Presumptive Eligibility Process
Q. When I check the member's presumptive
eligibility/hospital presumptive eligibility (PE/Hospital PE), I
cannot find his or her PE ID in Web interChange. How can I confirm
that I will be reimbursed for a service?
The eligibility verification letter clearly indicates the date a
member's coverage begins and ends and the plan to which the member
belongs, if applicable. This letter serves as the member's
identification card. If the member is eligible under the adult aid
category, providers should contact the managed care entity listed
on the letter to request prior authorization (PA).
Q. Where can a PE/Hospital PE member receive
The member is not limited to receiving services only from the
provider location where he or she was determined presumptively
eligible. Most PE/Hospital PE members can receive services covered
under their aid category from any IHCP-enrolled provider. PE Adult
members must receive services through providers enrolled with the
member's MCE network.
Q. What if a member's eligibility for services is denied via
a pharmacy's point-of-sale system?
It may take up to three days for a member's eligibility status
to be visible in all eligibility systems, particularly in the
eligibility systems of the managed care pharmacy benefit managers.
During that time, the member is eligible to receive services. The
eligibility verification letter clearly indicates the date a
member's coverage begins and ends and serves as a members'
identification card. If a member is enrolled with an MCE and the
pharmacy provider is unsure of the member's status, the provider
should contact the MCE listed on the eligibility verification
letter for guidance.