Right choices program (RCP)

Note: Effective January 1, 2010, the name of the Restricted Card Program changed to the Right Choices Program.

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 Solutions^SM 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/plan the member belongs.

The provider is responsible for checking the status of IHCP member eligibility prior to rendering services. While verifying eligibility, providers can confirm the member's restricted status.

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 provider to whom the member is restricted unless a referral is on file at the entity in which the member is assigned, or if the service is for an emergency condition. Claims for nonemergency services rendered by a provider not assigned or referred to a restricted member are denied.

If the member receives nonemergency services from providers that are not locked in, the IHCP does not reimburse the services. If a member visits a provider not on the member's lock-in table, the provider notifies the member before rendering the service that the IHCP will not cover the service, and the member signs a statement to that effect, the provider can bill the member for the services not eligible for payment due to the RCP restrictions.

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: 1-800-689-2759

Anthem - Hoosier Healthwise and HIP

P.O. Box 6144

Indianapolis, IN 46209-6144

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

MDwise - Care Select

P.O. Box 44214

Indianapolis, IN 46244-0214

1-800-440-2449

Fax: (317) 822-7519

MDwise - Hoosier Healthwise

P.O. Box 441423

Indianapolis, IN 46244-1423

1-800-356-1204

Fax: (317) 829-5530

MDwise - HIP

P.O. Box 44236

Indianapolis, IN 46244-0236

1-877-822-7196

Fax: (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