Right choices program (RCP)

Overview

The Right Choices Program monitors member utilization and, when appropriate, implements restrictions for members who would benefit from increased case coordination. Member utilization review identifies members who use Indiana Health Coverage Programs (IHCP) services more extensively than their peers.

Any Medicaid member who meets the RCP criteria may be enrolled in RCP regardless of whether the member is in Hoosier Healthwise, Healthy Indiana Plan (HIP), Care Select, or Traditional Medicaid. Anthem, MHS, MDwise, and ADVANTAGE Health SolutionsSM administer the RCP for their members in accordance with the State's policy and procedure guidelines.

Each RCP member is restricted to a physician, a pharmacy, and a hospital. In some situations, the member can be restricted to additional provider types, if such action is warranted. For example, the RCP member's lock-in physician can refer the member to a specialist. That specialist is then added to the member's list of providers. In an emergency, other providers can render services without the need for a referral.

Information received when checking eligibility

Because there are multiple vendors performing RCP administration duties, providers must verify member eligibility to determine to which Medicaid program or plan the member belongs.

The provider is responsible for checking the eligibility of IHCP members before rendering services. If no restrictions are listed, the member is not restricted to any specific provider. If the eligibility response lists restrictions, the member is restricted to receiving specific types of services only from the specific providers indicated.

Claims

The IHCP reimburses only the providers to whom the member is restricted unless a referral is on file at the entity to which the member is assigned, or if the service is for an emergency condition. The provider must notify the member, before rendering the service, that the services will not be covered by the IHCP and ask the member to sign a statement acknowledging they understand they are responsible for payment. The provider can bill the member for the services not eligible for payment due to the RCP restrictions. Claims for nonemergency services to a Right Choices member that are rendered by a provider that is not assigned or referred are denied.

Contacts

Providers may refer questions about RCP members to RCP administrators:

ADVANTAGE Health Solutions - Care Select and Traditional Medicaid
P.O. Box 40789
Indianapolis, IN 46240-0789
1-800-784-3981
Fax: 1-800-392-6894

Anthem - Hoosier Healthwise and HIP
P.O. Box 6144
Indianapolis, IN 46206-6144
1-866-902-1690, Option 3
Fax: 1-866-387-2959

Managed Health Services - Hoosier Healthwise and HIP
1099 N. Meridian Street, Suite 400
Indianapolis, IN 46204-4287
1-877-647-4848
Fax: 1-866-753-7240 or (317) 684-1785

MDwise - Care Select
P.O. Box 44214
Indianapolis, IN 46244-0214
1-800-356-1204 or (317) 630-2831
Fax: 1-877-822-7188 or (317) 822-7519

MDwise - Hoosier Healthwise
P.O. Box 441423
Indianapolis, IN 46244-1423
1-800-356-1204 or (317) 630-2831
Fax: 1-877-822-7190 or (317) 829-5530

MDwise - HIP
P.O. Box 441423
Indianapolis, IN 46244-1423
1-800-356-1204 or (317) 630-2831
Fax: 1-877-822-7192 or (317) 822-7192

More information

For more information, see the following chapters of the IHCP Provider Manual:

Chapter 2: Member Eligibility and Benefit Coverage
Chapter 3: Electronic Solutions
Chapter 13: Utilization Review