Emerging Practices in Medicaid Primary Care Case Management Programs. Support


States also provide support services to PCPs to assist them with their daily practices and contract responsibilities. Most states maintain a hotline that can assist providers with questions about member eligibility, covered services, authorization requirements, and other issues. Field staff help PCPs work with members who may not understand the program and help problem-solve contract compliance issues.

  • Oklahoma provides a toll-free information line for providers and a nurse-advice line that offers 24-7 fill-in coverage, that is, 24 hours a day, 7 days a week, for the PCP so that he/she can meet the contract requirements of a PCP. Staff within the nurse-advice service also follow up with members who appear to be using the emergency room excessively. Exceptional Needs Coordinators (ENCs) have been hired by Oklahoma's Medicaid agency to assist persons with special needs in managed care. One of their functions is to assist PCPs with arranging specialty care that the special needs member may require. They have also provided training to providers about the special needs populations that are required to enroll in managed care. The ENCs work in partnership with provider relations staff, providing a team approach to addressing the physician's concerns.
  • Primary care physicians participating in North Carolina's ACCESS II and III initiatives have found the case management provided to their patients by the network to be an asset to their practice. Case managers at the network level, supported by the network's portion of the case management fee, help the physicians coordinate the care of their patients.

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