We’ve reviewed the proposed chapters in depth and have feedback.

The feedback for Chapter 1 is as follows:

• On page 3 under GENERAL SCOPE OF THE PROGRAM it reads “The determination of medical necessity may be made by the Utilization Review Committee in certain facilities, a peer review organization, DMAS professional staff or DMAS contractors.” How do we know which of these 4 methods will be used for our facility/programs?
• On page 7, the third to last bullet reads “Payment of deductible and coinsurance up to the Medicaid limit less any applicable payments for health care benefits paid in part by Title XVIII (Medicare) for services covered by Medicaid.” Could you please clarify what this means?
• On page 12 it reads “Additionally, some services for managed care enrolled individuals are covered through fee-for-service; these are referred to as managed care carved-out services.” Where can we find a list of common carved-out services as these are not clearly defined within the manual? In which contracts might we find this information?
• On page 14 it reads “A provider may bill a member only when the provider has provided advanced written notice to the member, prior to rendering services that their MCO/Medicaid will not pay for the service.” This language appears to indicate that providers can bill Medicaid patients as private pay if we let them know ahead of time, and it’s a denied service – is that correct?