11. How will adding the physicians as Patient 1st to the group change the panel numbers? For example: Will this affect panel size?
Medicaid Response: The number of physicians/extenders has to support the panel size of the Group.
12. Should my specialty practice refuse to treat Medicaid recipients assigned to a Group PMP if we cannot verify the individual’s NPI?
Medicaid Response: A specialty provider should not refuse to treat a recipient if a valid referral has been received. When this occurs, notify an HP Provider Representative. Phone numbers may be obtained on the following link:
http://www.medicaid.alabama.gov/CONTENT/8.0_Contact/8.2.6.1_Provider_Reps_G1.aspx
13. A recipient is assigned to a group, and the Nurse Practitioner or Physician Assistant sees the patient, whose NPI should be on the referral?
Medicaid Response: The NP or PA should have an agreement with the collaborating physician. The collaborating physician’s name and NPI must be on the referral. The NP or PA’s name and number should also be included on the referral form with a note that consultant information should be sent to the NP or PA who referred the patient. The referral form should be signed by the NP or PA who made the referral.
For payment purposes: If the NP or PA provides care, their NPI must be on the claim form as the rendering provider.
14. Will prior authorizations deny without the PMP’s NPI listed on the referral form?
Medicaid’s Response: The group NPI number will no longer be recognized for referrals. This means the referring provider number on the referral and claim must be the NPI of the referring physician, not the NPI of the group. A group NPI number will cause a Prior Authorization (PA) and the claim to deny.
15. How does my Group practice enroll our Patient 1st PMP’s within the Group?
Medicaid Response: Individual Providers in a Group:
Individual providers within a PMP enrolled group may update the Group/Clinic Patient 1st Update Form and fax to Provider Enrollment at 334-215-4298. This form is located on the following link:
http://medicaid.alabama.gov/documents/5.0_Resources/5.4_Forms_Library/
5.4.4_Medical_Services_Program_Forms/5.4.4.7_Patient1st/5.4.4.7_Group_Clinic_
Patient1st_Update_Form_Revised_5-14-14.pdf
This will ensure a smooth enrollment of an individual PMP within a group.
16. Explain how claims with dates of service prior to June 3, 2014, will process?
Medicaid Response: A system change was made on Wednesday, June 25, 2014, to allow claims with dates of service on or before June 3, 2014, to continue to use the group NPI.
The Alabama Medicaid Agency will identify and reprocess any claims that denied for the group NPI if the following criteria are met:
· Claims were received between June 3, 2014 and June 24, 2014
· Claims dates of service were prior to June 3, 2014