A: The following individuals will be required to enroll in Care Select: aged, blind, the physically and mentally disabled, children receiving adoptive services, M.E.D. Works participants, individuals receiving room and board assistance, and the population on Home and Community-Based Services (HCBS) waivers. Providers should utilize the Eligibility Verifications Systems (EVS) prior to rendering services to confirm that the member is eligible for Care Select.

A: The following individuals are excluded from enrollment in Care Select Program: breast and cervical cancer patients, wards, foster children, persons in nursing homes, persons in intermediate care facilities for the mentally retarded (ICF/MRs) and state-operated facilities, persons receiving hospice services, and dual eligibles.

A: The implementation schedule is listed in the table below:

Region	Implementaion Date
Central	November 1, 2007
Northwest, North Central, Northeast, and East Central	March 1, 2008
Southwest, Southeast, and West Central	June 1, 2008

A: Waiver services rendered to waiver members will continue to require approval by their Waiver Case Manager and members must follow the Waiver Plan of Care. These services will not require a referral from their Indiana Care Select PMP. Claims submitted for non-Waiver services rendered by non-Waiver providers will require a referral from their Indiana Care Select PMP, unless the service rendered is a self-referral service for the Indiana Care Select Program. Waiver providers and Waiver Case Managers will continue to work closely together to identify and authorize waiver services for the Indiana Care Select Member. The current prior authorization (PA) process for the Waiver program will be used. However, it is the expectation of the State that strong communications between the Waiver Case Manager and the Indiana Care Select PMP will exist in order to ensure uninterrupted care.

A: Care Select has five standard PMP categories – family practice, general practice, internist, pediatrician, and OB/GYN. In addition, any physician specialist such as a cardiologist, psychiatrist, urologist, and so forth, may serve as a PMP.

A: Yes, to serve as a PMP for CMO members, you must first enroll as an IHCP provider with one of the PMP categories. After successfully enrolling in the IHCP, you must contract with one or more CMOs to provide primary care services for Care Select. The CMO will obtain a signed Care Select Provider Agreement Addendum and the appropriate paperwork to provide information about you and your location.

A: Yes, the State requires that the CMO credential all contracted providers in accordance with National Committee for Quality Assurance (NCQA). All PMPs and specialists must meet these credentialing standards to participate in the CMO’s network.

A: PMPs can determine the panel size limit for each CMO as applicable and there are no minimum or maximums requirements.

A: Yes, PMPs will be able to increase or decrease the panel size. PMPs must complete the appropriate PMP enrollment update form and submit to the applicable CMO(s). Please note, when a PMP submits a request to lower its panel size, members are not removed from the PMP’s panel.

A: No, the panels are maintained separately.

A: Yes, PMPs can have patients active in any or all three programs (Medicaid Select, RBMC or Care Select, and traditional fee-for-service) simultaneously.

A: If you don't know who to contact, call the Care Select Helpline at 1-866-963-7383. If the customer service representative cannot answer a case worker or provider’s questions, the representative will refer the caller to the appropriate number. For example, claims questions are referred to EDS.

A: Yes, Care Select members can have TPL. This information is available from one of the eligibility verification systems (Web InterChange, Automated Voice Response (AVR), or Omni) based on the eligibility information the member provided. Providers should refer to the IHCP Provider Manual for all policies related to TPL including guidelines used for claim submission and updating member’s TPL information.

A: Covered benefits will not change. Some services will be self-referral and will not require the physician to refer the patient for that service. However, these services may require PA from the CMO, just as they do currently.

A: Yes, providers receive a $15 per member, per month administrative fee payment.

A: In addition to the administrative fee, PMPs are reimbursed, based on the fee-for-service schedule. Claims are submitted to the state's fiscal agent, EDS, for processing and payment. EDS will pay the prevailing Medicaid reimbursement rate of file for each service appropriately billed to the IHCP. The CMOs will also be instituting a variety of provider incentives related to quality improvement goals which could be in the form of a bonus above the provider’s fee-for-service rates. The State will also reimburse PMPs $40 for care coordination conference services. The coordination conference call be billed using 99211 SC and is limited to twice per calendar year, per Care Select member.

A: The billing process will not change under Care Select. Providers will use the member’s current RID number and LPI and/or NPI to submit Care Select claims (in accordance with NPI mandatory date requirements) Claim filing policies and procedures outlined in the IHCP Provider Manual should be followed for all claim types.

A: Yes, all Care Select members may be auto-assigned. However, members have 30 days to select a PMP before they are auto-assigned. Members are only auto-assigned to the five traditional PMP types or to a non-traditional PMP type (specialist) if they were previously linked to that physician in the Care Select program. Members may also be linked to a non-traditional PMP type (specialist) on a self-selection basis. Members are able to change their PMP if they are auto-assigned or choose to see a different doctor than originally selected.

A: Yes, you will continue to see members if those members select you as their PMP or the members are referred to you from their assigned PMPs.

A: Only an IHCP or Medicaid-enrolled provider can provide self-referral services. Self-referral services include behavioral health, chiropractic, dental, family planning, HIV/AIDs targeted case management, podiatry, vision, and emergency services.

A: No, some services are self-referral and do not require PMP authorization. These services include: behavioral health, chiropractic, dental, emergency, family planning HIV/AIDS targeted case management, podiatry, vision, and pharmacy.

A: No, members may continue to see specialists that provide services under Indiana Health Coverage Programs (IHCP). However, members enrolled in Care Select are required to obtain a referral from their PMP to see the specialist.

A: No, members are able to access services at the same hospitals and fill their prescriptions at the same pharmacies.

A: No, the CMOs are not responsible for building a pharmacy network. Members can have their prescriptions filled by any IHCP-enrolled pharmacy. PA requests for prescription drugs that require PA must be submitted to ACS. Pharmacy claims must be submitted to EDS for processing and adjudication.

A: Yes, members will continue to have the same ID number and use the same Hoosier Health Card. However, the CMOs may choose to develop their own identification cards for their members.

A: EDS will process claims for the Care Select program. Providers should refer to the quick reference guide at www.indianamedicaid.com or the latest version of the monthly provider newsletter published and distributed by EDS. These newsletters are also available at the aforementioned Web site.

A: You are required to provide a referral by telephone or in writing. This requires the release of your provider ID number and a special two-digit certification code that allows the rendering provider to bill and receive reimbursement.

A: EDS will automatically assign a certification code upon the initial PMP Care Select enrollment and send a notification letter to the PMP providing the certification code and the effective dates. Thereafter, certification codes will re-issued to the PMPs on a quarterly basis and informed by letter notification.

A: No, institutionalized members are excluded from Care Select. There are no plans of including these members in the near future. Providers are reminded to always verify eligibility to ensure that a nursing home resident is enrolled in Medicaid with a Level of Care (LOC). Occasionally, nursing homes retroactively obtain an LOC for a member who has been living in the facility for a number of months. Until that LOC is entered, the member could be enrolled in Care Select.

A: PA is a key responsibility of the CMO. Those services that traditionally require PA such as some surgeries, inpatient stays, home health services, therapy services, and so forth will continue to require PA in the Care Select Program. Providers will be able mail, enter in Web interChange, or call in PA for those services. PA contact information can be found in the IHCP Web site at http://www.indianamedicaid.com/ihcp/ProviderServices/PAAttachmentAddresses.aspx or the IHCP quick reference guide. PA forms are located at http://www.indianamedicaid.com/ihcp/Publications/forms.aspx.

A: Health Care Excel (HCE) stopped accepting PA requests at 6:00 p.m. on October 31, 2007. All PA requests should be submitted to the new contractors. Any PA received by HCE prior to close of business (COB) on October 31, 2007, will be reviewed by November 15, 2007. If an Administrative Review request is received by HCE from the provider by COB on October 31, 2007, HCE will process the request. If HCE is notified by the State by COB on October 31, 2007, of an appeal request HCE will process the appeal and will attend the hearing if it is scheduled prior to December 31, 2007

A: All PA for carved-out services (example: dental services) should be obtained through the CMO assigned to the member as verified through the EVS.

A: The decision about standard PA requests is made within 48 hours of the receipt of request. If a decision is not made within ten days, weekends and State holidays excluded, after receipt of all required documentation, authorization is deemed to be granted within the coverage and limitations specified (405 IAC 5-3-14). The provider must wait until the approved PA decision form or the 278 response is returned to bill for the service or until verification can be made that ADVANTAGE Health Solutions-FFS, ADVANTAGE Health Solutions-CS, or MDwise-CS received the form or the 278 request and did not render a decision on the request within five days. Verification is accomplished using Web interChange PA inquiry or the AVR system. Additional information regarding PA can be found in Chapter 6 of the IHCP Provider Manual at www.indianamedicaid.com.

A: If a member changes programs between Traditional Medicaid (FFS), Care Select, and Hoosier Healthwise, or between Hoosier Healthwise or Care Select plans, all existing PAs are honored for 30 days. This requirement will only be applicable if the member is re-assigned programs between Hoosier Healthwise and Care Select or the Traditional Medicaid FFS program. PAs approved by either of the two Care Select vendors or the FFS vendor will be available in IndianaAIM for claims processing by EDS. The PAs may be for a specific procedure, such as surgery, or for ongoing procedures authorized for a specified duration, such as physical therapy or home healthcare. The IHCP honors the PA for 30 days or for the remainder of the PA dates of service, whichever comes first. Requiring a duplicate authorization from the new plan places an additional burden on the provider and can result in delayed or inappropriately denied treatments or services to the member.

A: Hearing and Appeals, as well as Administrative Reviews, will be completed by the PA vendor who denied the request. (In the event that the Hearing and Appeal or Administrative Review is submitted to the incorrect CMO or FFS organization, the request will be returned to the provider for submission to the appropriate organization for review.) If the member has been assigned to a different program since the request for PA was denied, providers can either appeal to the PA vendor that denied the request or submit a new PA request for review to the current CMO/FFS PA vendor for review. The policies and procedures regarding Hearing and Appeal or the Administrative Review process will remain the same as they are currently published. This information is distributed to the provider and member upon the generation of the PA decision letter or PA update. Further information regarding the Hearing and Appeal and the Administrative Review process can be found in Chapter 6 of the IHCP Provider Manual, Chapter 6 at www.indianamedicaid.com.

A: The reimbursement for ER services will continue to be processed according to the current outpatient reimbursement methodology. Providers must observe all billing rules outlined in Chapter 8 of the IHCP Provider Manual at www.indianamedicaid.com.

A: Yes, the CMOs will be responsible for PA request processing, utilization review, reporting and network development for all medical and behavioral health services covered under the program, with the exception of pharmacy. PA requests for behavioral health drugs (just like other drugs) would fall under the pharmacy carve-out, which will continue to be handled by ACS, the State’s pharmacy benefit manager. EDS will continue to be the entity responsible for claims processing for all claim types.

A: Yes, electronic claims can be submitted to EDS using the electronic claims vendor of their choice or use the claim submission function of EDS – Web interChange. Questions regarding signing up or the use of the Web interChange or EDI electronic claims must be directed to EDS at (317) 488-5160 or 1-877-877-5182.

A: Contracted CMO providers should use Web interChange, OMNI, or AVR to verify a member’s eligibility. Providers must always verify the eligibility prior to rendering services.

A: Members in the Restricted Card Program (RCP) transitioned to the CMOs beginning with the central region phase-in on November 1, 2007. Because the next CMO phase-in will not occur until March 1, 2008, the remainder of the regions will transition over by January 1, 2008. These RCP members will be assigned to ADVANTAGE as the Care Select Traditional Medicaid vendor. Because there will be multiple vendors performing RCP, providers must verify member eligibility to determine to which CMO the member belongs. The EVS that are available to the provider community will provide specific information regarding the member’s CMO and PMP assignment. You should continue the same process you use today for RCP care and referrals. Further information will be forthcoming in future publications. Information regarding the RCP can be found in Chapter 13, Member Utilization Review Process of the IHCP Provider Manual at www.indianamedicaid.com.