BCBS Secure Blue--MSHO BluePlus PMAP MN Senior Care For Kandiyohi County Public Health & Kandiyohi County Family Services----August 2006 Presented by Annette Sietsema, RN, BAN Kandiyohi County Public Health Nurse/Case Manager

BluePlus PMAP Members (population under age 65) Minnesota Senior Care (PMAP over age 65) Secure Blue Members Kandiyohi County Public Health & Kandiyohi County Family Services

A “Statement of Need” for PCA services “PCA Flexible Use Agreement” New documentation requirements* PCA individual provider numbers required* *The CM does not facilitate these areas Kandiyohi County Public Health & Kandiyohi County Family Services

Each program is slightly different. It is the FIRST step of each plan that is unique in its application. All subsequent steps for each plan are identical thereafter. Kandiyohi County Public Health & Kandiyohi County Family Services

 Who you gonna’ call? No not the Ghost Busters In fact YOU don’t have to call anyone It is now the responsibility of the PCA Provider to make the first contact Kandiyohi County Public Health & Kandiyohi County Family Services

 It is different for each type of BCBS plan…  Does the provider know that they need to make the first call?  Does the provider know who they have to call?  “I’m the case manager what am I suppose to do?” Kandiyohi County Public Health & Kandiyohi County Family Services

"Case Management in Hospital/Health Care Systems is a collaborative practice model including patients, nurses, social workers, physicians, other practitioners, caregivers and the community. The Case Management process encompasses communication and facilitates care along a continuum through effective resource coordination. The goals of Case Management include the achievement of optimal health, access to care and appropriate utilization of resources, balanced with the patient's right to self determination.“ Kandiyohi County Public Health & Kandiyohi County Family Services

You will play an important role in facilitating the initiation of PCA services for your clients. Much of what you will be doing will support and educate providers as we all begin this new (and somewhat cumbersome) process. Kandiyohi County Public Health & Kandiyohi County Family Services

We will examine Step #1 of each program separately (With great anticipation & bated breath…) Kandiyohi County Public Health & Kandiyohi County Family Services

PRIOR to rendering PCA services to a BCBS MN Public Programs member— PROVIDERS must contact the member’s individual case manager: CALL: Kandiyohi County Public Health & Kandiyohi County Family Services

PRIOR to rendering PCA services to a BCBS MN Public Programs member—PROVIDERS must contact the member’s individual case manager. CALL SENIOR PUBLIC PROGRAMS Kandiyohi County Public Health & Kandiyohi County Family Services

PRIOR to rendering PCA services to a BCBS MN Public Programs member—PROVIDERS must contact the member’s County Care Coordinator. If the PROVIDER does not know who the County CM is they may contact Sr. Public Programs Intake for assistance in locating the member’s county care coordinator. CALL SENIOR PUBLIC PROGRAMS Kandiyohi County Public Health & Kandiyohi County Family Services

For all three BCBS programs the subsequent steps are identical... Kandiyohi County Public Health & Kandiyohi County Family Services

An assessment of the member’s need for PCA services will be completed by a PHN, EW Case Manager or County Care Coordinator. Kandiyohi County Public Health & Kandiyohi County Family Services

A BCBS Case Manager (not us!) will submit the Statement of Need to the member’s primary care clinic after the assessment has been completed. Kandiyohi County Public Health & Kandiyohi County Family Services

The members primary care provider will review and order PCA services (a Nurse Practitioner is also qualified to do this) The practitioner is to return the form to BCBS within 24 hours. Kandiyohi County Public Health & Kandiyohi County Family Services

The BCBS Case Manager will forward a copy of the completed Statement of Need with the determination letter issued to the PCA provider and the member Kandiyohi County Public Health & Kandiyohi County Family Services

The County Care Manager (us) responsibility once the Provider has requested PCA services…. 1. Verify the need—you may need to make a home visit 2. Call Secure Blue (Bobbi Cooper) 3. Remind the PCA agency about the new process for PCA authorization of need 4. Update the CSP and fax to Secure Blue 5. Discuss “Flexible Use” option with client and fax completed form to Secure Blue—remember to obtain signature 6. (if BCBS does not receive the form they will assume that the PCA hours will be flexed month to month. Kandiyohi County Public Health & Kandiyohi County Family Services

bluecrossmn/documents/public/post71a_ pdf Kandiyohi County Public Health & Kandiyohi County Family Services

 Are we in love yet?... Kandiyohi County Public Health & Kandiyohi County Family Services

Any fool can make things bigger, more complex and more violent. It takes a touch of genius—and a lot of courage— to move in the opposite direction. ~Albert Einstein Kandiyohi County Public Health & Kandiyohi County Family Services

BCBS (2006). Legislative changes to PCA program. BCBS Provider Bulletin. As found at: bluecrossmn/documents/public/post71a_ pdf bluecrossmn/documents/public/post71a_ pdf Kandiyohi County Public Health & Kandiyohi County Family Services