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Managed care programs: care coordination - Ohio Admin. Code 5101:3-26-03.1

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Managed health care programs (MCP) must meet the following care coordination responsibilities:

  • Ensure that each member has a primary care provider who will serve as an ongoing source of primary care and assist with care coordination appropriate to the member’s needs;
  • Provide for a second opinion from a qualified health care professional within the MCP’s panel, upon request from the member;
  • Share specific information with non-panel providers designated by the department of job and family services;
  • Provide information to the department documenting the non-contracting providers identified by the MCP and the information the MCP provided to each provider;
  • Provide a centralized toll-free call-in system to provide members with medical advice and direct members to the appropriate care setting;
  • Maintain a log for the call-in system that includes the following information:
    • Identification of the member;
    • Date and time of call;
    • Member’s question, concern, or presenting problem;
    • Disposition of call; and
    • Primary care or other provider if contacted by the MCP.
  • Have services available to assist hearing impaired members and LEP members to use the call-in system;
  • Have a utilization management program with clearly defined structures and processes designed to maximize the effectiveness of the care provided to the member;
  • Provide care management services to coordinate and monitor treatment rendered to members with specific diagnoses or who require high-cost or extensive services;
  • Include and document the following related to the care management program:
    • Identification of members who potentially meet the criteria for care management;
    • Assessment of the member’s health conditions to determine the need for care management; and
    • Development, implementation, and ongoing monitoring of a care treatment plan for members in care management.
  • Report care management program-related data to the department, as required.

Primary care provider care coordination responsibilities include the following:

  • Assisting with coordination of the member’s overall care, as appropriate for the member;
  • Serving as the ongoing source of primary and preventative care;
  • Recommending referrals to specialists, as required;
  • Participating in the development of care management care treatment plans; and
  • Notifying the MCP of members who may benefit from care management. 

Current as of June 2015