Comprehensive Care Program

Clinician-directed care coordination services are a benefit of CCP for eligible clients who are under 21 years of age and have special health needs.

 


Clinician Directed Care Coordination Tips for Medicaid Billing

These non- face-to-face services require prior authorization:

For clients younger than 21 years of age who meet criteria [1]
By the provider who is providing the client's medical home [2]

The medical home clinician may request prior authorization for care coordination in advance of a visit, or may request it within 72 hours after a visit.  The prior authorization is valid for 6 months  for each specific client. In the 6 month eligibility period, the medical home provider may make phone calls to an unlimited number of specialists or other ancillary health care providers.   However, each specialist is only able to bill for 2 telephone consultations during that 6 month period. The medical home provider is not reimbursed directly for phone calls made, as they are considered  to be part of the care plan oversight/supervision that can be billed with 99339, 99340, 99374, 99375, 99377, 99378, 99379, or 99380 once per month. The clinician billing the care coordination services must personally perform the services and be the same clinician who signed the plan of care.  The coordinating clinician may be the client's primary care provider or a specialist.

Care plan oversight/supervision (99339, 99340, 99374, 99375, 99377, 99378, 99379, or 99380) may be reimbursed once every calendar month for each client when prior authorized.

Medical team conferences (99367) may be reimbursed once every 6 months for each client when prior authorized.

Non-face-to-face prolonged services (99358 and 99359) may both be reimbursed once for every client by each medical home clinician when prior authorized. Additional occurrences may be considered for prior authorization if the client meets further criteria. [3]

For a specialist to be reimbursed for a telephone consult, the medical home clinician providing the care plan oversight/supervision must have a prior authorization on file for the specific client. The specialist providing the telephone consultation (99499 with modifier U9) may be reimbursed for two consults every 6 months for each authorized client. Multiple specialists may provide consultation, each being reimbursed for no more than two consults every 6 months for each child who has care coordination services prior authorized.

Claims submitted by either the medical home clinician or the specialist before the date prior authorized will be denied.

[1] 2009 TMPPM 43.4.3.3 Prior Authorization Requirements
[2] 2009 TMPPM 43.1.7.2 Medical Home Concept
[3] 2009 TMPPM 43.4.3.4 Non-Face-to-Face Services: Non-Face-to-Face Prolonged Services