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Draft Medicaid Health Homes for Individuals with Chronic Conditions Targeted Case Management Billing-Year One

August 19, 2011

I'm the Health Home Care Management Provider - WHO DO I BILL?
Targeted Case Management (TCM) Provider Non-Targeted Case Management Provider
Existing TCM Slots New Health Home (TCM) Slots1 Fee-For-Service (FFS) Health Home Patient Managed Care Plan - Health Home Patients (Not a TCM Provider)
1. If Managed Care Patient, bill eMedNY. 1. If MC patient (with Managed Care Plan Approval), bill eMedNY. FFS Patient and I directly contract with State for HH services, bill eMedNY. Patient is enrolled in Managed Care Plan – and I contract directly with Managed Care plan to provide HH services (I am approved lead by State), bill Managed Care Plan.
2. If Fee-For-Service (FFS) Patient, bill eMedNY. 2.

a) If FFS patient and I directly contract with State for HH services, bill eMedNY.

b) If FFS patient and I am a subcontractor with another lead HH (retain approval to bill) bill eMedNY.

2. FFS Patient and I subcontract with another lead HH, bill lead HH. 2. Patient is enrolled with Managed Care plan and I subcontract with a Plan contracted HH Lead Contractor, bill lead Contractor.

Footnotes

  • 1. Nothing prevents a TCM provider from negotiating supplemental payments from lead health home plans or providers.