Managed Care Resources

Resources

Member Enrollment Report

• Eligibles and Enrolled Members by County – Current

Report Templates

Contract Section       Report 

3.6	Manual Maternity Kicker
3.17	Call Center Performance
4.2	High Cost No Experience Drug	updated
4.3	Additional Services Form
4.3	Additional Services Evaluation Report
4.3	Additional Service Template Report
4.8	Member Incentive Form
5.4	Care Management
6.3	Provider Network
7.3	PCMH
7.4	FQHC/RHC Wrap Detail Data
7.4	FQHC/RHC Wrap Summary Data
8.3	Service Authorization
9.1	Member Grievance and Appeal Report Quarterly
9.1	Member Grievance and Appeal Report Annual
9.2	Provider Dispute Log
10.9	TPL Cost Avoidance
10.9	TPL COB Savings
10.9	TPL Recoveries
10.9	TPL Casualty Cases
11.1	PI Fraud and Abuse Definitions
11.1	PI Rules for Share Point Suspension Termination Exclusion
11.1	PI Instructions-Use of SharePoint Suspension Termination Exclusion
11.10	Pharmacy Lock In Member Letter
11.10	Pharmacy Lock In Member Instructions
11.10	Pharmacy Lock In Member Removal Letter
11.10	Pharmacy Lock In Pharmacy Letter
12.4	MCO Material Minimal Change Attestation
13.1	Claims Payment Accuracy
13.1	GME Report
13.1	PRTF
14.6	Encounter Submission Summary
15.2	Performance Improvements Projects - Clinical
15.2	Performance Improvements Projects - Non-clinical
15.5	Alternative Payment Models
16.3	Managed Care Question and Answer Grid

 Additional Resources

HIPAA 5010 834 Transaction Layout

Enrollment Broker 5010 834 Transaction Guide

Encounter Errors Mapping to 277CA

Enrollment Broker Provider File Format

 

Reference Tools

• Health Plan Initiated Member Disenrollment Form
• Disclosure of Ownership and Control Interest Statement SCDHHS Form 1514
• Managed Care Eligibility
• Managed Care Supplement
• Universal Prior Authorization Request Form: Medications
• Universal Synagis Prior Authorization Form
• MCO Universal Newborn Prior Authorization Form
• MCO Universal BabyNet Prior Authorization Form

Managed Care Organization Notification forms

• Waiver/PACE Enrollment
• Hospice Notification

Pharmacy

• Current Preferred Drug List (PDL)
• Pharmacy Override Information Grid

MCO Comprehensive Drug Lists

• Absolute Total Care Comprehensive Drug List
• Healthy Blue by BlueChoice of SC Comprehensive Drug List
• Humana Benefit Plan of SC Comprehensive Drug List
• First Choice by Select Health Comprehensive Drug List
• Molina HealthCare Comprehensive Drug List

Contact - pharmacy@scdhhs.gov