FAQs - Care Select
Q: What is Care Select?
A: Care Select is a disease management program designed
by the State of Indiana to enhance the care provided by addressing
the member's chronic conditions and help members better understand
their disease. Members select a doctor to serve as their
primary medical provider (PMP). The PMP is responsible for
providing or coordinating the member's care. The care management
organizations (CMOs) - ADVANTAGE Health Solutions(SM)
and MDwise - provide education, information, and additional
assistance to the Care Select members.
Q: Who is eligible for Care Select?
A: The following individuals are eligible for Care
Select: the aged, blind, physically and mentally disabled,
children receiving adoptive services, and wards and foster
children. Providers should use the Eligibility Verifications System
(EVS) prior to rendering services to confirm that the member is
eligible for Care Select.
Q: Who is not included in Care Select?
A: The following individuals are excluded from enrollment in
Care Select: breast and cervical cancer patients, persons
in nursing homes, persons in intermediate care facilities for the
mentally retarded (ICF/MRs) and state-operated facilities, persons
receiving hospice services, the M.E.D. Works participants,
individuals receiving room and board assistance, the population on
Home and Community-Based Services (HCBS) waivers, members on
spend-down, and dually eligible members.
Q: Who is eligible to be a PMP for Care Select?
A: Care Select has five standard PMP categories -
family practice, general practice, internist, pediatrician, and
obstetrician/gynecologist. In addition, any physician specialist
such as a cardiologist, psychiatrist, urologist, and so forth, may
serve as a PMP.
Q: Do I need to complete an application or contract to
participate with Care Select?
A: Yes, to serve as a PMP for CMO members, you must first enroll
as an Indiana Health Coverage Programs (IHCP) provider in one of
the PMP categories. After successfully enrolling in the IHCP, you
must contract with one or more CMOs to provide primary care
services for Care Select. The CMO obtains a signed
Care Select Provider Agreement Addendum and the
appropriate paperwork to provide information about you and your
location.
Q: Is there a credentialing process for PMPs and
specialists?
A: Yes, the state requires that the CMO credential all
contracted providers, in accordance with the National Committee for
Quality Assurance (NCQA). All PMPs and specialists must meet these
credentialing standards to participate in the CMO's network.
Q: What panel size is allowed?
A: PMPs can determine the panel size limit for each CMO as
applicable, and there are no requirements for minimum or maximum
size.
Q: Is a PMP able to increase or decrease the panel size?
A: Yes, PMPs are able to increase or decrease the panel size.
PMPs must complete the appropriate PMP enrollment update form and
submit it to the applicable CMOs. Please note: When a PMP submits a
request to lower the PMP's panel size, members are not removed from
the PMP's panel.
Q: Can this panel be combined with a Hoosier Healthwise
panel?
A: No, the panels are maintained separately.
Q: Can a PMP be in more than one program at a time?
A: Yes, PMPs can have patients active in any or all three
programs (RBMC, Care Select, and Traditional
fee-for-service) simultaneously.
Q: If a caseworker or provider has questions concerning
Care Select, whom should they call?
A: If you don't know who to contact, call the Care
Select Helpline at 1-866-963-7383. If the customer service
representative cannot answer a caseworker's or provider's question,
the representative refers the caller to the appropriate number. For
example, claims questions are referred to HP.
Q: Do Care Select members have third-party liability
(TPL)?
A: Yes, Care Select members can have TPL. This
information is available from the Eligibility Verification System
(Web interChange, Automated Voice Response or AVR, or Omni), based
on the eligibility information the member provided. Providers
should refer to the IHCP Provider Manual for all policies related
to TPL, including guidelines for claim submission and updating
members' TPL information.
Q: What benefits are covered in Care Select?
A: Some services are self-referral and do not require the
physician to refer the patient for that service. However, these
services may require PA from the CMO.
Q: Is there any payment for serving as a PMP?
A: Yes, providers receive a $15 per member, per month
administrative fee payment.
Q: How are PMPs reimbursed?
A: In addition to the administrative fee, PMPs are reimbursed
based on the fee-for-service schedule. Claims are submitted to the
state's fiscal agent, HP, for processing and payment. HP pays the
prevailing Medicaid reimbursement rate on file for each service
appropriately billed to the IHCP. The CMOs also offer a variety of
provider incentives related to quality improvement goals, which
could be in the form of a bonus above the provider's
fee-for-service rates. The State also reimburses PMPs $20 for care
coordination conference services. The coordination conference can
be billed using 99211 SC and is limited to twice per calendar year,
per Care Select member.
Q: Is the recipient identification number (RID Number) used in
Care Select? Do providers use their Legacy Provider
Identifiers (LPIs) or National Provider Identifiers (NPIs) in
Care Select?
A: The billing process does not change under Care
Select. Providers use the member's current RID number and the
provider's LPI or NPI to submit Care Select claims.
(Atypical providers such as nonemergency transportation and HCBS
waiver providers do not use the NPI; these providers identify
themselves using their LPIs.) Claim filing policies and procedures
outlined in the IHCP
Provider Manual should be followed for all claim types.
Q: Are members auto-assigned to Care Select?
A: Initially, outreach is attempted by the enrollment broker
(EB) to make a CMO/PMP assignment. Members can make a choice
(opt-in) or they can choose not to participate (opt-in declined).
If the EB cannot reach a member, the member is auto-assigned to a
new PMP.
Q: Can providers continue to see members they already see?
A: Yes, a provider continues to see members if those members
select the provider as their PMP, or if the members are referred to
the provider from their assigned PMPs.
Q: Who can provide self-referral services?
A: Only an IHCP- or Medicaid-enrolled provider can provide
self-referral services. Self-referral services include behavioral
health, chiropractic, dental, family planning, HIV/AIDs targeted
case management, podiatry, vision, and emergency services.
Q: Do all services require referrals?
A: No, some services are self-referral and do not require PMP
authorization. These services include: behavioral health,
chiropractic, dental, emergency, family planning HIV/AIDS targeted
case management, podiatry, vision, and pharmacy.
Q: Does this affect the specialists that members may see?
A: No, members may continue to see specialists that provide
services under the Indiana Health Coverage Programs (IHCP).
However, members enrolled in Care Select are required to
obtain referrals from their PMPs to see specialists.
Q: Does this change available hospitals or pharmacies?
A: No, members are able to access services at the same hospitals
and fill their prescriptions at the same pharmacies.
Q: Will CMOs require their members to use only pharmacies that
are contracted with the CMO?
A: No, CMOs are not responsible for building a pharmacy network.
Members can have their prescriptions filled by any IHCP-enrolled
pharmacy. PA requests for prescription drugs that require PA must
be submitted to ACS-a Xerox Company. Pharmacy claims must be
submitted to HP for processing and adjudication.
Q: Do members use the Hoosier Health Card?
A: Yes, members continue to have the same identification (ID)
number and use the same Hoosier Health Card. However, CMOs may
choose to develop their own identification cards for their
members.
Q: Who processes claims for the Care Select
program?
A: HP processes claims for the Care Select program.
Providers should refer to the IHCP Provider Quick Reference
for contact information.
Q: How do I provide referrals for these members?
A: Providers are required to provide referrals by telephone or
in writing. This requires the release of provider ID numbers and a
special two-digit certification code that allows the rendering
provider to bill and receive reimbursement.
Q: How do I obtain a certification code?
A: As of January 1, 2011, OMPP has discontinued the use of
certification codes.
Q: Do nursing home patients have Care Select?
A: No, institutionalized members are excluded from Care
Select. There are no plans for including these members in the
near future. Providers are reminded to always verify eligibility to
ensure that a nursing home resident is enrolled in Medicaid with a
Level of Care (LOC). Occasionally, nursing homes retroactively
obtain an LOC for a member who has been living in the facility for
a number of months. Until that LOC is entered, the member could be
enrolled in Care Select.
Q: What services require PA? What are the PA requirements?
Where are PAs sent?
A: PA, or prior authorization, is a key responsibility of the
CMO. Services that traditionally require PA, such as some
surgeries, inpatient stays, home health services, therapy services,
and so forth, require PA in Care Select. Providers may
mail, enter in Web interChange, fax, or call in PA for those
services. For more information about PA, see
Care Select Prior Authorization Contact Information on
this Web site or see the IHCP Provider
Quick Reference. PA forms are located on the Forms page.
Q: Whom do I contact for PA carved-out services?
A: All PA for carved-out services (for example, dental services)
should be obtained through the CMO assigned to the member, as
verified through the EVS.
Q: What is the turnaround time for PA requests?
A: The decision about standard PA requests is made within five
business days (weekends and State holidays excluded) of the receipt
of request. If a decision is not made within 10 business days,
after receipt of all required documentation, authorization is
deemed to be granted within the coverage and limitations specified
(405 IAC 5-3-14). The provider must wait until the
approved PA decision form or the 278 response is returned to bill
for the service; or until verification can be made that ADVANTAGE
Health Solutions(SM)-FFS, ADVANTAGE Health Solutions-CS,
or MDwise-CS received the form or the 278 request, and did not
render a decision on the request within five business days for
Care Select and 10 business days for FFS. Verification is
accomplished using Web interChange PA inquiry or the AVR system.
Additional information regarding PA can be found in Chapter 6 of the IHCP Provider
Manual.
Q: How are PAs handled for a member who changes programs?
A: If a member changes programs between Traditional Medicaid
(FFS), Care Select, and Hoosier Healthwise, or between
Hoosier Healthwise and Care Select plans, all existing PAs
are honored for 30 calendar days. This requirement is applicable
only if the member is re-assigned programs between Hoosier
Healthwise and Care Select, or the Traditional Medicaid
FFS program. PAs approved by either of the two Care Select
vendors or the FFS vendor are available in IndianaAIM for
claims processing by HP. The PAs may be for specific procedures,
such as surgery, or for ongoing procedures authorized for a
specified duration, such as physical therapy or home healthcare.
The IHCP honors the PA for 30 days or for the remainder of the PA
dates of service, whichever comes first. Requiring a duplicate
authorization from the new plan places an additional burden on the
provider and can result in delayed or inappropriately denied
treatments or services to the member.
Q: Where do I submit Hearing and Appeals, and Administrative
Reviews?
A: Hearing and Appeals, as well as Administrative Reviews, are
completed by the PA vendor that denied the request. (In the event
that the Hearing and Appeal or Administrative Review is submitted
to the incorrect CMO or FFS organization, the request is returned
to the provider for submission to the appropriate organization for
review.) If the member has been assigned to a different program
since the request for PA was denied, providers can appeal to the PA
vendor that denied the request or submit a new PA request for
review to the current MCO/CMO/FFS PA vendor for review. The
policies and procedures regarding Hearing and Appeal or the
Administrative Review process are distributed to the provider and
member upon the generation of the PA decision letter or PA update.
Further information regarding the Hearing and Appeal and the
Administrative Review process can be found in Chapter 6 of the IHCP Provider
Manual.
Q: What is the emergency room (ER) reimbursement? How is ER
utilization handled?
A: The reimbursement for ER services is processed according to
the outpatient reimbursement methodology. Providers must observe
all billing rules outlined in Chapter 8 of the
IHCP Provider Manual.
Q: Is the CMO responsible for reviewing, approving, denying,
and modifying mental health PA requests?
A: Yes, the CMOs are responsible for PA request processing,
utilization review, reporting, and network development for all
medical and behavioral health services covered under the program,
with the exception of pharmacy. PA requests for behavioral health
drugs (just like other prescription drugs) fall under the pharmacy
carve-out, which is handled by ACS-a Xerox Company, the State's
pharmacy benefit manager. HP continues to be the entity responsible
for claims processing for all claim types.
Q: Is HP able to receive claims electronically?
A: Yes, electronic claims can be submitted to HP using the
electronic claims vendor of the provider's choice or using the
claim submission function of Web interChange. Questions regarding
sign-up or use of the Web interChange or electronic data
interchange (EDI) claims
must be directed to HP at (317) 488-5160 or 1-877-877-5182.
Q: What methods of eligibility are used for members in Care
Select?
A: All IHCP providers should use Web interChange, Omni, or AVR
to verify a member's eligibility. Providers must always verify the
eligibility prior to rendering services.
Q: What organization handles the Right Choices members?
A: Members in the Right Choices Program (RCP) were transitioned
to the CMOs during the implementation. Because there are multiple
vendors providing RCP services, providers must verify member
eligibility to determine to which CMO the member belongs. The EVS
that are available to the provider community provide specific
information regarding the member's CMO and PMP assignment.
Information regarding the RCP can be found in Chapter 13 of the IHCP Provider
Manual.