Managed Care Organizations

A Medicaid MCO operates much the same as a Health Maintenance Organization (HMO), as care is furnished through a network of providers (primary and specialty), hospitals, pharmacies, etc. Services rendered are authorized by the MCO to ensure appropriate care management, disease management, and care coordination.

MCOs require members to choose a Primary Care Physician (PCP) who serves as the primary point of contact. Members are expected to contact their PCP first before seeking treatment elsewhere. The PCP may diagnose and treat the problem, or refer the member to a specialist within the MCO network. The process for authorizing services within the MCOs may be different for each plan. Providers should check with the appropriate plan to ensure there is no disruption in services.

Notes for Physicians:

Authorization is not required for services provided in a hospital emergency department. An admission to a hospital through the emergency department may require authorization. The hospital should always check with the patient's plan for authorization requirements. The physician component for inpatient services always requires authorization. The hospital should contact the plan for authorization within 48 hours of the member's admission. Specialist referrals for follow-up care after discharge from a hospital also require authorization.

There are several Medicaid MCOs currently operating in South Carolina.

For more information please click link below.
Managed Care Organizations

MCO Policy and Procedures Guide - effective October 1, 2009

Sample MCO Contract Amendment - effective October 1, 2009

Sample MCO contract - 2008

Sample MCO contract - 2007

MCO Policy and Procedures Guide -2008

MCO Policy and Procedures Guide -2007

Federal managed care requirements may be found in Title 42 of the Code of Federal Regulations .

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