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.
