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Intensive case management (ICM) reimbursement program

Background

Keystone First submits all validated diagnosis to the Department of Human Services so an accurate summary of disease acuity within our member population is recorded to predict expenditures for delivery of care.

To accomplish this accurate representation of our membership, one of the tools we have developed is the intensive case management (ICM) reimbursement program.

ICM program objectives

  • Assist PCPs by identifying members with chronic and/or complex medical needs.
  • Assure chronically ill members are routinely accessing primary care services.
  • Improve appointment compliance through member outreach.
  • Report complete and accurate diagnosis and disease acuity information to DPW and secure adequate rates.
  • Offer additional reimbursement to PCPs delivering care to chronically ill patients ($40 once every 180 days).

Frequently asked questions

How are ICM members identified?

ICM members are identified as those with claim history indicating chronic and comorbid conditions based on the Chronic Illness and Disability Payment System (CDPS)

How and when are practices notified about ICM members?

Notification is through NaviNet using the following methods and criteria:

  • Eligibility and benefits "alert" messages when:

    • The PCP has not submitted any claims for a particular member within the previous six months
  • Action items:
    • The PCP has not submitted any claims for a particular member within the previous six months, or
    • The PCP has submitted claims within the previous six months, but did not report any or all of the chronic/comorbid diagnosis codes we found in claim history

How does the ICM reimbursement program work? (Refer to the work flow process for specific instructions)

Using NaviNet:

  • Review action item or alert message
  • Validate or update the diagnosis by:
    • Scheduling an office visit, submitting a complex case management worksheet and generating a new claim, or
    • Completing a review of medical records and updating diagnosis information with a claim adjustment

How do we submit for reimbursement?

  • Submit a new claim or adjusted claim using miscellaneous code 99499.
  • Reimbursement is received approximately within 10-15 business days, depending on the method of submission.

Is there any other assistance offered for ICM members?

Upon your request, Keystone First will contact ICM members to offer:

  • Appointment scheduling
  • Appointment reminders
  • Transportation assistance

If you have any questions about the Intensive Case Management Reimbursement Program, please contact your Account Executive.