CMS Technical Instructions: Primary Care Case Management Reporting

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.

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]

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.

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.

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 MCR00007).^[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.

PCCM payments made to a provider should be reported in the FTX00002 segment. The proxy plan ID number should be reported in the CONTRACT-ID on the FTX file. The provider’s identification numbers should be reported in the PAYEE-ID field with the PAYEE-ID-TYPE = “05” or “06”. Additionally, the PAYEE-MCR-PLAN-TYPE should be set to “02” for traditional PCCM.

Finally, traditional PCCM providers should have information related to the PCCM program reported in the Provider file in the affiliated program segment (PRV00009). The AFFILIATED-PROGRAM-TYPE should be coded with a value of “2“ and the traditional PCCM proxy plan ID should be reported in the AFFILIATED-PROGRAM-ID field.

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”.

Enhanced PCCM payments should be reported in the FTX00002 segment. The managed care plan ID number should be reported in the PAYEE-ID field with the PAYEE-ID-TYPE = “02” or “03”. Additionally, the PAYEE-MCR-PLAN-TYPE should be set to “03” for enhanced PCCM.

Please also refer to CMS Technical Instructions: Reporting MANAGED-CARE-PLAN-ID in the Eligible File and CMS Technical Instructions: Required Non-Claims Segment Effective and End Date Data Element.