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Definition of the Prenatal Care Coordination Benefit
Prenatal care coordination (PNCC) was added as a Wisconsin Medicaid benefit as authorized by Act 39, the 1991-93 state budget, as amended by Act 269 Laws of 1991.
Prenatal care coordination services help a recipient and, when appropriate, the recipient’s family gain access to medical, social, educational, and other services related to the recipient’s pregnancy. Wisconsin Medicaid PNCC services are available to Medicaid-eligible pregnant women with a high risk for adverse pregnancy outcomes during pregnancy through the first 60 days following delivery.
Prenatal care coordination services include all of the following:
The goal of the PNCC benefit is to improve birth outcomes among women who are deemed at high risk for poor birth outcomes. The main objectives for obtaining this goal include ensuring that women at high risk:
Prenatal care coordination services do not end with the completion of the initial assessment, unless the assessment determines the recipient does not need further assistance. To obtain the program’s goal, it is critical that providers have the ability to offer all five components of the PNCC benefit, and not just the assessment, to eligible recipients.
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The policies in this handbook govern services provided within the scope of professional practice as defined in ss. 49.46(2)(b)12, Wis. Stats., and HFS 105.52 and 107.34, Wis. Admin. Code. Please refer to the Covered Services and Related Limitations chapter of this handbook for more information on covered services and related limitations.
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Chapter HFS 105.52(1), Wis. Admin. Code, defines the following types of providers and agencies as eligible for Medicaid certification as PNCC providers:
For Medicaid certification as a PNCC service provider, qualified agencies must submit a comprehensive agency outreach and care management plan to Wisconsin Medicaid for approval. Refer to Appendix 18 of this handbook for information on plan submission requirements.
Medicaid-certified PNCC providers may subcontract with agencies not certified by Medicaid for PNCC services. However, the Medicaid-certified provider retains all legal and fiscal responsibility for the services provided by subcontractors.
It is the certified provider’s responsibility to ensure that the subcontractor provides services and maintains records in accordance with the Medicaid requirements for the provision of PNCC services. According to HFS 105.02(6)(a), Wis. Admin. Code, the following records must be maintained:
Contracts or agreements with persons or organizations for the furnishing of items or services, payment for which may be made in whole or in part, directly or indirectly, by MA (Medicaid).
For more information on recordkeeping as it relates to PNCC services, refer to Recordkeeping in the Covered Services and Related Limitations chapter of this handbook. Please refer to the Recipient Rights and Responsibilities section of the All-Provider Handbook for additional information on required recordkeeping.
The Medicaid-certified provider is responsible for ensuring that its subcontractors:
Wisconsin Medicaid sends provider materials to Medicaid-certified providers only, unless materials are specifically requested by individuals or agencies who are not certified by Medicaid. Published issues of Wisconsin Medicaid and BadgerCare Updates, the All-Provider Handbook, this handbook, and other provider publications may be reviewed and downloaded online at dhs.wisconsin.gov/medicaid/.
Although the subcontracted agency may bill Wisconsin Medicaid using the certified provider’s Medicaid number, Wisconsin Medicaid only reimburses the certified provider.
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Wisconsin Medicaid providers should always verify a recipient’s eligibility before delivering services, both to determine eligibility for the current date and to discover any limitations to the recipient’s coverage. Wisconsin Medicaid’s Eligibility Verification System (EVS) provides eligibility information that providers can access a number of ways.
Refer to the Important Telephone Numbers page at the beginning of this handbook for detailed information on the methods of verifying eligibility. Refer to the Provider Resources section of the All-Provider Handbook for more information about these methods of verifying recipient eligibility.
Presumptive Eligibility is a Medicaid eligibility category that can allow an uninsured pregnant woman to receive pregnancy-related outpatient services while her application for Wisconsin Medicaid is being processed.
Under Presumptive Eligibility, pregnant women are eligible to receive all covered pregnancy-related outpatient services (including PNCC services). All Medicaid-certified outpatient providers can provide these services to women covered under Presumptive Eligibility. Inpatient services are not covered under Presumptive Eligibility. (Generally, Wisconsin Medicaid eligibility is determined by the time of delivery.)
Qualified providers may become certified to make Presumptive Eligibility determinations. Refer to the Provider Certification section of the All-Provider Handbook for more information on becoming certified to determine Presumptive Eligibility. For general information on Presumptive Eligibility, refer to the Recipient Rights and Responsibilities section of the All-Provider Handbook.
Prenatal care coordination is not covered by state-contracted Medicaid HMOs or special managed care programs (such as programs for people with disabilities). Therefore, submit claims for PNCC services directly to Wisconsin Medicaid for recipients enrolled in these programs.
Medicaid-certified PNCC providers located in counties with state-contracted HMOs must have on file a signed copy of a Memorandum of Understanding (MOU) with each HMO in their service area. The MOU encourages coordination between the provider and the HMO and reduces duplication of services. Refer to Appendix 15 of this handbook for a model MOU form.
Prenatal care coordination services are not subject to recipient copayment.
For recipients, participation in the PNCC program is voluntary. The recipient voluntarily participates in the program by maintaining contact with and receiving services from the care coordination provider. The care coordination provider may not "lock-in" recipients or deny the recipient’s freedom to choose providers. Recipients may participate, to the full extent of their ability, in all decisions regarding appropriate services and providers.
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