Clients Enrolled in a Managed Care Plan - Anesthesiology

Clients Enrolled in a Managed Care Plan - Anesthesiology - Medicaid

A Medicaid client enrolled in a managed health care plan, such as a health maintenance organization (HMO), must receive all health care services through that plan.Each plan may offer more benefits and/or fewer restrictions that the Medicaid scope of benefits explained in the section of the provider manual. Each plan specifies services which are covered, those which require prior authorization, the process to request authorization and the conditions for authorization.

All questions concerning services covered by or payment from a managed care plan must be directed to the appropriate plan. Medicaid does NOT process prior authorization requests for services to be provided to a Medicaid client who is enrolled in a capitated managed care plan when the services are included in the contract with the plan. Providers requesting prior authorization for services for a client enrolled in a managed care plan will be referred to that plan.

A list of HMO’s with which Medicaid has a contract to provide health care services is included as an attachment to the provider manual. Please note that Medicaid staff make every effort to provide complete and accurate information on all inquiries as to a client’s enrollment in a managed care plan. Because eligibility information as to what plan the patient must use is available to providers, a “fee-for-service” claim will not be paid even when information is given in error by Medicaid staff.

Client NOT Enrolled in a Managed Care Plan (Fee-for-Service Clients)

Medicaid clients who are not enrolled in a managed care plan may receive services from any provider who accepts Medicaid. This provider manual explains the conditions of coverage for Medicaid fee-for-service clients.