indiana health coverage programs (ihcp) 101provider.indianamedicaid.com/media/28802/indiana helath...

74
October 2007 Insert photo here Indiana Health Coverage Programs (IHCP) 101 Presented by EDS Provider Field Consultants

Upload: hoangdieu

Post on 05-May-2018

220 views

Category:

Documents


3 download

TRANSCRIPT

Page 1: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

October 2007

Insert photo here

Indiana Health Coverage Programs (IHCP) 101Presented by

EDS Provider Field Consultants

Page 2: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 1012 / OCTOBER 2007

Agenda• Session Objectives• IHCP Team• Provider Enrollment• Member Eligibility• EDS’ Role in Eligibility• Eligibility Verification Systems• Indiana Health Coverage Programs• Pharmacy• Prior Authorization• Third Party Liability• Billing an IHCP Member• Claim Filing• Medicare Crossovers• Voids and Replacements• Adjustment Form• Helpful Tools• Questions

Page 3: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 1013 / OCTOBER 2007

Session Objectives

At the end of this session, providers will be able to:• Understand the roles of the IHCP contractors• Understand the importance and use of the EVS• Identify the populations served by the various IHCP programs

• Understand the role of the risk-based managed care organizations and the populations they serve

• Follow claim filing procedures• Understand the use of the internal control number (ICN)• Understand how to complete the Adjustment Request Form

Page 4: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 1014 / OCTOBER 2007

IHCP Team

• Indiana Family and Social Services Administration (IFSSA):–Office of Medicaid Policy and Planning (OMPP) and Children’s

Health Insurance Program (CHIP) Office–Local Office of the Division of Family Resources

• Contractors:–EDS–Health Care Excel (HCE) / Advantage Health Solutions

–Affiliated Computer Services (ACS)–Myers and Stauffer, LC

• Managed Care Contractors:–AmeriChoice / MAXIMUS–Anthem–Managed Health Services (MHS) –MDwise

Page 5: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 1015 / OCTOBER 2007

Office of Medicaid Policy and Planning (OMPP)

The OMPP and the CHIP Office:

• Determine rules and regulations (IAC)

• Determine and approve reimbursement level

• Address cost containment issues

• Establish IHCP policies

Page 6: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 1016 / OCTOBER 2007

Health Care Excel

• Health Care Excel (HCE) will process medical prior authorization (PA) requests for traditional Medicaid members through October 31, 2007.

• Effective November 1, 2007, medical PA requests will be processed by Advantage Health Solutions

• Prior authorization does not guarantee payment.

• HCE reviews prior authorization requests for medical necessity.

–Providers must verify member eligibility prior to rendering service.

Page 7: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 1017 / OCTOBER 2007

Prior Authorization• Through October 31, 2007, mail PA requests to:

Health Care Excel Prior Authorization Department

P. O. Box 531520Indianapolis, IN 46253-1520

• Obtain emergency PA by calling the HCE Prior Authorization Department at (317)347-4511 or (800) 457-4518.

• On and after 11-1-07, mail PA requests to:

ADVANTAGE Health Plan-FFS

P.O. Box 40789

Indianapolis, Indiana 46240

• Or call 1-800-269-5720

Page 8: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 1018 / OCTOBER 2007

Affiliated Computer Services (ACS)

• ACS manages the pharmacy benefit for Indiana Medicaid, which includes the following responsibilities:

–Administer the preferred drug list (PDL)

–Process prior authorizations for prescription drugs

• Includes drugs not on the PDL

–Facilitate drug rebate services

–Interact with the Drug Utilization Review (DUR) Board

–Interact with the Therapeutics Subcommittee

Page 9: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 1019 / OCTOBER 2007

Myers and Stauffer, LC

• A certified public accounting firm that provides professional accounting, consulting, data management and analysis services to government-sponsored healthcare programs

• Rate-setting contractor for the OMPP

Page 10: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10110 / OCTOBER 2007

Managed Care Organizations

• Effective January 1, 2007, three managed care organizations (MCOs) began serving the approximately 535,000 Hoosiers who receive Medicaid through the Hoosier Healthwise program. The MCOs are:

•Anthem

•Managed Health Services (MHS)

•MDwise

• Medical care is managed through each MCO’s network of contracted primary medical providers (PMPs) and specialists

• The MCO assumes financial risk for services rendered to members in its network

Page 11: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10111 / OCTOBER 2007

EDS Provider Enrollment

The EDS Provider Enrollment Unit:

• Enrolls new Medicaid providers

• Services providers undergoing change of ownership

• Maintains and updates the provider file

• Recertifies certain provider types and out-of-state providers

Contact the Provider Enrollment Helpline at 1-877-707-5750

Page 12: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10112 / OCTOBER 2007

Where Does Eligibility Begin?Member Eligibility

A person may apply for programs at various locations, including local offices of the Division of Family Resources (DFR)

A caseworker at the DFR:

• Determines member eligibility status

• Enters the application into the Indiana Client Eligibility System (ICES)

• Makes spend-down determinations

• Maintains member eligibility files

Page 13: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10113 / OCTOBER 2007

Eligibility Modernization ProjectMember Eligibility

• IFSSA has partnered with a coalition led by IBM. The coalition includes national and Indiana experts in human services, technology, and job training and placement.

• Benefits of the modernization project include:

–Improved job placement and training

–Updated technology

–Reduced processing errors

–Improved identification of potential fraud

–Improved processes for intake and Medicaid eligibility determinations

Page 14: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10114 / OCTOBER 2007

Member EligibilityEligibility Modernization Project

• The first counties to be phased-in are: Blackford, Carroll, Cass, Delaware, Grant, Howard, Madison, Miami, Randolph, Tipton, Wabash, and White

• Implementation begins late October 2007

Page 15: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10115 / OCTOBER 2007

EDS’ Role in Eligibility

• Receives data from ICES

• Performs ICES-related updates to IndianaAIM within 72 hours

• Maintains third party liability (TPL) and Medicare information

• Provides the eligibility verification system (EVS) –Web interChange, Automated Voice Response (AVR), and Omni

• Makes EVS available to providers 24 hours a day, seven days a week

Page 16: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10116 / OCTOBER 2007

Eligibility Verification Systems

• Available at: www.indianamedicaid.com

interChange Home

Indiana MedicaidAdministrator Menu Check InquiryClaim SubmissionClaim InquiryEligibility InquiryPA SubmissionPA InquiryProvider ProfileHelpFAQHow to Obtain an IDContact UsLogonLogoffChange Password

Web interChange

Page 17: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10117 / OCTOBER 2007

Eligibility Verification SystemsWeb interChange

The following enhanced features are only available through Web interChange:

• County caseworker, county information, and case identification numbers

• Detailed TPL information

• Online TPL update requests

Page 18: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10118 / OCTOBER 2007

Eligibility Verification SystemsAutomated Voice Response System

AVR provides the following:

• Member eligibility verification

• Benefit limits

• Prior authorization

• Claim status

• Check write

Contact AVR at (317) 692-0819 in the Indianapolis local area or 1-800-738-6770

AVR instructions are in Chapter 3 of the IHCP Provider Manual

Page 19: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10119 / OCTOBER 2007

OmniEligibility Verification Systems

• Is cost effective for high-volume providers

• Uses plastic Hoosier Health card

• Allows manual entry

• Prints two-ply forms

• Requires upgrade for benefit limit information (refer to IHCP Provider Bulletin BT200711)

See Chapter 3 of the IHCP Provider Manual for more information

Page 20: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10120 / OCTOBER 2007

Indiana Health Coverage Programs

IHCP(Four Subprograms)

Traditional Medicaid

Hoosier Healthwise

Risk-Based Managed Care

590 Medicaid SelectCare Select

Page 21: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10121 / OCTOBER 2007

• Applies to individuals with income in excess of the Traditional Medicaid threshold

• Spend-down is credited on claims based on the order they are processed

• ARC 178 appears on the remittance advice when spend-down is credited on claims

• Providers should bill the member for the amount listed beside ARC 178

• Member is responsible to pay upon receipt of the Spend-down Summary Notice

Traditional MedicaidSpend-down

Page 22: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10122 / OCTOBER 2007

Qualified Medicare Beneficiary-Only (QMB-Only)Traditional Medicaid

• State program pays for Medicare Part B premiums, co-insurance, and deductibles

• Medicare non-covered services are also denied as non-covered by the IHCP and are the member’s responsibility–Provider must obtain a signed waiver to bill the member

• The IHCP only covers Medicare covered services

See Chapter 2 of the IHCP Provider Manual for more information

Page 23: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10123 / OCTOBER 2007

Qualified Medicare Beneficiary-Also (QMB-Also)Traditional Medicaid

• QMB-Also (no spend-down)

–The member is eligible for the full array of IHCP covered benefits

–The IHCP reimburses the Medicare coinsurance and deductible

–The IHCP reimburses for Medicaid covered services that are non-covered by Medicare

• QMB-Also (with spend-down)

–Medicare non-covered services credit spend-down

–Medicare coinsurance and deductible do not credit spend-down

–The IHCP reimburses the Medicare coinsurance and deductible

Page 24: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10124 / OCTOBER 2007

Restricted Card

• IHCP members needing an educational contact to prevent the over-utilization of services will have restrictions placed on their access to:– Pharmacies– Hospitals– Physicians– Other services

• HCE administers the Restricted Card Program for the fee-for-service delivery system (non-RBMC). Contact HCE at317-347-4500 or 1-800-457-4515.

• Effective January 1, 2008, Advantage Health Solutions will administer the Restricted Card Program for traditional Medicaid members

Page 25: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10125 / OCTOBER 2007

Restricted Card

Members must obtain a referral letter from the restricted physician, unless the service is an emergency.

• Non-restricted hospitals require a letter from the restricted physician and the letter must contain the following:– Physician name

– Provider number

– Medical condition

• Field 17 of the CMS-1500 must contain the name of the restricted physician

• Field 17a of CMS-1500 claims may have the ZZ qualifier and restricted physician’s taxonomy code (when required for 1-to-1 match)

• Field 17b of CMS-1500 claims must have the restricted physician’s NPI number

Page 26: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10126 / OCTOBER 2007

590 Program

• 590 members include residents of State-owned facilities under the direction of the IFSSA, the Division of Mental Health and Addiction (DMHA), and the Indiana State Department of Health (ISDH)

• Providers must be enrolled in the 590 Program

• Providers must bill all claims with a paid amount less than $150 to the facility

• PA is required for all services provided to 590 members when the provider bills a total of $500 or more per claim

Page 27: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10127 / OCTOBER 2007

Medicaid Select

The following are covered groups under Medicaid Select / Care Select:

• Children receiving adoption assistance

• Aged

• Blind

• Physically and mentally disabled

• Medicare and IHCP dual eligible members (not included in the Care Select population)

• Individuals receiving room and board assistance

• M.E.D. Works participants (Medicaid for Employees with Disabilities)

Page 28: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10128 / OCTOBER 2007

Medicaid Select

The following are not covered groups under Medicaid Select:

• Breast and cervical cancer patients

• Individuals for whom the IHCP pays only the Medicare Part B premium

• Wards

• Foster children

• Members in nursing homes, intermediate care facilities for the mentally retarded (ICFs/MR), and state-operated facilities

• Members on waivers

• Members receiving hospice services

• Members with spend-down

Page 29: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10129 / OCTOBER 2007

Medicaid Select

AmeriChoice provides the following:• Provider Services – Develops and

administers the Medicaid Select / Care Select network

• Enrollment Broker – Educates and enrolls eligible members (links member with a PMP) into the program

• Member Services – Manages Medicaid Select Helpline – 1-877-MEDSELECT (1-877-633-7353) Hoosier Healthwise Helpline (1-800-889-9949, Option 3)

• Beginning January 1, 2008, MAXIMUS will transition to the role of enrollment broker for Hoosier Healthwise

Page 30: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10130 / OCTOBER 2007

Medicaid Select

• Physicians in the following areas may be a Medicaid Select PMP:

–Family practice

–General practice

–Internist

–Pediatrician

–OB/GYN

• Physician specialists may also enroll as PMPs

• PMP changes will be processed by EDS from January 1 through May 31, 2008

Page 31: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10131 / OCTOBER 2007

Medicaid Select

Billing institutional claims:

• Contact the PMP for authorization when required

• Bill on a UB-04:

–Two-digit certification code: Field 37

–PMP NPI: Field 78

• Providers that submit electronic (837I) claims via means other than Web interChange, should consult their software or clearinghouse vendor

Page 32: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10132 / OCTOBER 2007

Medicaid Select

Billing professional claims:

• Contact the PMP for authorization when required

• Bill on a CMS-1500 (08/05 version accepted April 1, 2007):

–PMP ZZ Qualifier and Taxonomy Code: Field 17a, Shaded area (when required for 1-to-1 match)

–PMP NPI – Field 17b

–Two-digit certification code: Field 19

• Providers that submit electronic (837P) claims via means other than Web interChange, should consult their software or clearinghouse vendor

Page 33: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10133 / OCTOBER 2007

Medicaid Select

• Members enrolled in Medicaid Select can self-refer for the following services:

―Chiropractic

―Family planning

―HIV care coordination

―Podiatry

―Vision care (except surgery)

―Service for true emergencies

―Mental health, by provider type and specialty

―Transportation

―Individualized education plan

―Dental

―Durable medical equipment / home medical equipment

Page 34: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10134 / OCTOBER 2007

Care SelectProgram Benefits

• Benefits of the Care Select program include:–Improved quality of care and health outcomes for

members

–Improved client safety

–Qualitative adherence to treatment plans

–Direct communication between the primary medical provider and the Care Management Organizations

–Controlled fiscal growth

Page 35: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10135 / OCTOBER 2007

Care Management OrganizationsCare Select

• Two health plans were selected to function as care management organizations (or, CMOs) for the Care Select program–Advantage Health Solutions

• www.advantageplan.com

• 1-866-504-6708

–MDwise

• MDwise also serves as one of Indiana’s three Hoosier Healthwise managed care organizations (MCOs)

• www.mdwise.org

• 1-866-440-2449

Page 36: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10136 / OCTOBER 2007

Enrollment Broker Transition

• Currently, AmeriChoice serves as the enrollment broker for Hoosier Healthwise and Medicaid Select

• Beginning November 1, 2007, MAXIMUS Administrative Services, Inc. (MAXIMUS) will transition to the Care Select enrollment broker

• Beginning January 1, 2008, MAXIMUS will transition to the Hoosier Healthwise enrollment broker

• AmeriChoice and MAXIMUS will share the same phone number

• Contact the enrollment broker at: 1-866-963-7383

Page 37: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10137 / OCTOBER 2007

Implementation ScheduleCare Select

• The Care Select Program will be phased in by geographic regions:

• November 1, 2007 – Central Region–Boone, Hamilton, Hancock, Hendricks, Johnson,

Madison, Marion, Morgan, Putnam, Rush, Shelby

• March 1, 2008 – Northwest, North Central, Northeast, and East Central–Jasper, Lake, LaPorte, Newton, Porter, Elkhart,

Fulton, Marshall, Pulaski, Starke, St. Joseph, Adams, Allen, Dekalb, Huntington, Kosciusko, Lagrange, Miami, Noble, Steuben, Wabash, Wells, Whitley, Blackford, Cass, Delaware, Fayette, Grant, Henry, Howard, Jay, Randolph, Tipton, Union, Wayne

Page 38: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10138 / OCTOBER 2007

Implementation ScheduleCare Select

• June 1, 2008 – Southwest, Southeast, West Central–Brown, Daviess, Dubois, Gibson, Greene, Knox,

Lawrence, Martin, Monroe, Posey, Orange, Owen, Perry, Pike, Spencer, Vanderburgh, Warrick, Bartholomew, Clark, Crawford, Dearborn, Decatur, Floyd, Franklin, Harrison, Jackson, Jefferson, Jennings, Ohio, Ripley, Scott, Switzerland, Washington, Benton, Carroll, Clay, Clinton, Fountain, Montgomery, Parke, Sullivan, Tippecanoe, Vermillion, Vigo, Warren, White

Page 39: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10139 / OCTOBER 2007

Hoosier HealthwiseBenefit Packages

Benefit packages determine the scope of services covered:

• Package A – Full benefits

• Package B – Pregnancy

• Package C – Children’s Health Insurance Program (CHIP)

• Package E – Emergency

Page 40: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10140 / OCTOBER 2007

Hoosier Healthwise

• Member is eligible for Hoosier Healthwise Package A, Standard Plan–Member eligible for the full array of IHCP benefits

–Member is, or will soon be enrolled in managed care

–EVS identifies the member’s PMP

–EVS identifies member’s managed care plan and delivery system (for example, fee-for-service, RBMC)

Benefit Package A

Page 41: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10141 / OCTOBER 2007

Hoosier Healthwise

• Member is eligible for Hoosier Healthwise Package B, Pregnancy Coverage–Package B includes treatment of

conditions that may complicate pregnancy

–Members may be enrolled in a managed care plan

Benefit Package B

Page 42: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10142 / OCTOBER 2007

Hoosier Healthwise

• Package B coverage includes transportation and pharmacy services related to the following categories: –Pregnancy

–Prenatal care

–Delivery

–Postnatal care

–Urgent care

–Family planning

–Dental services

Benefit Package B

Page 43: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10143 / OCTOBER 2007

Hoosier Healthwise

• Member is eligible for Hoosier Healthwise Package C Children’s Health Insurance Plan–Package C covers children

younger than 19 years old

–Family must satisfy cost-sharing requirements

–Premium must be paid before eligibility is granted

–Members must be enrolled in a managed care plan

Benefit Package C

Page 44: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10144 / OCTOBER 2007

Hoosier Healthwise

• Member is eligible for Hoosier Healthwise Package E, Emergency Services

• These members are ONLY eligible for:–Labor and delivery until mother is stable

–Medical emergencies

• A medical condition of sufficient severity (including severe pain) that the absence of medical attention could result in placing the member’s health in serious jeopardy, serious impairment of bodily functions, or serious dysfunction of any organ or part

• Non-emergency services may be billed to the member if a signed waiver was obtained prior to rendering services

Benefit Package E

Page 45: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10145 / OCTOBER 2007

Risk-Based Managed Care

• Enables coordination and continuity of healthcare services

• Provides for a comprehensive and holistic care management model to facilitate better health outcomes

• Promotes early intervention and treatment to reduce the need for critical and expensive medical services

• Supports efficient use of medical services

• Promotes cost savings for the Medicaid program

Benefits of the RBMC Delivery Model

Page 46: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10146 / OCTOBER 2007

Risk-Based Managed Care

Member enrollment is effective in Hoosier Healthwise and Medicaid Selectonly on the 1st and 15th of the month

For example: If a person is enrolled in fee-for-service on August 1, the person could switch to a Hoosier Healthwise MCO on August 15.

Enrollment Effective Dates

Page 47: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10147 / OCTOBER 2007

Risk-Based Managed Care

IHCP providers that are out of network (have not signed a contract with the MCO) must contact the appropriate MCO for specific policies and procedures for authorization and billing.

Page 48: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10148 / OCTOBER 2007

Risk-Based Managed Care

• Anthem– 1-866-408-6132

– www. anthem.com

• Managed Health Services―1-800-414-9475―www.managedhealthservices.com

• MDwise―1-800-356-1204―www.mdwise.org

Resources

Page 49: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10149 / OCTOBER 2007

Risk-Based Managed Care

Members enrolled in RBMC can self-refer for the following in-network services:

• Chiropractic

• Family planning

• HIV care coordination

• Podiatry

• Vision care (except surgery)

• Treatment of true emergency

Self Referral

Page 50: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10150 / OCTOBER 2007

Risk-Based Managed Care

• MCOs are not responsible for authorizing or paying for carved-out services:–Dental

–Individualized education plans

–Psychiatric Residential Treatment Facilities (PRTF)

–Medicaid Rehabilitation Option (MRO)

–Inpatient state-owned psychiatric hospital

• EDS processes claims for carved-out services–Prior authorization must be obtained from HCE for

carved-out services, if applicable.

Exceptions

Page 51: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10151 / OCTOBER 2007

Risk-Based Managed Care

• Claims billed to EDS for services that are not carved out of the MCOs’ responsibility deny with edits 2017 or 2018. Providers should:–Verify eligibility to determine the

appropriate MCO

–Submit claims to the appropriate MCO

Claims

Page 52: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10152 / OCTOBER 2007

Pharmacy

• The IHCP only accepts pharmacy or compound drug claims for drugs or biologicals.

• Providers must continue to verify IHCP member eligibility.

• EDS processes all pharmacy claims for non-RBMC members.

• ACS processes prior authorization requests for pharmacy services. Contact ACS at 1-866-879-0106.

• Contact EDS Customer Assistance at 1-800-577-1278, Option 1.

Page 53: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10153 / OCTOBER 2007

Prior Authorization

• HCE processes all prior authorization (PA) requests for non-pharmacy supplies and non-RBMC members.

• HCE reviews PA requests for medical necessity.

• Providers must verify member eligibility prior to rendering service.

• PA does not guarantee payment.

Page 54: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10154 / OCTOBER 2007

Prior Authorization

To support continuity of care, HCE and the MCOs must honor approved prior authorizations for the first 30 days from the date a member changes from Traditional Medicaid to RBMC and vice versa, or from one MCO to another MCO.

Example: Member changes from traditional Medicaid to RBMC on the 15th day of the month. The PA is valid for 30 calendar days or until units are exhausted, whichever occurs first.

Page 55: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10155 / OCTOBER 2007

Third Party Liability

• Blanket denials

• TPL denials and payments

• 90-day provision

• Medicare HMO claims

• Updates to TPL information

Refer to Chapter 5 of the IHCP Provider Manual for more information

Page 56: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10156 / OCTOBER 2007

Third Party Liability

• The IHCP is the payer of last resort

• Exceptions:–Victim Assistance

–First Steps

–Children’s Special Healthcare Services

–Hospital Care for the Indigent (HCI)

Page 57: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10157 / OCTOBER 2007

Billing an IHCP Member

• Members must sign a waiver before receiving non-covered services

• The waiver must include information about one of the following situations:–The service is non-covered

–The member exceeded the program rules for benefit limitations or prior authorization

Page 58: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10158 / OCTOBER 2007

Billing an IHCP Member

A waiver is not necessary in the following instances:

• The member failed to advise the provider of IHCP eligibility within 12 months from the date of service

• The charges credited to spend-down

• The member must pay State-mandated program co-payments

• Amounts are above the $600 dental cap

Page 59: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10159 / OCTOBER 2007

Claim Filing

• File claims electronically using one of the following methods ortools:

–Web interChange

• At the logon screen, click “How to Obtain an ID”

• Print the Administrator Request Form to obtain a user ID and password

–File Exchange

• Provides a way to collect, store, manage, and distribute sensitive information securely between a trading partner and the IHCP

• Is secure, fast, and easy to use

• Accepts compressed ZIP files that contain one or many claims

• Contact EDS Electronic Solutions Help Desk (317) 488-5160 or 1-877-877-5182 for information on how to set up File Exchange

Page 60: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10160 / OCTOBER 2007

Claim Filing

• File claims on paper using the appropriate paper claim form:–CMS-1500 (08-05)

–UB-04

–ADA 2006 Dental Claim Form

–Pharmacy Claim Forms

Page 61: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10161 / OCTOBER 2007

Claim FilingProcedures

• Do not staple or clip documentation to claim

• Verify claim form is signed

• Send claims to the proper P.O. Box

• Review remittance advice closely

Page 62: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10162 / OCTOBER 2007

Mailing AddressesClaim Filing

• EDS CMS-1500 ClaimsP.O. Box 7269Indianapolis, IN 46207-7269

• EDS Medical Crossover ClaimsP.O. Box 7267Indianapolis, IN 46207-7267

• EDS UB-04 ClaimsP.O. Box 7271Indianapolis, IN 46207-7271

• Dental ClaimsP.O. Box 7268Indianapolis, IN 46207-7268

Page 63: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10163 / OCTOBER 2007

Claim FilingInternal Control Number

The ICN is a 13-digit number assigned to each claim.

Region Year Julian Date

Batch Range Sequence

031 15020 07 000

Page 64: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10164 / OCTOBER 2007

MedicareCrossovers

Types:

• Automatic crossovers

• Electronic crossovers via Web interChange

• Paper CMS-1500 and UB-04 claim forms–Submit Medicare denied line items on a

separate claim form with the Medicare Remittance Notice (MRN) attached

Page 65: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10165 / OCTOBER 2007

MedicareCrossovers

• CMS-1500–Report the sum of the Medicare

coinsurance, deductible, and psychiatric reduction on the leftside of block 22

–Report the Medicare paid amount on the right side of block 22

–Do not report Medicare information in blocks 29 and 30 of the claim form

• Do not include the Medicare Remittance Notice (EOB) when all detail lines are approved by Medicare

Page 66: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10166 / OCTOBER 2007

Voids and ReplacementsType and Region Codes

• Void and replacement region codes:–50 – Non-check-related adjustment

–51 – Check-related adjustment

–55 – Retro-rate adjustment initiated by EDS for long-term care providers

–56 – Mass adjustment initiated by EDS

–61 – Provider-initiated replacement containing attachments and/or claim notes

–62 – Provider-initiated replacement with no attachments and/or claim notes

–63 – Provider-initiated void

Page 67: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10167 / OCTOBER 2007

Voids and Replacements

• Voids can be performed on suspended and paid claims only

• Replacements can be performed on suspended, paid and denied claims

• Voids and replacements can be performed to correct incorrect or partial payment, including zero dollar amount

• Denied details can be replaced or billed as a new claim except when specific services must be billed on the same claim form– Example: transportation, multiple surgeries

• To avoid unintentional recoupments, submit paper adjustments for claims finalized more than one year from the date of service

Note: Paper replacements can only be processed on paid claims

Electronic Submission

Page 68: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10168 / OCTOBER 2007

Adjustment Form

INDIANA FAMILY AND SOCIAL SERVICES ADMINISTRATION

CMS-1500, Dental, Crossover Part B Paid Claim Adjustment Request

Mail completed requests to:

EDS - Adjustments, P.O. Box 7265, Indianapolis, IN. 46207-7265

(2) Reason For Adjustment:(Check Appropriate Box)

Change TPL Amt. Change Patient Deductible Amount

Offset or Refund of entire amount

(please check block 10)

Change information as indicated in blocks 13-16

Medicare Adjustment (Attach all MRNs that apply to this adjustment)

Page 69: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10169 / OCTOBER 2007

Adjustment Form

INDIANA FAMILY AND SOCIAL SERVICES ADMINISTRATION

CMS-1500, Dental, Crossover Part B Paid Claim Adjustment Request

Mail completed requests to:

EDS - Adjustments, P.O. Box 7265, Indianapolis, IN. 46207-7265

(3) Claim Number (ICN)2006031891230

(4) Recipient ID No.100023456799

(5) Date Of Service

From 1/1/06 Through 1/2/06

(6)Recipient Name

Medicaid Member

(7) Amount Paid

100.00

(8) Remittance Advice Date: 2/15/06

Page 70: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10170 / OCTOBER 2007

Modifications to Duplicate Logic

• IndianaAIM now reads all five digits of the procedure code andall modifiers

• Applicable to claims and replacement claims received on or after September 27, 2007

• Applicable to the following claim types:–Medical–Medical Crossover Part B–Outpatient–Outpatient Crossover C–Home Health

• Effective August 1, 2007:–Crossover claims billed on a CMS-1500 claim form no longer deny

with edits 5007 (exact duplicate, header), or 5008 (suspect duplicate, header)

–These claims now emulate the possible, and exact duplicate logic applied to medical claims, which apply the 5000 (possible duplicate), and 5001 (exact duplicate) edits

Page 71: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10171 / OCTOBER 2007

Modifications to Duplicate Logic

Example 1:

10/25/07 73560 LT10/25/07 73560 RT

Example 2:

10/26/07 H0044 HW HQ AH10/26/07 H0044 HW HQ HE

The second detail line will no longer deny as a duplicate to the first detail line

Page 72: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10172 / OCTOBER 2007

Helpful ToolsAvenues of Resolution

• IHCP Web site at www.indianamedicaid.com

• IHCP Provider Manual (Web, CD-ROM, or paper)

• Customer Assistance

• Written Correspondence

• Provider Field Representative

Page 73: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

INDIANA HEALTH COVERAGE PROGRAMS (IHCP) 10173 / OCTOBER 2007

Questions

Page 74: Indiana Health Coverage Programs (IHCP) 101provider.indianamedicaid.com/media/28802/indiana helath coverage... · Indiana Health Coverage Programs (IHCP) 101 ... • Indiana Health

October 2007

Presentation by EDS Provider Field ConsultantsEDS950 N. Meridian St., Suite 1150Indianapolis, IN 46204EDS and the EDS logo are registered trademarks of Electronic Data Systems Corporation. EDS is an equal opportunity employer and values the diversity of its people. © 2007 Electronic Data Systems Corporation. All rights reserved.