Communication Tool - Michigan



Communication ToolMichigan Department of Health and Human ServicesMaternal Infant Health ProgramREFERRAL AND CONTACT INFORMATION LISTReport Date Sent to MIHPReport Date Sent to MHPNotes FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Health PlanFax NumberHealth Plan Contact Person FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????MIHP ProgramFax NumberMIHP Contact Person FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Medicaid ID NumberLast NameFirst NameDate of BirthAddressCityZip CodePhoneComments (If infant, include parent(s) name and Medicaid # if applicable)REFERRAL FOLLOW-UP LISTReport Date Sent to MIHPReport Date Sent to MHPNotes FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Health PlanFax NumberHealth Plan Contact Person and Phone Number/Email FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????MIHP ProgramFax NumberMIHP Contact Person Phone Number/Email FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Medicaid ID NumberFirst and Last NameEDD if applicableDate of BirthIf Infant, parent(s) name and Medicaid number(s) if applicableBeneficiary/ Referral Status:1=Enrolled2= Enrolled/Transferred from another MIHP (list agency)3= Enrolled in another MIHP (list agency)4=Declined5= Unable to contact6=Other (provide additional information)7=DischargedPhysician Order? If yes:1=RD, 2=additional 9 infant visits,3= SEor NoPermissions1=No scored risk2=Enrolled after 12 months3=Remain open after 18 monthsDate enrolled in MIHPThe Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or MUNICATION TOOL INSTRUCTIONSThese instructions are intended to clarify data. If you have questions about these instructions, MIHP Providers should contact an MIHP State Consultant. MHPs should contact a Contract Manager.MHPThe MHP must use this tool to send referrals to the MIHP on a monthly basis. The MHP will primarily use Page 1 of this Tool – the REFERRAL AND CONTACT INFORMATION LIST page. The MHP should complete the fields at the top portion of each page except for the “Date Sent to MHP. The “Notes” field can be used by either the MHP or the MIHP, as needed.The MHP should populate the name, Medicaid ID number, DOB, address, and phone number. In the comments column, if the beneficiary listed is an infant, include the name and Medicaid ID of the parent(s).Multiple beneficiaries can be listed on this tool.MIHPThe MIHP must use this tool to track information gathered after attempting to contact every beneficiary referral sent by the MHP, then sends the completed tool back to the MHP on a monthly basis. MIHPs also use this form to identify beneficiaries who were not referred by the MHP, but are now enrolled in the MIHP. On page 2 of this Tool - REFERRAL FOLLOW-UP LIST, the MIHP should populate the Medicaid ID number, name, DOB, and if infant, include the name and Medicaid ID of the parent(s).Then for each beneficiary the MIHP must indicate the referral status. Using the numbers as listed on the form, indicate if the beneficiary:Was enrolled in the MIHP (after a referral from the MHP or was enrolled prior to becoming a member of the plan).Was enrolled as a result from a transfer from another MIHP (with name of the other agency).Was enrolled in another MIHP (with the name of the other agency).Declined to enroll (with reason in the comments, if known).Unable to contact (with number of attempts at contact). The MHP then determines whether or not to roll the beneficiary over to the MIHP-MHP Referral and Communication Tool for the following month.Other (with an explanation in the comments).Discharge date.The MIHP must indicate if a physician order is in effect for the beneficiary by stating “Yes” or “No”. If yes, indicate if the order is for: Registered Dietitian.Additional set of 9 infant visits (after the initial 9 visits).Substance exposed infants.The MIHP must also include if they have received consultant approval to provide services in the following circumstances: Beneficiary had no scored risks on the Risk Identifier.Was enrolled after the age of 12 months.Continues to be served by the MIHP after reaching 18 months of age.If after an enrollment was reported to the MHP and a physician order goes into effect or permission is granted to serve an infant over the age of 18 months, the agency has two options: Report these events on the original form sent to the MHP at the time of enrollment.Use a new form, completing all of the fields.If after an enrollment was reported to the MHP and a beneficiary’s address changes, the MIHP should use Page 1 of this form to report an address change. When doing so, indicate that this an address change in the comments box. Note: Out-of-network MIHPs are required to call the MHP before continuing to serve the beneficiary once they are enrolled in a plan. ................
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