A woman eligible for MA under BCCPT is approved in category PH and program status code 20.
Initial applications are received in the CAOs from the Community Health Coordinators.
When a completed PA600B is received from the Community Health Coordinator, the CAO authorizes MA eligibility under BCCPT within five work days unless the client reports having health insurance.
When the client reports having health insurance, a referral to HIPP must be made by the CAO for a determination. The CAO will not approve MA under BCCPT until the HIPP staff shows whether or not the individual has creditable coverage. HIPP staff has five days to determine creditable coverage.
These applications must be authorized within five work days from the HIPP response if determined there is no creditable coverage.
All applications must be reviewed for other categories of MA based upon information on the application.
NOTE: When a referral to HIPP is needed to confirm creditable coverage, the five day work requirement begins the date the CAO gets a response.
NOTE: Medicare Part A and Medicare Part B are considered creditable coverage. Select Plan is not considered creditable coverage.
NOTE: Do not delay the opening of Medicaid under BCCPT while reviewing for other categories of Medicaid.
Enter health insurance information into the TPL system where appropriate.
A partial renewal is needed for each woman enrolled under BCCPT whose initial length of treatment is expected to last less than twelve months. A complete renewal is needed every twelve months for a woman enrolled in MA under BCCPT who continues to need treatment.
The partial or annual renewal date is based upon the ICD.9 codes that the provider checks on the PA 600B or the PA 600BR. This information is entered on the Disability screen in e-CIS.
At the partial renewal, the need for continued treatment must be proven before the eligibility period can be extended.
The Office of Medical Assistance Programs (OMAP) will review all medical records presented during the partial review to make sure all steps taken and services given were medically necessary under the rules of the Office of the Medical Director (OMD).
The CAO will be notified that:
There is a continued need for a specific length of treatment.
Length of treatment can be decreased.
Treatment is stopping because it is no longer needed or because the client has failed to provide proof of the need for treatment.
The CAO should either continue or end eligibility under BCCPT based upon the recommendation from OMAP, even if it's different from what the provider states on the document.
A referral to HIPP is necessary for all clients who report having health insurance.
If BCCPT eligibility ends, the CAO worker will review for other categories of MA.
NOTE: Notice must be sent to the client whenever a client is approved for a shorter period of treatment or is no longer eligible for BCCPT.
At the complete renewal, the continued need for treatment must be proven. If the renewal form shows that the woman has creditable coverage, that must be proven too.
About 45 days before the partial or annual renewal date, the CAO receives an alert. The CAO must mail the PA 600BR form to the client with a letter telling the client what is needed and the deadline for getting the information to the CAO.
The client and her medical provider complete the form and return it with medical records supporting the need for treatment to:
Office of Medical Assistance Programs
Division of Medical Review/BCCPT
P.O. Box 8171
Harrisburg, PA 17105
OMAP will review all medical records submitted with the form for medical necessity under the rules of the Office of the Medical Director (OMD). OMAP will notify the CAO of continued eligibility, a shorter period of eligibility, or the stopping of eligibility under BCCPT.
If not notified by OMAP of the renewal status within 10 days after the due date, the CAO will contact OMAP. If the client fails to turn in the PA600BR, the CAO must then take the steps to end benefits.
NOTE: The CAO will not end BCCPT benefits before receiving notification from OMAP.
The CAO sends a notice to the applicant or recipient telling her of her BCCPT eligibility or ineligibility (See Appendix A for reason and option codes.)
Updated July 24, 2013, Replacing February 14, 2012