Is a Medicaid Program permitted to return the Primary Care Provider (PCP) for the State Contracted Managed Care Organization (MCO) that a Medicaid member is enrolled in? Or is that information supposed to come from the source (the MCO)? I remember a conversation at an X12 work group meeting where it was stated that ‘other coverage’ and additional information should only be provided if the sender is the source for the information. In this case, the Medicaid Agency contracts with the MCO to cover the patient. The MCO enrolls the person with a PCP and sends an interface with the PCP information back to the Medicaid agency so the Medicaid agency has the info on file. Some States actually have the Medicaid agency assign the PCP and then that is shared with the MCO but in this case it’s done the opposite way around.
In this scenario we are only populating the PER segment in the 271 respsonse with "Information Contact" and that information would be the name of MCO the Medicaid beneficiary is enrolled in
There are two questions in this request.
Answer 1: No, a Medicaid Program is not permitted to return the Primary Care Provider (PCP) for the State Contracted Managed Care Organization (MCO) that a Medicaid member is enrolled in.
Section 1.4.7.1 Item 6 requires information sources to return the following:
“Other payers or plans if known in 2120C/D. (Note: Do not return details of coverage or benefits associated with other payers or plans, the Information Receiver should initiate a separate 270 request to the other payer or plan to determine the level of coverage.)”
The MCO is the other payer or plan in this scenario and Medicaid must not return details associated with coverage (such as the PCP). Medicaid must identify the MCO in the 2120 NM1 segment and may provide additional information in the 2120 loop such as the PER segment.
Answer 2: Yes, The provider should be sending the 270 request to the MCO to determine the patient’s status and benefits including the PCP.