Oh Caresource - part 1

If you haven't received your certified letter yet, Caresource is reducing everyone's rate starting in May to 80% of the Medicaid rate. I started getting calls on Friday about it, and unless someone else has a solution, there's not much we can do except leave the network. I had seen a lot of new contracts coming being offered at 80% but I thought they would only go forward with new contacts at that rate. 

I've heard rumors that it's because they can't continue to keep up with the ABA rates that were just raised last summer by DCH, or that they expect to take over the Peachstate caseload who's rate is lower for most newer contracts, but no confirmations on any rumors so far. With the new CMOs eventually coming into the picture, I thought they would understand the competition isn't offering a lower rate. So much for being a non-profit...

If you haven't received the letter it looks like this: 

Notice it says 45 days yet most are receiving them this week. 

So as your patients to change to another CMO when they can or email them stating you disagree and leave the network. You can find the redetermination date for each patient on GAMMIS on the eligibility page when you search right under the name, or the parents can call GA Families  (1-888-423-6765) to ask when they can switch. 

Why yes there's something wrong with eligibility this month on GAMMIS

UPDATE:

Some parents are also getting emails from DCH saying they're working on it...

Parents should email Emily Yona: emily.yona@dch.ga.gov

When my assistant Ruby and I were checking eligibility yesterday, we saw the issue online with eligibility for a lot of kids. She kept texting me, something is wrong. I kept agreeing. 

Here was what made us clue in: 

When  you would check a patient that had Katie Beckett or SSI and was active last month, this month their redetermination date was from last year long ago, something that would have triggered eligibility for January instead of now...

Some of the CMO kids are eligible with the CMO via their website, but not on GAMMIS

I don't know what the issue is, hoping it will be fixed, but from everything I'm seeing online, parents are stressed too with not being able to reach anyone at Medicaid today or DFCS. 

So it's up to you on whether you see the patients, but due note, if you do, you're taking a chance they do not have coverage. However, I would definitely recheck these after the 3^rd or 4^th day of this month, as often the eligibility changes/gets updated again then. Just stating on observation .

Caresource being Caresource

medicaid-ga-policy-reimburse-py-1428-20260201.pdf

Download PDF • 177KB

Recently, as most have seen by now since I'm late getting this out, CareSource has been denying claims that have a primary unspecified diagnosis code. This was an old rule that was put in place long ago when ICD10 first came out. 

You should never ever use an unspecified diagnosis code as a primary diagnosis. Therapists should use a specific diagnosis code from the evaluation as primary. Here are some examples and exceptions: 

Child evaluated for OT, has fine motor delay, diagnosis of CP from pediatrician: 

Can be listed as: 

1. F82

2. G80.9

   Or 

1. M62.81

2. G80.9

The description of G80.9 is: 

Cerebral palsy, unspecified

The key word here being unspecified. 

Here's another example:

Child is evaluated for speech. Therapist states in evaluation it's a delay.  The diagnosis needs to be specific to be primary: 

1. F80.0

   Or

2. F80.2

Can't use F80.9 because this code states: 

Developmental disorder of speech and language, unspecified

Can't use R62.50 because: 

Unspecified lack of expected normal physiological development in childhood

But could use: 

R62.0 

Delayed milestone in childhood

I've heard feedback from therapists stating, we have to use what the dr puts on the Rx. WRONG. 

The dr is sending the child to you to get a diagnosis. You're performing an evaluation to determine a diagnosis. The dr is signing off on your plan of care that states what you're saying the diagnosis is.  Dr offices simply put down whatever generic diagnosis code on purpose to fulfill the need of having something until it's determined by the evaluation. 

On other news with Caresource, as of February 1st, they will be reducing payment for multiple therapies being seen the same day just like Peachstate. With that being said, let me remind everyone that it is important for providers to complain to DCH when there is a problem with a CMO so that it's recorded for the purpose of contract renewals.