MCOs will begin coverage on the date the services began on the IFSP (planned services page). This will remain in effect after the continuity of care period is over.
Which MCO's have quality incentive programs and how do you qualify?
Each Healthy Connections Medicaid MCO has a quality incentive program. Providers are encouraged to contact individual MCOs to inquire about program details. Providers can also contact SCDHHS Provider Relations for additional information.
On the July 17 webinar it was stated 3 times that balance billing would be allowed until
Jan. 1, 2020. In the middle of October, it was stated it would stop Oct. 1, 2019. Why the change?
Information provided during the July 17 webinar was correct. As stated on the webinar, providers will not be reimbursed for a rate difference between Medicaid rates and rates contracted with MCOs. Providers will be paid the rate that is agreed upon in the contract with the MCO. Once a provider has credentialed and contracted with an MCO, the provider should expect to be paid the MCO contract rate. SCDHHS/BabyNet will not pay any additional amounts to providers above the MCO contract rate.
Providers not credentialed and contracted with an MCO as of Jan. 1, 2020, will not be reimbursed for services provided to BabyNet children enrolled in an MCO.
This information is consistent with the communication that was provided in an
Oct. 10, 2019, alert, which stated:
“This alignment includes observation of 42 CFR 447.15, whereby providers in the Medicaid program accept, as payment in full, the amount paid by the agency plus any amount for which the individual beneficiary is responsible. Accordingly, the MCO reimbursed rate will be payment in full. During the continuity of care period, reimbursement will be paid at the fee for service (FFS) rate for services provided to beneficiaries who are not enrolled in an MCO. Reimbursement for providers enrolled in an MCO will be paid at the MCO-negotiated rate. Effective Jan. 1, 2020, after the continuity of care period, the MCO-negotiated rate will be the only rate reimbursed and only providers who are credentialed with an MCO will be eligible for reimbursement.”
Do we still bill claims in BRIDGES if patient has an MCO?
Providers must enter service logs (or service notes) into BRIDGES for every encounter with a BabyNet eligible child. A claim will automatically be created and transmitted to the Medicaid system once the service log is entered. No additional claims input is necessary in BRIDGES.
If we are already credentialed/enrolled with a specific MCO, does the MCO Universal Prior Authorization Form for BabyNet have to be sent for a patient who is enrolled with that specific MCO, even though a provider is in network with that MCO and has a prior authorization on file with them?
As a rule, providers should follow the guidelines set by each specific MCO governing prior authorizations. During the continuity of care period, the information listed on the IFSP Planned Services page dictates what services and amounts of service are covered. Any services or amounts above what is listed on the IFSP will require prior authorization in order for the claim to be reimbursed.
Prior authorization guidelines in place with MCOs may differ after the end of the continuity of care period. Providers should inquire as to the appropriate process for prior authorizations with their contracting MCO.
About the Universal Prior Authorization Form for BabyNet, do we have to send this in for future authorizations, or can we just get an authorization from the MCO per their requirements?
As a rule, providers should follow the guidelines set by each specific MCO governing prior authorizations. During the continuity of care period, the information listed on the IFSP Planned Services page dictates what services and amounts of service are covered. Any services or amounts above what is listed on the IFSP will require prior authorization to be reimbursed.
Prior authorization guidelines in place with MCOs may differ after the continuity of care period has concluded. Providers should inquire as to the appropriate process for prior authorizations with their contracting MCO.
I noticed that one child's IFSP end dates changed and was shortened. Will that change our MCO authorization time period that was approved based on longer end date?"
This question should be posed to the relevant MCO for their input. Deviations from the IFSP may require additional authorization.
Does every BabyNet child who has an MCO have to have the Universal Prior Authorization Form for BabyNet on file with the MCO? If so, is this only during this interim time or does that actually start in Jan 2020. Blue Choice Medicaid told us this does not start until Jan 2020. Can you explain the purpose of that Universal Prior Authorization Form for BabyNet? For example, we are in network with Blue Choice Medicaid. No form of authorization is required. Do we still have to do the MCO authorization form from BabyNet?
As a rule, providers should follow the guidelines set by each specific MCO governing prior authorizations. During the continuity of care period, the information listed on the IFSP Planned Services page dictates what services and amounts of service are covered. Any services or amounts above what is listed on the IFSP will require prior authorization to be reimbursed.
Prior authorization guidelines in place with MCOs may differ after the end of the continuity of care period. Providers should inquire as to the appropriate process for prior authorizations with their contracting MCO.
Will BabyNet pay for the treatments if the MCO denies authorization or service?
During the continuity of care period, the information listed on the IFSP Planned Services page dictates what services and amounts of service are covered. MCOs should pay for services and amounts listed on the IFSP during the continuity of care period. Any services or amounts above what is listed on the IFSP will require prior authorization from the MCO to be reimbursed.
Molina requires an authorization for reevaluations. Often times, providers and EIs are unaware that children have received initial evaluations until the claim has been denied. In order to receive reimbursement, the provider would have to contact the EI and request to have the plan changed to a reevaluation & rebill the service as a re-evaluation, however Molina does not provide retro authorizations. If the resubmitted claim is denied due to lack of authorization, will BabyNet provide the reimbursement?
As a general rule, providers will need to work with individual MCOs to be reimbursed for services provided to BabyNet children enrolled in that MCO. SCDHHS/BabyNet will not pay reimbursements above and beyond what the MCO has agreed to pay a provider in their contract with that provider.
Providers should ensure that all services to be performed are listed on the IFSP correctly before the service is rendered. Claims need to reflect the services listed on the IFSP. Any necessary updates or corrections to the IFSP should be completed by the service coordinator before claims are submitted for payment. Decisions regarding reimbursements for services not listed on the prior authorization are up to each MCO and should be discussed with them.
Because therapy providers have to wait on the EI to enter the therapy onto the BRIDGES planned services page before we can fax the universal authorization request to the MCO, will the MCO be required to backdate the authorizations to match the dates on the Babynet Planned Services Page? OR do providers need to put the child's therapy on HOLD until that info has been entered into BRIDGES and FAXED?
Services listed on the IFSP Planned Services page should not be delayed. Providers should begin to render the services listed on the IFSP and file a claim once the prior authorization paperwork is complete. MCOs should reimburse for services and amounts listed on the IFSP.
The Continuity of Care period ends on Jan. 1, 2020. And that we will then go back to getting authorizations the old way. Is this correct? or will we continue to send in the Planned Services Page from Babynet, and that this will serve as the medical necessity?
As a rule, providers should follow the guidelines set by each specific MCO governing prior authorizations. During the continuity of care period, the information listed on the IFSP Planned Services page dictates what services and amounts of service are covered. Any services or amounts above what is listed on the IFSP will require prior authorization to be reimbursed.
Prior authorization guidelines in place with MCOs may differ after the end of the continuity of care period. Providers should inquire as to the appropriate process for prior authorizations with their contracting MCO.
I have tried repeatedly to access MCO's reimbursement rates for speech therapy. I do not find it in their manuals. Please help me understand where to find this information or provide current reimbursement rates for the individual MCO's for all therapy services.
Please contact the appropriate MCO for guidance on how to locate this information. A
table of contact information has been made available on the SCDHHS BabyNet FAQ page. Providers can also contact SCDHHS Provider Relations at
BabyNet@scdhhs.gov for assistance with specific inquiries if there are persistent issues.
I’m looking for clarity regarding if BabyNet providers will have to be contracted with the major insurance companies or just with the Medicaid MCOs?
SCDHHS has requested that BabyNet providers contact the MCOs serving the South Carolina Healthy Connections Medicaid program so that they can become credentialed and contracted. No guidance has been provided regarding contracts with specific insurance companies outside of the Healthy Connections MCOs. SCDHHS does not require contracts with any entity outside of the Healthy Connections Medicaid program.
With these new referrals. Are we able to pick them up if an MCO has all of our paperwork and we are waiting for them to do credentialing?
Providers must be credentialed and contracted with a BabyNet child’s MCO in order to provide services. It can take up to 60 days for MCOs to complete the credentialing process with providers.
Are we able to continue with the current kids past Jan. 1 if we are still waiting on credentialing?
Providers must be credentialed and contracted with a BabyNet child’s MCO in order to provide services. It can take up to 60 days for MCOs to complete the credentialing process with providers.