What Is Plan Navigator?

The Plan Navigator page is used to search for and edit a Medicaid Management Information System (MMIS) or pharmacy benefit plan or to add a new benefit plan for a line of business. Procedures for MMIS plans and field descriptions for maintaining MMIS plans are provided in topics on the various Plan Navigator components.

Procedures for pharmacy plans are provided in the Help for PBM OS+.

• Navigator

  The Navigator is used to move through the various plans and is visually organized to show you the hierarchical relationship between the customer, lines of business, benefit plans assigned to that line of business, and then the components of each of those benefit plans. Click a benefit plan or one of its components in the Navigator and the corresponding information is displayed on the right side of the Plan Navigator page.

• MMIS Plan Components

  • Main Plan Identification

    Before you can add a benefit plan, you must identify the line of business with which it is associated, provide a unique plan ID, and describe what kind of plan it is. You do this on the main Plan Navigator page for an MMIS plan that is first presented when adding or editing a plan. The MMIS benefit plan page also contains panels to enter the following information:

    • Capitation/Case Management Information - In order to use the Capitation/Case Management fields, the type of benefit plan must indicate it is for managed care or a plan using primary care physicians.
    • Provider Network Information - On the main Plan Navigator page, you also associate networks of providers that are allowed to perform services covered by the benefit plan. As a claim is processed, ND MMIS checks to make sure that the provider on the claim is assigned to one of the networks associated with the appropriate benefit plan.

  • Coverage

    You set up coverage information for a benefit plan on Plan Navigator - Coverage.

  • Service Authorization

    If any of the services covered under the plan require prior authorization, you must define what those services are and if the service authorization information has to be submitted on the claim or if it can be looked up in ND MMIS. You set up this information for a benefit plan on Plan Navigator - Service Authorization Requirement.

  • Referral

    If any of the services covered under the plan require a referral, you must define what those services are and if the referral information has to be submitted on the claim or if it can be looked up in ND MMIS. You set up this information for a benefit plan on Plan Navigator - Referral Requirement.

  • Plan Limits

    On Plan Navigator - Plan Limits you set limits to restrict the dollar amount or number of units of service that can be covered for a particular benefit plan. You can also establish rules about what should be paid or not (cutback) if these limits are exceeded.

  • Co-Pay - This functionality is reserved for future use.

    Co-pays are most often set up for Medicaid HMOs or other managed care benefit plans. You set up this information for a benefit plan on Plan Navigator - Co-Pay.

  • Co-Insurance - This functionality is reserved for future use.

    Co-insurance is most often set up for Medicaid HMOs or other managed care benefit plans. You set up this information for a benefit plan on Plan Navigator - Co-Insurance.

  • Deductible - This functionality is reserved for future use.

    Deductibles are most often set up for Medicaid HMOs or other managed care benefit plans. You set up deductible limits for a benefit plan on Plan Navigator - Deductible. You can set limits for three different coverage tiers, if applicable: an individual, an individual plus one, and a family.

  • Out of Pocket - This functionality is reserved for future use.

    Out-of-pocket maximum limits are most often set up for Medicaid HMOs or other managed care benefit plans. You set up out-of-pocket limits for a benefit plan on Plan Navigator - Out of Pocket. If applicable, you can set limits for three different coverage tiers: an individual, an individual plus one, and a family.

  • Cutback Rule Sequence - This functionality is reserved for future use.

    Cutback rule sequences are most often set up for Medicaid HMOs or other managed care benefit plans to manage the processing order of the various rules that often apply (co-pay amounts, deductibles, out-of-pocket maximums, etc.). You setup the effective dates and rule types for the cutback rules for a benefit plan on Plan Navigator - Cutback Rule Sequence.

Instructions

How to View a Benefit Plan

How to Add or Edit an MMIS Benefit Plan

• How to Add or Edit an MMIS Benefit Plan
• How to Add or Edit Main Identifying Information for an MMIS Plan
• How to Add or Edit Coverage for a Benefit Plan
• How to Add or Edit Service Authorization Requirements for a Benefit Plan
• How to Add or Edit Referral Requirements for a Benefit Plan
• How to Add or Edit Plan Limits for a Benefit Plan

If managed care functionality is available:

• How to Add or Edit Co-Pays for a Benefit Plan
• How to Add or Edit Co-Insurance for a Benefit Plan
• How to Add or Edit Deductibles for a Benefit Plan
• How to Add or Edit Out of Pocket for a Benefit Plan
• How to Add or Edit Cutback Rule Sequences for a Benefit Plan

How to Close a Benefit Plan

How to Delete a Component of a Benefit Plan

How to Void a Component of a Benefit Plan

Field Descriptions

Plan Navigator - Navigator Page

For an MMIS Benefit Plan:

• Plan Navigator - Main Page
• Plan Navigator - Coverage Page
• Plan Navigator - Service Authorization Requirement Page
• Plan Navigator - Referral Requirement Page
• Plan Navigator - Plan Limits Page
• If managed care functionality is available:
  • Plan Navigator - Co-Pay Page
  • Plan Navigator - Co-Insurance Page
  • Plan Navigator - Deductible Page
  • Plan Navigator - Out of Pocket Page
  • Plan Navigator - Cutback Rule Sequence Page

See Also

About Benefit Plans

Before Using a Benefit Plan

Version as of 5/16/14.