Administration Fee Listing Monthly case management fees are paid for every member actively assigned to a Care Select PMP. Fee listings are mailed to the PMP each month and list the members for whom the PMP is receiving adminstrative payment. The administrative fee for Care Select PMPs is $15.00.
Balanced Budget Act of 1997 Public Law 105-33 that makes numerous changes to various titles of the Social Security Act and creates a new Title XXI, the State Children’s Health Insurance Program (CHIP).
Banner Message An informational communication, delivered in conjunction with an IHCP provider’s Remittance Advice (RA).  The banner page conveys important information about program changes and upcoming training sessions.
Bulletin Educational information distributed to IHCP providers, usually pertaining to current or upcoming IHCP events, changes, or policy decisions.
Capitation rate A set of fixed fees that the OMPP pays monthly to an eligible managed care organization for each enrolled Hoosier Healthwise member for the provision of covered medical and health services whether the enrollee received services during the month for which the fee is intended. These rates vary by eligibility category.
Care Management Organization (CMO) The Care Management Organization is an entity that is a Primary Care Case Manager as defined by 42 Code of Federal Regulations (CFR) 438.2.
Care Select Care Select is a care management program that administers managed care for the aged, blind and disabled Medicaid population including the members in the waiver program, MedWorks participants, and members receiving adoption assistance. The Care Select program was implemented in a phased in process, beginning with Central Region, effective November 1, 2007 with a completion date of March 1, 2008.
Care Select Administrative Fee Listing Monthly case management fees of $15 are paid for every member actively assigned to a Care Select PMP. Fee listings are mailed to the PMP each month and list the members for whom the PMP is receiving adminstrative payment.
Central Region An enrollment area in Central Indiana that includes the following counties: Boone, Hamilton, Hancock, Hendricks, Johnson, Madison, Marion, Morgan, Putnam, Rush, and Shelby. The enrollment area for Hoosier Healthwise - RBMC was effective January 1, 2007 and the Care Select program effective November 1, 2007.
Central Region - Terminated December 31, 2006 A Hoosier Healthwise enrollment area in Central Indiana that includes the following counties: Benton, Blackford, Boone, Carroll, Clinton, Delaware, Fayette, Fountain, Grant, Hamilton, Hancock, Hendricks, Henry, Howard, Jay, Johnson, Madison, Marion, Montgomery, Morgan, Parke, Putnam, Randolph, Rush, Shelby, Tippecanoe, Tipton, Union, Vermillion, Warren, and Wayne.
Certification Code Letter Certification codes are assigned to each PMP enrolled in the Care Select network. PMPs use the certification code to authorize specialty care or other medical services/equipment for members assigned to their panel. The Certification Code Letter is generated and mailed quarterly to each actively enrolled Care Select PMP. The letter informs the PMP of their confidential certification code for the current and previous quarters.
Check (Reimbursement) Payment made to an IHCP provider, pursuant to Federal and State law, as compensation for providing covered services to members.
Children’s Health Insurance Program (CHIP) A part of the Balanced Budget Act of 1997 that includes an expansion of the Medicaid program that extends coverage to children ages zero to 19 years old whose family income is the federal poverty level.
CMO See Care Management Organization
CMS Center for Medicare and Medicaid Services - The federal government agency responsible for the IHCP.  Name changed in 2001 from Health Care Financing Administration (see HCFA).
Early Periodic Screening, Diagnosis, and Treatment (EPSDT)/
HealthWatch Services

Those services described at 405 IAC 5-15 as required by Federal law pursuant to 42 U.S.C. 1396d, which include certain preventive services to children under 21 years of age with emphasis given to early detection and prevention of conditions that may result in more costly treatment or long term effects.

East Central Region An enrollment area in East Central Indiana that includes the following counties: Blackford, Cass, Delaware, Fayette, Grant, Henry, Howard, Jay, Randolph, Tipton, Union, and Wayne. The enrollment area for Hooser Healthwise - RBMC was effective January 1, 2007 and the Care Select program effective March 1, 2008.
Emergency Medical Condition A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
Emergency Services With respect to an individual enrolled with a managed care organization, covered inpatient and outpatient services that are furnished by a provider that is qualified to furnish such services and are needed to evaluate or stabilize an emergency medical condition.
Encounter Claims Reports of individual patient encounters with a managed care organization’s network that contain fee-for-service equivalent detail as to procedures, diagnoses, place of service, billed amounts, and rendering or billing providers. Sometimes referred to as shadow claims.
Enrollment Roster Reports sent to the MCO and the Care Select PMPs, twice monthly, for their information of members assigned to their panel.
EQRO External Quality Review Organization
FQHC Federally Qualified Health Center—A publicly funded health care network established under the Omnibus Budget Reconciliation Act (OBRA) of 1989 to increase access to medical care for the homeless, the underinsured and uninsured
HCFA Health Care Financing Administration—The federal government agency responsible for the IHCP (Medicaid).  Name changed in 2001 to Center for Medicare and Medicaid Services (see CMS).
Health Insurance Includes, but is not limited to, coverage by any health care insurer, Health Maintenance Organization, or an employer-administered ERISA plan.
Home and Community Based Services (HCBS) Waiver Program

  

 Eligible participants in HCBS Waiver programs are eligible for IHCP and receive home or community based services not otherwise reimbursed by the Program.. Participants in an HCBW program would require institutionalization in the absence of the waiver services. Additional information about waiver services may be found in the IHCP Provider Manual.
Hoosier Healthwise Hoosier Healthwise is a health insurance program for Indiana children, pregnant women, and low-income families. Health care is provided at little or no cost to Indiana families enrolled in the program.
Hoosier Healthwise Welcome Letter The welcome letter service as the member’s notification of enrollment in the Hoosier Healthwise program.  The letter confirms the member’s PMP selection and service location address assignment and provides a contact number for any questions regarding the member assignment.
ICES Indiana Client Eligibility System. Caseworkers from the Division of Family and Children use this system to help determine applicants’ eligibility for medical assistance, food stamps, and Temporary Assistance for Needy Families (TANF).
IHCP Indiana Health Coverage Programs - the IHCP receive federal and state funds to allow reimbursement for reasonable and necessary medical care for persons meeting eligibility requirements.  Each state administers its own program within broad federal guidelines. In Indiana, the IHCP are administered by the Indiana Family and Social Services Administration (IFSSA), Office of Medicaid Policy and Planning (OMPP).
Indiana Family and Social Services Administration (IFSSA) The umbrella agency responsible for administering many of Indiana’s social services programs, including those administered by the Office of Medicaid Policy and Planning and the Office of the Children’s Health Insurance Program.
IndianaAIM The Indiana Advanced Information Management System; another name for the State’s Medicaid Management Information System (MMIS).
Managed Care Organization Enrollee or Member An IHCP or CHIP enrollee participating in Hoosier Healthwise and enrolled in one of the Hoosier Healthwise managed care organizations.
MCE Managed Care Entity – an individual or organization that participates in the managed care program, either by provision of managed care services or through program administration.
MCO Managed Care Organization - Lawful entities authorized to operate a prepaid health care delivery plan (as an HMO) on a capitated basis that arranges, administers and pays for the delivery of health care services to members as designated by the OMPP.
MCU Managed Care Unit - The EDS Managed Care Unit provides support services to the OMPP in the administration of the Managed Care Programs.
Medicaid Covered Service A service provided or authorized by an IHCP provider for an IHCP enrollee for which payment is available under the IHCP as set forth in 405 IAC 5. A list of covered services is referenced in IC 12-15-5-1.
Medicaid Management Information System (MMIS) The IHCP payment and information system of the Indiana Family and Social Services Administration; also known as IndianaAIM.
Medicaid or Medical Assistance Program Medicaid is a federal-state mandated medical assistance program administered by the State to provide reasonable and necessary medical care for persons meeting medical and financial eligibility requirements pursuant to federal law, 42 U.S.C. 1396 and state law, IC 12-15. The Medicaid program in Indiana is known as Indiana Health Coverage Programs (IHCP).
Medicaid Recipient/Indiana Health Coverage Programs Enrollee An IHCP enrollee in one of these aid categories: Aged; Blind and Disabled; Temporary Assistance for Needy Families; Pregnancy Medicaid; Children’s Medicaid.
Medically Necessary Medically necessary services covered by the IHCP are specified in 405 IAC 5.
Member or Enrollee An IHCP recipient who is enrolled in any of the state’s health coverage programs.
Member Enrollment Roster Reports sent to MCO and the Care Select PMPs, twice monthly, for their information of members assigned to their panel.
Member Welcome Letter The welcome letter serves as the member's notification of enrollment in the Managed Care programs. The letter confirms the member's PMP selection and service location address assignment and provides a contact number for any questions regarding the member assignment.
North Central Region An enrollment area in North Central Indiana that includes the following counties: Elkhart, Fulton, Marshall, Pulaski, St. Joseph, and Starke. The enrollment area for Hoosier Healthwise - RBMC was effective January 1, 2007 and the Care Select program effective March 1, 2008.
Northeast Region An enrollment area in Northeast Indiana that includes the following counties: Adams, Allen, Dekalb, Huntington, Kosciusko, LaGrange, Miami, Noble, Steuben, Wabash, Wells, and Whitley. The enrollment area for Hoosier Healthwise - RBMC was effective January 1, 2007 and the Care Select program effective March 1, 2008.
Northern Region - Terminated December 31, 2006 A Hoosier Healthwise enrollment area in Northern Indiana that includes the following counties: Adams, Allen, Cass, Dekalb, Elkhart, Fulton, Huntington, Jasper, Kosciosko, LaGrange, LaPorte, Marshall, Miami, Newton, Noble, Porter, Pulaski, St. Joseph, Starke, Steuben, Wabash, Wells, White and Whitley.
Northwest Region An enrollment area in Northwest Indiana that includes the following counties: Jasper, Lake, LaPorte, Newton, and Porter. The enrollment area for Hoosier Healthwise - RBMC was effective January 1, 2007 and the Care Select program effective March 1, 2008.
Office of Children’s Health Insurance Program (CHIP) The office within the Indiana Families and Social Services Administration that administers the Children’s Health Insurance Program. The CHIP office is responsible for developing the policies and procedures for Hoosier Healthwise Package C enrollees.
Office of Medicaid Policy and Planning (OMPP) The office within the Indiana Families and Social Services Administration that is the designated state agency that administers the Indiana Health Coverage Programs. The OMPP is responsible for developing the policies and procedures for Hoosier Healthwise.
Out of State/IFSSA Region: An enrollment area for the Managed Care Programs created for Auto-assignments to out-of-state PMPs with the Indiana Family and Social Services (IFSSA) designation. IFSSA out-of-state designations are defined in 405 IAC 5-5-2 and delineated as cities that reside outside the state of Indiana, excluded from out-of-state prior authorization (PA) requirements and required to follow in-state PA requirements. The cities defined as IFSSA out-of-state designations are as follows:
 
      Chicago, Illinois   Sturgis, Michigan
      Danville, Illinois   Cincinnati, Ohio
      Watseka, Illinois   Hamilton, Ohio
      Louisville, Kentucky   Harrison, Ohio
      Owensboro, Kentucky   Oxford, Ohio
PMP Disenrollment Letter Letter to the PMP confirming the effective date of a PMP disenrollment from an MCO or Care Select.
Quality Assurance/ Quality Control (QA/QC) QA/QC are interrelated methods of monitoring the services that MCOs arrange or administer for its enrollees.
Quality Improvement Committee (QIC) The committee established by the OMPP that provides oversight for the appropriateness and quality of care provided to enrollees by establishing standards and guidelines for the provision of care. The QIC is responsible for integrating the quality improvement process and services as a coordinating and advisory body.
RBMC Risk-Based Managed Care is a program in which MCOs contract with the State to provide medical service to members under a risk-based arrangement, the State pays the contracted MCO on a per member per month basis (also known as capitation).
Remittance Advice (RA) Providers receive a weekly RA statement about the status of processed claims.  RAs provide information about claims that are paid, denied, in process, or adjusted. The RA also provides information about other financial transactions that were processed.
RHC Rural Health Clinic—A cost-based reimbursement system of clinics created under the Rural Health Clinic Services Act of 1977 to provide better access to services for people in rural, medically underserved areas through the use of mid-level practitioners
SE EDS Systems Unit Engineer
Southeast Region An enrollment area in Southeast Indiana that includes the following counties: Bartholomew, Clark, Crawford, Dearborn, Decatur, Floyd, Franklin, Harrison, Jackson, Jefferson, Jennings, Ohio, Ripley, Scott, Switzerland, and Washington. The enrollment area for Hoosier Healthwise - RBMC was effective January 1, 2007 and the Care Select program effective March 1, 2008.
Southern Region - Terminated December 31, 2006 A Hoosier Healthwise enrollment area in Southern Indiana that includes the following counties: Bartholomew; Brown, Clark, Clay, Crawford, Daviess, Dearborn, Decatur, Dubois, Floyd, Franklin, Gibson, Greened, Harrison, Jackson, Jefferson, Jennings, Knox, Lawrence, Martin, Monroe, Ohio, Orange, Owen, Perry, Pike, Posey, Ripley, Scott, Spencer, Sullivan, Switzerland, Vanderburgh, Vigo, Warrick, and Washington.
Southwest Region An enrollment area in Southwest Indiana that includes the following counties: Brown, Daviess, Dubois, Gibson, Greene, Knox, Lawrence, Martin, Monroe, Orange, Owen, Perry, Pike, Posey, Spencer, Vanderburgh, and Warrick. The enrollment area for Hoosier Healthwise - RBMC was effective January 1, 2007 and the Care Select program effective March 1, 2008.
TANF Temporary Assistance to Needy Families for caretakers and children under age 18 years of age that meet eligibility requirements.
Third Party Any person or entity that is or may be liable to pay for health care and services rendered to an IHCP enrollee. Some examples of third parties include an individual or group plan health insurer, casualty insurer, a health maintenance organization (HMO), or an employer-administered ERISA plan.
Utilization Review (UR) A process by which the MCO or CMO performs ongoing monitoring of the services arranged for and administered by the MCO or CMO and provided by its participating providers to ensure that members receive appropriate and medically necessary health care services.
West Central Region An enrollment area in West Cenral Indiana that includes the following counties: Benton, Carroll, Clay, Clinton, Fountain, Montgomery, Parke, Sullivan, Tippecanoe, Vermillion, Vigo, Warren, and White. The enrollment area for Hoosier Healthwise - RBMC was effective January 1, 2007 and the Care Select program effective March 1, 2008.