not have to see your PCP first to see a doctor or other provider for mental health, alcohol or substances abuse services. You can ask for these services whenever you feel like you need them.