Upload
vernon-hines
View
218
Download
0
Tags:
Embed Size (px)
Citation preview
Case Manager: Personal Care Attendant
(PCA) Learning ModuleBCBS Secure Blue--MSHO
BluePlus PMAPMN Senior Care
For Kandiyohi County Public Health & Kandiyohi County Family Services----August 2006
Presented by Annette Sietsema, RN, BANKandiyohi County Public Health Nurse/Case Manager
BCBS Members Affected
•BluePlus PMAP Members•(population under age 65)
•Minnesota Senior Care•(PMAP over age 65)
•Secure Blue Members
Kandiyohi County Public Health & Kandiyohi County Family Services
Legislative (2005) Changes
to the PCA Program•A “Statement of Need” for PCA services•“PCA Flexible Use Agreement”•New documentation requirements*•PCA individual provider numbers required*
*The CM does not facilitate these areas
Kandiyohi County Public Health & Kandiyohi County Family Services
PCA Referral ProcessEach program is slightly different.
It is the FIRST step of each plan that is unique in its application.
All subsequent steps for each plan are identical thereafter.
Kandiyohi County Public Health & Kandiyohi County Family Services
It all begins with a phone call…
Who you gonna’ call?• No not the Ghost Busters• In fact YOU don’t have to call anyone
• It is now the responsibility of the PCA Provider to make the first contact
Kandiyohi County Public Health & Kandiyohi County Family Services
So who does the PCA provider call?
It is different for each type of BCBS plan…
Does the provider know that they need to make the first call?
Does the provider know who they have to call?
“I’m the case manager what am I suppose to do?”
Kandiyohi County Public Health & Kandiyohi County Family Services
Your new titles will be: EducatorAdvocate
Collaborator"Case Management in Hospital/Health Care Systems is a collaborative practice model including patients, nurses, social workers, physicians,
other practitioners, caregivers and the community. The Case Management process encompasses communication and facilitates care
along a continuum through effective resource coordination. The goals of Case Management include the achievement of optimal health, access to care and appropriate utilization of resources, balanced with the patient's
right to self determination.“http://www.acmaweb.org
Kandiyohi County Public Health & Kandiyohi County Family Services
Educating the ProviderYou will play an important role in facilitating the initiation of PCA services for your clients. Much of what you will be
doing will support and educate providers as we all begin this new (and somewhat cumbersome) process.
Kandiyohi County Public Health & Kandiyohi County Family Services
STEP #1We will examine Step #1 of each program separately
(With great anticipation & bated breath…)
Kandiyohi County Public Health & Kandiyohi County Family Services
Step #1: Blue Plus PMAPPRIOR to rendering PCA services to a BCBS MN Public Programs member
—PROVIDERS must contact the member’s individual case manager:
CALL: 651-662-5520
1-888-878-0139
Kandiyohi County Public Health & Kandiyohi County Family Services
Step #1: MN Senior CarePRIOR to rendering PCA services to a BCBS MN Public Programs member
—PROVIDERS must contact the member’s individual case manager.CALL SENIOR PUBLIC PROGRAMS INTAKE @
651-662-55401-800-711-9868
Kandiyohi County Public Health & Kandiyohi County Family Services
Step #1: Secure Blue--MSHO
PRIOR to rendering PCA services to a BCBS MN Public Programs member—PROVIDERS must contact the member’s County Care Coordinator. If the PROVIDER does not know who the County CM
is they may contact Sr. Public Programs Intake for assistance in locating the member’s county care coordinator.
CALL SENIOR PUBLIC PROGRAMS INTAKE @651-662-5540
1-800-711-9868
Kandiyohi County Public Health & Kandiyohi County Family Services
Steps Two, Three, Four & Five
For all three BCBS programs the subsequent steps are identical...
Kandiyohi County Public Health & Kandiyohi County Family Services
Step #2An assessment of the member’s need for PCA services will be completed by a PHN, EW Case Manager or County Care
Coordinator.
Kandiyohi County Public Health & Kandiyohi County Family Services
Step #3A BCBS Case Manager (not us!) will submit the Statement
of Need to the member’s primary care clinic after the assessment has been completed.
Kandiyohi County Public Health & Kandiyohi County Family Services
Kandiyohi County Public Health & Kandiyohi County Family Services
Step #4The members primary care provider will review and order
PCA services (a Nurse Practitioner is also qualified to do this)
The practitioner is to return the form to BCBS within 24 hours.
Step #5The BCBS Case Manager will forward a copy of the
completed Statement of Need with the determination letter issued to the PCA provider and the member
Kandiyohi County Public Health & Kandiyohi County Family Services
A closer look…at Secure Blue/MSHO
The County Care Manager (us) responsibility once the Provider has requested PCA services….
1. Verify the need—you may need to make a home visit2. Call Secure Blue (Bobbi Cooper)3. Remind the PCA agency about the new process for PCA
authorization of need4. Update the CSP and fax to Secure Blue5. Discuss “Flexible Use” option with client and fax
completed form to Secure Blue—remember to obtain signature
6. (if BCBS does not receive the form they will assume that the PCA hours will be flexed month to month.
Kandiyohi County Public Health & Kandiyohi County Family Services
Flexible Use Optionhttp://www.bluecrossmn.com/bc/wcs/groups/bcbsmn/@mbc_bluecrossmn/documents/public/post71a_080647.pdf
Kandiyohi County Public Health & Kandiyohi County Family Services
Questions/Comments Are we in love yet?...
Kandiyohi County Public Health & Kandiyohi County Family Services
Closing ThoughtsAny fool can make things bigger, more
complex and more violent. It takes a touch of genius—and a lot of courage
—to move in the opposite direction.~Albert Einstein
Kandiyohi County Public Health & Kandiyohi County Family Services
ReferenceBCBS (2006). Legislative changes to PCA program. BCBS Provider Bulletin. As found at: http://www.bluecrossmn.com/bc/wcs/groups/bcbsmn/@mbc_bluecrossmn/documents/public/post71a_080647.pdf
Kandiyohi County Public Health & Kandiyohi County Family Services