Presumptive Eligibility Process FAQs

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 services?

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.