Family and Children's Medicaid MA-3435 COMMUNITY CARE OF NORTH CAROLINA/CAROLINA ACCESS

X. INFORMATION AND REFERRAL RESPONSIBILITY

The county DSS is not responsible for resolving recipient complaints, billing or claims issues, overrides, provider recruitment or enrollment. The county is responsible for referring all inquiries or concerns from providers and recipients to the appropriate place. Please use the following guide.

A. Complaints

1. The complaint process is an important component of CCNC/CA. It ensures providers are meeting their contractual obligations and that enrollees have access to appropriate and timely medical care. There are four categories of recipient complaints:

a. Quality of Care Complaints -This category includes complaints of substandard medical care or refusal to refer to a specialist issue.

b. Professional Conduct -This category includes inappropriate behavior by the provider or office staff such as rudeness or verbal abusiveness as well as complaints alleging physical, sexual or substance abuse.

c. Contract Violations - This category includes complaints related to appointment availability, telephone coverage after office hours, office wait times, hospital admitting privileges, and disenrollment issues.

d. Program Fraud or Abuse - This includes inappropriate billing practices, maximizing reimbursement through coding, unauthorized use of a PCP referral number, and requesting cash payments from enrollees prior to billing Medicaid or NCHC.

2. When a CCNC/CA enrollee contacts the DSS regarding any of the above complaints, the employee receiving the call must:

a. Ensure that the identifying information of both the enrollees and providers involved remains confidential.

b. Explain to the enrollee that he must register his complaint in writing to the Division of Medical Assistance (DMA).

c. Give or mail the enrollee the CCNC/CA Complaint Form and Complaint Form Instructions, DMA 9001. Ask him to read the instructions carefully and complete and sign the form and mail to the address on the form. Also provide the CCNC/CA toll free number 888/245-0179.

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d. The Managed Care Section at DMA is responsible for all research, tracking, and follow-up.

e. If additional information is required from the county record, the Managed Care section will contact the CCNC/CA contact person.

B. Overrides

Overrides are authorization numbers issued by HP that allow providers to receive reimbursement for medical services when unusual circumstances warrant. Overrides may be granted due to worker error or any exceptional medical situation, program malfunctions, or extenuating circumstances beyond the control of the responsible parties.

1. When a provider contacts the DSS requesting an override for a past date of service, the employee receiving the call must:

a. Advise the provider he must complete the CCNC/CA Override Request form and submit it to HP if a denial for EOB 270 or 286 or the Primary Care Provider has been contacted and has refused to authorize treatment for past service. The request must be submitted within six months of the date of service. The Override Request form can be accessed at DMA’s web page at http://www.ncdhhs.gov/dma/medicaid/index.htm

b. HP either approves or denies the override request and telephones or faxes the provider the decision.

c. If a change in the provider number or exempt status is required, this information is relayed to the CCNC/CA contact to key in EIS for the ongoing month.

2. When a recipient contacts the DSS to request an override, instruct the recipient to contact the provider to request the override. ONLY A PROVIDER MAY REQUEST AN OVERRIDE.

3. HP (formerly EDS) generates a monthly Override Report. The Managed Care Section monitors this report.

a. When overrides due to worker error are excessive, the Managed Care Section will relay this information to the MPR supervisor.

b. The MPR will work with counties on an individual basis for corrective action.

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C. General CCNC/CA Provider Inquiries

If a provider contacts DSS, make the following referrals:

QUESTION	REFERRAL
Verify Medicaid and NCHC eligibility	HP Automated Voice Response (AVR) 800-723-4337
Billing inquiries, claim resolution, or override requests	HP Provider Services 800-688-6696
Recruitment	Community Care Consultant 888/245-0179
Provider education, training, workshops	Community Care Consultant 888/245-0179or HP 800-688-6696
Provider Enrollment and Changes in PCP Agreement	CSC (Computer Sciences Corporation) 866-844-1113.
Health Check Questions	Community Care Consultant 888/245-0179
Questions regarding CCNC/CA	Community Care Consultant 888/245-0179
ER Management Report	HP Provider Services 800-688-6696

D. CCNC/CA Recipient Inquiries

1. If a recipient contacts the DSS regarding a general Medicaid question or issue relating to CCNC/CA education or enrollment, refer the recipient to his IMC. The IMC (and supervisor, if necessary) will make every attempt to answer CCNC/CA questions or resolve issues relating to education and enrollment. For CCNC/CA questions outside the scope of education and enrollment which the IMC cannot answer, refer the recipient to the Managed Care Customer Service Center, Monday-Friday, except state holidays, at 1-(888) 245-0179. In the Triangle area, call (919) 855-4780 (English/Spanish). For the hearing impaired call the CARE-LINE, Information and Referral Service number at 1-(800) 662-7030 or if in the Triangle area, call (919) 733-4851.

2. If a CCNC/CA enrollee contacts the DSS regarding a North Carolina Health Choice question on medical or provider services that cannot be resolved by the IMC or supervisor, refer the recipient to DMA at 919-855-4000.

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E. CCNC/CA Forms

1. The DMA-9006, CCNC/CA Enrollment Form, DMA-9002, CCNC/CA Medical Exemption Request, and the DMA-9001, Carolina Complaint, package (which is mandatory). Please make copies for your use.

2. EIS generates notices to all NCHC recipients who have been linked to a CCNC/CA provider, indicating the provider name along with the daytime and after hours phone numbers.

3. EIS generates notices to all NCHC recipients who have been linked to a CCNC/CA provider, indicating the provider name along with the daytime and after hours phone numbers.

4. EIS generates notices to all NCHC recipients who have changed their CCNC/CA provider, indicating the change and the new provider’s information.

F. Instructions for Acquiring Material

1. PCP Directory – Forward the material to your CCNC/CA Contact or the person responsible for maintaining the directory.

2. CCNC/CA Reports – Follow your county’s retention schedule for retaining reports.

3. SSI documentation – This should remain in the county. Consult with your supervisor about the best person to keep this documentation.

4. Provider complaint documentation – Send all records, notes, and forms to:

Managed Care Section

Division of Medical Assistance

2501 Mail Service Center

Raleigh, NC 27699-2501

If you are currently investigating or following up with any contractual issues, forward this information to your Community Care Consultant.

5. Override requests – Shred this information based on your county’s policy.

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6. Exempt Requests – The County must file this documentation regarding exempt request in the recipient’s case record.

7. Provider Contracts and any other information related to providers – Shred according to your county policy.

8. CCNC/CA handbooks, per instructions on the DMA-2000a, contact 919-855-4160 to request.