Q: What is
Hoosier Healthwise risk-based managed care? A:
Hoosier Healthwise is a managed care program for low income families, children,
and pregnant women. The Office of Medicaid Policy and Planning (OMPP)
pays contracted managed care organizations (MCOs) a monthly premium for each
Indiana Health Coverage Programs (IHCP) enrollee in the MCO’s network.
The MCO assumes financial risk for the services rendered to members in its
network. The MCO manages the care of Hoosier Healthwise members through
its network of primary medical providers (PMPs), specialists, and other
contracted health care providers
Q:
Who is eligible to be a PMP for this program? A:
Hoosier Healthwise has five standard PMP categories – family practice, general
practice, internist, pediatrician, and OB/GYN.
Q:
Will I need to complete an application or contract? A:
To serve as a PMP for MCO members, you must first enroll as an IHCP
provider with one of the five standard PMP categories. After successfully
enrolling in the IHCP, you must contract with one or more MCO to provide
primary care services for risk-based managed care (RBMC) members.
Q: What are the differences between prior authorization and PMP
authorization in RBMC? A: Prior
authorization (PA) and PMP referral are two different processes. A Care Select PMP provides PMP referral by giving a certificate code to other
providers, which authorizes the provider to provide services to the member as
specified by the PMP. Self-referral services do not require the member's
PMP approval, but may require PA. The care management organizations (CMOs) make the PA
determinations for Care Select members.
PMPs contracted with an MCO may be allowed to make referrals to
in-network specialists without a written referral, other than medical record
documentation. MCOs may have different policies on how they handle
referrals within their network.
Each MCO provides PA determinations for its members. Most often,
services for MCO members provided by out-of-network providers (providers who do
not have a contract with the member’s MCO) require PA. Contact the
member’s MCO for information on services requiring PA.
NOTE: PA is not a guarantee of reimbursement, and providers must
continue to verify member eligibility and program assignment through the
eligibility verification system (EVS).
Q: Who can provide
self-referral services? 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. The member’s MCO is responsible for the payment of self
referral services.
Q: Can a PMP be in more than one program at a time?
A:
PMPs can have patients active in any or all of the three programs (Care
Select, RBMC or MCO, and traditional fee-for-service) simultaneously.
Q: If a caseworker or provider has
questions concerning the Hoosier Healthwise Managed Care program, who should
they call? A: If you don't know who to
contact, call the Hoosier Healthwise Helpline at 1-800-889-9949 and select
Option 3 for Provider Services. Those who wish to speak to a Benefit
Advocate should call the same number and select Option 2 for Member
Services. 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 the
appropriate MCO or EDS.
Q: Do Hoosier Healthwise members have third party liability (TPL)?
A: Yes, Hoosier Healthwise members in Package A and B 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. Hoosier
Healthwise Package C members may not have commercial insurance coverage, but may also be enrolled in
the First Steps and Children with Special Health Care Services (CSHCS) programs.
Q: How long does it take to remove a member from an obstetric PMP’s
panel when delivery and follow-up care has been completed? A: Members
enrolled in a pregnancy-only aid category (Package B) generally lose eligibility 60 days after
delivery. However, some pregnant members are enrolled in other aid categories and may remain
eligible for benefits beyond 60 days after delivery (Package A members). In these cases, the
member must contact the Hoosier Healthwise Helpline or a local Benefit Advocate to choose another PMP
to provide care that is not related to pregnancy care.
Q: Who handles RBMC claims disputes? A:
Providers must send MCO claim disputes to the member’s MCO (Anthem, Managed Health Services (MHS),
or MDwise). Medicaid rule 405 IAC 1-1.6 outlines the MCO
claims dispute process for out-of-network providers. Although a provider may make verbal inquiries at
any time, the rule requires the provider to send an informal, written objection to the MCO within 60
days of the provider’s receipt of claim payment or denial. If the matter is not resolved to the
provider’s satisfaction within 30 days of the commencement of the informal process, the provider has
60 days to submit a formal appeal to the MCO. Contracted providers have a similar dispute process
in their contracts with the MCO.
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