Managed Care Resources

Resources

Member Enrollment Report

• Eligibles and Enrolled Members by County – Current

Report Templates

Contract Section       Report 

	Attestation for Managed Care Reports
3	Manual Maternity Kicker
3	Call Center Performance
4	High Cost No Experience Drug	updated
4	Additional Services Form
4	Additional Services Evaluation Report
4	Additional Services Template Report
4	Additional Services Impact Report
4	Member Incentives Template
5	Case Management
6	Provider Network
6	Non-Par Report
7	PCMH
7	FQHC/RHC Wrap Detail Data
7	FQHC/RHC Wrap Summary Data
8	Service Authorization
9	Member Grievance and Appeal Report Quarterly
9	Member Grievance and Appeal Report Annual
9	Provider Dispute Log
10	TPL Cost Avoidance
10	TPL COB Savings
10	TPL Recoveries
10	TPL Casualty Cases
11	PI Fraud and Abuse Definitions
11	PI Rules for Share Point Suspension Termination Exclusion
11	PI Instructions-Use of SharePoint Suspension Termination Exclusion
11	Pharmacy Lock In Member Letter
11	Pharmacy Lock In Member Instructions
11	Pharmacy Lock In Member Removal Letter
11	Pharmacy Lock In Pharmacy Letter
12	MCO Material Minimal Change Attestation
13	Claims Payment Accuracy
13	GME Report
13	PRTF
14	Encounter Submission Summary
15	Performance Improvements Projects - Clinical
15	Performance Improvements Projects - Non-clinical
15	Alternative Payment Models
16	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 Certification Requirements - Applicant

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