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Effective: December 1, 2006 | |
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28.15.35ar1 - Adjustments (Archive) |
Archived: June 1, 2009 |
A managed care adjustment is a capitation payment A method of payment for health services that involves a monthly per person rate paid on a prospective basis to a managed care organization. Capitation occurs six working days before the end of the month. made outside of the usual capitation schedule. An adjustment may be payment to a health plan (or managed care organization An organization certified by the Minnesota Department of Health which agrees to provide all defined health care benefits to individuals in return for a capitated payment. MCOs are also referred to as "health plans.") for a current or past month, or, recovery of a capitation payment that was previously made.
An adjustment request does not guarantee an adjustment will be made. The DHS Managed Care unit reviews each request on a case-by-case basis based on federal and state law and health plan contract terms.
Note: For information about possible adjustments when adding newborns to an MA or MinnesotaCare case, see Adding/Removing People From Managed Care.
For MinnesotaCare, request adjustments in the following situations:
l When an enrollee is hospitalized on the effective date of a change in health plans. In this case DHS will recover the capitation payment made to the new plan and will make a retroactive capitation payment to the previous plan.
l When necessary to maintain continuous coverage, continuity of care, or to resolve a service issue. Refer these requests to appropriate staff. Decisions are made on case-by-case basis.
Do not make an adjustment when there has been a systems, coding, or enrollment form error. The household’s enrollment will be changed for the
Follow your agency's procedures to request adjustments from the DHS managed care unit when:
l People are enrolled into health plans incorrectly and retroactive disenrollment would result in continuity of care issues. If there are no service issues, disenroll the person for the .
l People are disenrolled from health plans incorrectly.
l People are hospitalized on the effective date of an enrollment change.
If the change is for a future month and no erroneous capitation payment has been made, delete the incorrect span or change the incorrect information on the RPPH panel.