PLEASE MAKE THE FOLLOWING CHANGES TO THE 1/01/02 VERSION OF APPENDIX A:

PLEASE MAKE THE FOLLOWING CHANGES TO THE 1/01/02 VERSION OF APPENDIX C:

PLEASE FILE ADJUSTMENTS FOR CLAIMS WHICH MAY HAVE BEEN INCORRECTLY PAID.  

COMMUNITY CARE PROVIDERS

REFERRAL AUTHORIZATIONS 

WHEN REVIEWING REQUESTS FOR REFERRAL AUTHORIZATIONS FOR EMERGENCY ROOM SERVICES, COMMUNITYCARE PCP'S SHOULD CAREFULLY REVIEW THE EMERGENCY ROOM
FACE SHEET AND ISSUE OR DENY THE REFERRAL BASED ON WHETHER OR NOT THE PRESENTING SYMPTOMS MEET THE "PRUDENT LAYPERSON STANDARD." 

THE LINKED PCP SHOULD PROVIDE THE ENROLLEE WITH A TWO MONTH TRANSITION REFERRAL TO A NEW PCP IF THE ENROLLEE IS LINKED TO THE WRONG PCP DUE TO AN ADMINISTRATIVE ERROR OR A CHANGE IN PCP HAS BEEN APPROVED, AND IT IS NOT YET REFLECTED ON THE REVS/MEVS SYSTEM. APPROVED PCP CHANGES SHOULD TAKE UP TO 60 DAYS TO BE SHOWN CORRECTLY ON REVS/MEVS. 

EXEMPTIONS FOR MEDICALLY HIGH RISK RECIPIENTS 

UNDER CERTAIN CIRCUMSTANCES, AN ENROLLEE'S MEDICAL CONDITION MAY WARRANT THE DIRECT CARE AND SUPERVISION OF A NON-PRIMARY CARE SPECIALIST. EXEMPTIONS ARE RESERVED FOR PATIENTS WHOSE TOTAL MEDICAL CARE REVOLVES AROUND THEIR PREDOMINANT MEDICAL PROBLEM. IN SOME INSTANCES THE SPECIALIST MAY BE ACTING AS THE ENROLLEE'S PRIMARY CARE PHYSICIAN PRIOR TO COMMUNITYCARE ENROLLMENT.

EXEMPTIONS FOR MEDICALLY HIGH RISK RECIPIENTS SUBMITTED IN WRITING BY THE REQUESTING PHYSICIAN SHOULD DOCUMENT THE PATIENT'S SPECIFIC MEDICAL CONDITION, RATIONALE FOR THE EXEMPTION, AND MEDICAID NUMBER. UPON BHSF APPROVAL OF THE EXEMPTION, THE REQUESTING PHYSICIAN MAY SERVE AS THE CASE MANAGER UNTIL THE SPECIAL NEEDS CARE IS NO LONGER REQUIRED. THE WRITTEN REQUEST SHOULD CLEARLY IDENTIFY THAT THE REQUESTING PHYSICIAN WILL SERVE AS THE CASE MANAGER FOR THE RECIPIENT AND THE REQUEST SHOULD BE SUPPORTED BY MEDICAL DOCUMENTATION THAT SUPPORTS THE SPECIFIC DIAGNOSES OR MEDICAL PROBLEM. 

WHEN A MEDICALLY HIGH RISK ENROLLEES' CONDITION IS EXPECTED TO IMPROVE, AND/OR CASE MANAGEMENT BY THE SPECIALIST IS NOT NECESSARY, THE PCP MAY ISSUE A LONG-TERM REFERRAL FOR UP TO ONE YEAR TO THE SPECIALIST IN LIEU OF THE RECIPIENT BEING EXEMPT, THEREFORE MAINTAINING PRIMARY CARE BY THE PCP.