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Serving Wyoming Medicaid Providers

 

 

Patient Centered Medical Home (PCMH)

GENERAL PCMH INFORMATION


State Plan Amendment

CMS approved a State Plan Amendment on Primary Care Medical Homes.

The Amendment allows Wyoming to pay an additional per-member per-month case management fee to primary care practitioners that meet certain requirements, such as reporting clinical quality measures into an online state database.

Another requirement that practices must meet to obtain the case management fee is that they must attest to meeting core medical home functions.  As defined by NCQA's 21011 or 2014 Patient Centered Medical Home (PCMH) standards.  Specifically, practices are asked to submit their Summary Score Report from NCQA's Interactive Survey System (ISS) - the system practices can be used to score themselves and upload documentation in preparation for NCQA Recognition. 

PCMH Definition

A Patient Centered Medical Home (PCMH) is a value based purchasing model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and is focused on quality and safety. 

It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system, and is a philosophy of health care delivery that encourages providers and care teams to coordinate on their patient's care from the simplest to the most complex conditions.

Above all, it is a model for achieving primary care excellence so that care is received in the manner that best fits a patient's medical needs.

Who Can Enroll as a PCMH?

The following providers may apply to become a PCMH:

1.  Certain Nurse Practitioners

  • Taxonomies: 363L00000X, 363LA2200X, 363LF0000X, 363LX0001X, 363LP0200X

2.  Select Physicians

  • Taxonomies: 207Q00000X, 207R00000X, 2080N0001X, 208D00000X, 208000000X

3.  OB/GYN

  • Taxonomies: 207V00000X, 207VG0400X, 207VX0000X

4.  Federally Qualified Health Centers (FQHC)

5.  Rural Health Centers (RHC)

6.  Indian Health Services

Which Client Benefit Plans are Eligible for Additional Payment?

  • ABIW
  • ADSS
  • CMHW
  • COAW/DDAW/SUAW
  • COCW/DDCW/SUCW
  • EID
  • HSPC
  • IP65
  • KIDA
  • MATR
  • MCAD
  • NH
  • NONH
  • PE
  • WLTC

Advantages to Becoming a PCMH

  • Practices will be assigned a level of Health Home Indicator.  These indicators will be assigned to one of the following payment levels.
    • No payment (pay 0%) for Procedure Code S0280, or S0281
    • Pay 100 % of charge for Procedure Code S0280, or S0281
  • The qualifying practice will receive a Per Member: Per Month (PMPM) quarterly payment

NCQA Recognition

National Committee for Quality Assurance (NCQA) recognition is not required by Wyoming Medicaid, practices are encouraged to seek it.

Getting NCQA recognition provides practices with extra tools to participate in PCMH, and a 20% discount off of anything purchased from the NCQA website.

The following information explains how to access the ISS tool, how to complete the survey report, and how to print it out and submit it along with Wyoming Medicaid's Attestation Form.

Practices applying for NCQA Recognition must collect and upload supporting documentation that provides evidence of their compliance with the standards.  After a survey is submitted, these documents are reviewed by experts at NCQA which make scoring decisions that ultimately impact whether or not a practice is recognized and at what level.

 

PCMH Enrollment / Requirements / Expectations / Acceptance

1.  Complete the PCMH Attestation of Facility Compliance Form

Sheree Nall  6101 Yellowstone Ste, 210 Cheyenne, WY 82007

2.  It is necessary to have access to the State Level Registry Portal (SLR) to submit monthly Clinical Quality Measures (CQMS) for Wyoming Quality Care Coordination Program:

  • If you have already registered on the CMS site and received an EHR program payment from Wyoming Medicaid, you do not need to re-register.
    •  To enter your CQMs, go to the CQM login page and use your existing EHR existing login information
  • If you are a first time user go to the CQM login page, select the register button.
  • Note: SLR/CQM training Guide

3. It is necessary to request access to the Continuity of Care Doucment (CCD) system.  Send your request to THRCCDViewerAccess@conduent.com include the following information:

  • Clinic Name
  • Primary Contact (individual) to access the Continuity of Care Document (CCD)
  • Address
  • Phone Number
  • Provider Names

4.  Once a practice has been notified that they are accepted by Wyoming Medicaid as a PCMH they must complete the following to qualify for the PMPM quarterly payments:

  • Submit monthly practice data to the State Level Registry (SLR) Portal on required Clinical Quality Measures (CQM)
  • Review Continuity of Care Documents (CCD) on at least 50% of all Medicaid encounters within the quarter
  • Each quarter, Wyoming Medicaid will review each provider to ensure that all of the conditions of participations have been met.  Each quarter, each provider will be notified via email of approval and level of qualification or denial reason for denial.

5.  In order to claim the PMPM:

  • An office visit/encounter must be billed within the previous 365 days
  • Review CCDs on at least 50% of the Medicaid visits/encounters
  • Submit data to the SLR Portal
  • Comply with all NCQA PCMH Elements

NCQA's PCMH Survey Tool (ISS)

Practices will need access to the NCQA's PCMH Survey Tool.

  • To purchase, visit the NCQA website
    • The survey tool includes a full copy of the PCMH standard and guidelines, the ability to self-score against those standards (functionality that is being used by Wyoming), and the ability to upload supporting documentation and submit for NCQA PCMH recognition.
  • Once the tool is purchased the new practice will:
    • Have access to it indefinitely
    • Need to log in and visit the 'Survey Tool' tab and work through the survey element-by-element
    • Self-score to ensure the Summary Score Report reflects their practices status and is compliant with Wyoming's requirements
  • Practices that have already purchased access to NCQA's PCMH Survey Tool, including those practices that have applied for or received recognition, can print out their Summary Score Report following these instructions:
    • Log into three practice's PCMH Survey Tool and click "Print" in the upper left hand corner
    • Click "Print Numeric Results" in the middle of the page
    • Click through the agreement and then click the "Patient Centered Medical Home" link next to "Evaluation Option"

NCQA Online Trainings

NCQA offers free online trainings that can orient practices to the survey tool and how to self-score.

PCMH Overview Power Point Presentation

Billing for PCMH & PMPM


Upon quarterly approval, the practice will bill for each client for each month within the previous quarter.  Clients must be on a full coverage Medicaid plan to qualify as a valid patient.

All billing will be completed on the CMS-1500 claim form or 837P electronic transactions.  After July 1, 2015 all claims must be billed electronically.

Procedure Codes:

  • S0280 -- 1st billing only -- Medical home program, comprehensive care coordination and planning, initial plan.  (This will establish that this is the first time that your office has billed for this client as a PCMH.)
  • S0281 -- Sequential billing -- Medical home program, comprehensive care coordination and planning, maintenance of plan.
    • S0281 is only allowed one time per client per month (11 months following the S0280).  It will be the provider's responsibility to know which clients are within their PCMH and to coordinate with other practitioner's offices or facilities to determine PCMH.
  • Only one (1) unit per month per client with the maximum allowable of 12 units per year (S0280 and S0281 combined).

If two (2) providers bill for the same client during the same time frame the first claim received will pay and the second one will deny  However, the paid claim will be adjusted and the money taken back by Medicaid.  It will be the practices responsibility to know which clients are within their PCMH and to coordinate with other practices to determine PCMH and bill accordingly. 

FQHC / RHC Reminder

FQHC / RHC facilities are to bill with their physician's NPI number to receive payment.

Contacts / Resources

 

Websites:

For Questions regarding NCQA's PCMH program, or how to use the Patient Centered Medical Home Survey Tool:

  • Contact Mina Harkins, Assistant Vice President for Recognition Program Policy at Harkins@ncga.org

To Verify Wyoming Medicaid Eligibility

  • Provider Relations 1-800-251-1268

Forms / Presentations

 

CCD Viewer Power Point Presentation

CCD Example

NAMD Webinar 2014

PCMH Attestation Form

PCMH Overview Power Point Presentation

SLR PCMH Power Point Presentation


External Linking Policy

This page contains external links that are not the responsibility of, or under the control of the Wyoming Medicaid Program.  Wyoming Medicaid does not endorse any commercial products, services, or web sites.  The Wyoming Medicaid Program may not be held liable for the informational content or services provided on any external web sites which link from the Wyoming Medicaid website.