MCO Contracts

Q:         Do providers need MCO contracts to bill for services provided to Medicaid or PAC enrollees?

A:         Under the SAII, non-participating providers (providers without MCO contracts) can bill for services as long as they follow the self-referral protocol.  This option allows a patient to select a treatment program regardless of whether that program has a contract with the MCO in which they are enrolled.  The self-referral protocol outlines the specific authorization and notification requirements and timelines.

Q:         Do providers need to contract separately with MCOs for PAC and Medicaid program?

A:         No.  If a provider has a contract with an MCO to provide coverage for its Medicaid (HealthChoice) clients, it will cover PAC unless the contract specifically states otherwise.   

Q:         Why should I contract with an MCO?

A:         You don’t have to contract with an MCO because the SAII allows providers to bill MCOs as non-participating providers as long as they follow the protocols outlined in the self-referral protocol.

There may be advantages to contracting with MCOs, including:

1. -          MCOs may direct clients to the provider;
2. -          A contracted provider may have a closer working relationship with the MCOs and may get more assistance from the MCO in troubleshooting issues;
3. -          A contracted provider may be more likely to be reimbursed for continued services provided after the services described in the self-referral protocol are completed; and
4. -          A contracted provider may negotiate coverage for additional services. 

In the past, one of the advantages to contracting with an MCO was to negotiate better rates; however, now that the Medicaid fees increased in January 2010, MCOs will be required to pay at least this fee and it is unlikely MCOs will pay more to contracted providers. 

Q:         Does an MCO have to contract with all OHCQ-Certified Addictions Providers?

A:         No, MCOs are not required to contract with all OHCQ-certified addictions providers.   There are minimum standards for the qualifications of an MCO’s provider network and OHCQ-certified addictions providers meet the minimum standard, but MCOs are allowed to require providers to meet their own credentialing standards before contracting with a provider.  MCOs may require their contracted providers to be licensed and meet their individual credentialing requirements or they credential the OHCQ-certified addictions provider as an organization rather than an individual provider.   MCOs may also make exceptions to the credentialing requirements. 

Q:         Does a provider need to meet MCOs’ credentialing requirements to be reimbursed for services under the SAII?

A:         No.  The SAII allows all OHCQ-certified addictions providers to be reimbursed for self-referred services.  However, there are federal Medicaid requirements regarding the licensure requirements for providers to bill for Medicaid or PAC services.  These requirements were outlined in a . 

Q:         Do I have to be JCAHO accredited to contract with an MCO?

A:         No.  While many MCOs prefer that providers be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), they typically will not reject an application solely due to lack of JCAHO certification.  If a provider is not JCAHO accredited, the MCO may require additional information, such as a provider’s quality improvement plan, and they will likely conduct a site visit as part of the credentialing process. 

Q:         How do I start the process of contracting with MCOs?

A:        Contact each MCO and request a provider application.  You should call the provider   relations  contact listed on the DHMH website and make this request.  You can let the MCO staff person know that you are an OHCQ certified addictions program and would like an application for an organization.  The MCO may have an “organizational” or “facility application.” Applications for the MCOs can also be found on DHMH’s website.   The provider may also want to focus on those MCOs that will be participating in the PAC program – Amerigroup, Jai, Maryland Physicians Care, Priority Partners and United HealthCare (also known as Americhoice).   If your OHCQ certification has expired and you are operating under a Letter of Good Standing, you must submit both the original OHCQ certification and the Letter of Good Standing with your application.

Q.         A provider recently submitted a contract to an MCO.  The contract application was denied and the provider was informed by the MCO  they couldn’t accept the “Letter in Good Standing” from OHCQ (Office of Health Care Quality).    What else do they need?

A.         When an application for an MCO contract is submitted, the provider must submit the most recent certification (even if expired) along with the Letter of Good Standing from OHCQ (Office of Health Care.