Brief Issue Description
This guidance document outlines the challenges states have faced when reporting primary care case management (PCCM) programs in the OT Claims file, Eligible file and the Managed Care file and recommends guidance for states’ reporting.
Background Discussion
Context
A PCCM program allows a physician, nurse practitioner, physician assistant, or certified nurse-midwife to locate, coordinate, and monitor a beneficiary’s covered primary care[1].PCCM programs utilize providers (typically primary care providers) who receive per member per month (PMPM) payments directly for the provision of PCCM services (hereafter referred to in this guidance document as traditional PCCM). There are some PCCM programs in which payments are made to an entity to provide the case management and other services (referred to in this guidance as document enhanced PCCM[2]).
Challenge
Reporting traditional PCCM payments leads to challenges that do not exist when reporting managed care plan capitation payments. The T-MSIS Data Dictionary requires that the managed care plan ID, national provider ID, and provider ID fields all be reported with the same value for capitation payments (T-MSIS data elements COT066, COT112, and COT113). However, if each traditional PCCM has a managed care plan ID based on its provider ID, then that plan ID should also be reported on the Managed Care Plan file and the Eligible file. This creates some potential data reporting challenges for the state regarding the Managed Care file and the ability to link successfully to the Claims and Eligible files. For example, if the Managed Care file STATE-PLAN-ID data element is populated using the managed care plan ID and the Eligible file MANAGED-CARE-PLAN-ID data element is populated using the provider ID, problems will arise when trying to link the Managed Care file with the Eligible file.
Under current T-MSIS business rules, the state cannot assign a single plan ID to all PCCM payments (or a plan ID for each population that is targeted), as this would lead to business rule failures for OT Claims file payment submissions. For all capitation and PCCM payments on the OT file, the PLAN-ID-NUMBER, BILLING-PROV-NUM and BILLING-PROV-NPI-NUM must all be reported with a plan ID. Prior guidance on this issue required the provider NPI number to be reported in these fields and beneficiaries enrolled in a PCCM program would have that provider’s NPI number reported in the MANAGED-CARE-PLAN-ID field on the eligibility file. The guidance below updates how these fields should be reported.
CMS Guidance
Traditional PCCM and enhanced PCCM have different organizational structures. Therefore, the guidance for these two types of PCCMs need to be different, as documented below.
Traditional PCCM
For traditional PCCM reporting, the state Medicaid agency should create one proxy managed care plan ID for the agency’s PCCM program. This proxy plan ID should be reported on the Managed Care file. Limited information regarding the PCCM program will be reported on the managed care file. Only the main managed care segment (MCR00002) of the managed care file will have information for the agency’s PCCM program reported. The rest of the managed care segments will be populated as blank records (MCR00003 through MCR00009)[3]. Only the following elements on the main managed care segment (MCR00002) will be populated for the traditional PCCM proxy IDs:
- MCR019 : STATE‐PLAN‐ID‐NUM – Report the proxy ID created for the PCCM program
- MCR020 : MANAGED‐CARE‐CONTRACT‐EFF‐DATE – Date PCCM program was effective
- MCR021 : MANAGED‐CARE‐CONTRACT‐END‐DATE – Date PCCM program ended. If it did not end, report per T‐MSIS data dictionary specifications.
- MCR022 : MANAGED‐CARE‐NAME – The name of the PCCM program
- MCR024 : MANAGED‐CARE‐PLAN‐TYPE – Report a value of "02" for traditional PCCM.
- MCR030: MANAGED-CARE-MAIN-REC-EFF-DATE – When a segment is reported, the segment effective date is always required.
- MCR031: MANAGED-CARE-MAIN-REC-END-DATE – For historical segments that are no longer active, the end date should always be reported when applicable. The end date can only ever be missing if a segment is active indefinitely, though most states use a default high end-date such as 29991231 in this circumstance.
For beneficiaries enrolled in a traditional PCCM, this proxy plan ID should be reported in the MANAGED-CARE-PLAN-ID field on the managed care participation eligibility segment (ELG00014) with an ENROLLED-MANAGED-CARE-PLAN-TYPE=”02” for traditional PCCM. For PCCM payments made to a provider, the proxy plan ID number should be reported in the PLAN-ID-NUMBER on the Claim OT file. The provider’s identification numbers will still be reported in the appropriate fields on the PCCM payment (BILLING-PROV-NUM and BILLING-PROV-NPI-NUM). These payments should be reported with a TYPE-OF-CLAIM value of “2” or “B” (for Medicaid and S-CHIP respectively) and a TYPE-OF-SERVICE value of “120” (PCCM payments).
Finally, traditional PCCM providers should have information related to the PCCM program reported in the Provider file in the affiliated program segment (PRV00009). The program type value (AFFILIATED-PROGRAM-TYPE) should be coded with a value of “2: and the traditional PCCM proxy ID should be reported in the AFFILIATED-PROGRAM-ID field.
Enhanced PCCM
Enhanced PCCM programs should be reported like other traditional managed care plans. The plan ID number assigned to the PCCM entity should be reported in the data element, STATE-PLAN-ID-NUM, reported on the main managed care file segment (MCR00002) with a MANAGED-CARE-PLAN-TYPE of “03”. For beneficiaries enrolled in an enhanced PCCM, this managed care plan ID should be reported in the MANAGED-CARE-PLAN-ID field on the managed care participation eligibility segment (ELG00014) with an ENROLLED-MANAGED-CARE-PLAN-TYPE of “03”. For enhanced PCCM payments, the managed care plan ID number should be reported in the PLAN-ID-NUMBER on the Claim OT file. The managed care plan ID should also be reported in the provider identifier fields, BILLING-PROV-NUM and BILLING-PROV-NPI-NUM, since the payments are being made to the entity. These payments should be reported with a TYPE-OF-CLAIM value of “2” or “B” (for Medicaid and S-CHIP respectively) and a TYPE-OF-SERVICE value of “120” (PCCM payments).
Please also refer to CMS Guidance: Best Practice for Reporting Managed-Care-Plan-ID in the Eligible File and CMS MACBIS T-MSIS Reporting Reminder: Required non-claims segment effective and end date data elements in T-MSIS.
[1] Section 1905(t) of the Social Security Act and 42 CFR §438.2.
[2] In the final managed care rule, "enhanced PCCM" is renamed "PCCM entity" and defined in 42 CFR §438.2.
[3] Reporting blank record segments for MCR00003 through MCR00009 in the Managed Care file for traditional PCCM programs may result in data quality warnings. States should disregard these warnings for traditional PCCM records in the Managed Care file.