PM 20-24-04: MCO Services

WAG 20-24-04

Managed Care Organizations (MCOs) are responsible for providing the same medical services that are covered under Medicaid.Deleted Text.

  • New Text.Refer general customer questions about managed care plans to the plan in which the customer is enrolled.
  • Refer the customer to the Health Benefits Hotline, 1-866-255-5437 for general questions not related to managed care.

A Revised Text.customer enrolled in a MCO should receive all services through the MCO's network of providers. Customers can only see providers who are outside of the MCO's network if prior authorization has been granted by the MCO. Customers and providers should work directly with the MCO if there are questions about prior authorizations.

An exception to this is family planning services which may be provided by a Network or non-Network provider and no prior authorization is necessary. A customer who is out of the service area and needs medical attention that is not an emergency must call the MCO for a referral.

In an emergency, the customer can go to the nearest hospital to receive services. Each MCO has emergency after-hours phone numbers available for customers to call.

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