23-642m Know What You Are Responsible for to Coordinate Care for Your D-SNP Patients

Date: 08/18/23

PPGs and the Health Plan both have dedicated functions to respond to member needs

Understanding who is responsible for what can make coordinating care for your D-SNP patients much easier.

The table on the next page outlines the responsibilities of Wellcare By Health Net (Health Net), the participating physician group (PPG) and those that are shared between both.

For more information on policies regarding care and case management, refer to the: Utilization Management > Care Management section of the Medicare Provider Operations Manual in the Provider Library.

Wellcare By Health Net	Shared Responsibilities	PPG
Outreach to members identified for care management as post-discharge and/or high priority based on provider notifications and/or internally derived algorithms. Conduct assessments with members. Create member-centric and member-approved individualized care plans (ICP). ICP creation/revisions (and related outreach). Provider collaboration as a member of the interdisciplinary care team (ICT). Coordinate/collaborate with the ICT team based on member risk/acuity/needs. Facilitate ICT/IDCT meetings (and related outreach) as needed. Coordination of care. Assist with referrals to community-based resources for social determinants of health (SDoH) needs Assist with access to benefits to address member identified needs. Address gaps in care.	Coordination or referral for services, as needed. Support managing chronic conditions to reduce hospitalizations.	Timely notification of admissions, transfers, or discharges to/from facilities to the plan if the PPG is responsible for prior authorizations/claims. Authorize all needed services where the PPG is/remains delegated for utilization management, if applicable. Communicate with the Health Plan’s Case Management, as needed, to exchange information and ensure smooth transitions. Participation on ICT/IDCT, if invited. Facilitate timely post-discharge appointments to primary care physician (PCP) and/or specialist; document efforts. Conduct care coordination on patient population based on need. Refer high risk/catastrophic members to the Health Plan for case management, if applicable. Coordinate activities with the Health Plan’s case managers and ancillary providers as indicated.

Additional information

Relevant sections of Health Net’s provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library on Health Net’s provider portal > Provider Library under Quick Links, or go directly to provider library.

If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by telephone or through the Health Net provider portal.

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.