Monday Memo  

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Monday, February 20, 2012
  Clinical Accuracy Spoken Here  

MCO Key Elements

Patient Eligibility
The initial step is always to confirm that the patient is an eligible member of the MCO. If it is determined and confirmed that the patient is not, there are no next steps.

Primary Payer Determination
If the patient has both Commercial and Medicare coverage, the next step is to determine whether the MCO is the primary payer. Depending upon the size of an employer group, the MCO may or may not be the primary payer.

[Reference: MCO Continuum, Module A, Prior Authorizations]

  Excellence in Case Mgmt  

MCO Single Case Agreements

Single Case Agreements (SCAs) are used when an out-of-network provider, which has no contractual agreements with an MCO, is either already in the process of delivering medically necessary emergency care or being considered for the provision of specific predefined services.

MCO CMs in concert with their HCM counterparts are an integral part of identifying opportunities for and formulating SCAs. These agreements are frequently developed through a combination of conference calls and electronic exchanges between the MCO and provider representatives.

[Reference: MCO Continuum, Module A, Prior Authorizations]

  Improving Patient Care...  

MCO Continuum: Medical Necessity

Medicare uses medical necessity as a way to determine if it should pay for goods or services. CMS considers medical necessity to include that which is reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the function of a malformed body member. Medicare laws prohibit payment for services and items deemed by local Medicare Carriers as not medically reasonable and necessary. [Centers for Medicare and Medicaid Services (CMS)]



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