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FAQs - Hoosier Healthwise

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•  FAQs - Hoosier Healthwise 

FAQs - Hoosier Healthwise

Q: What is Hoosier Healthwise risk-based managed care?

A: Hoosier Healthwise is a managed care program for low-income families, children, and pregnant women. The Office of Medicaid Policy and Planning (OMPP) pays contracted managed care organizations (MCOs) a monthly premium for each Indiana Health Coverage Programs (IHCP) enrollee in the MCO's network. The MCO assumes financial risk for the services rendered to members in its network. The MCO manages the care of Hoosier Healthwise members through its network of primary medical providers (PMPs), specialists, and other contracted healthcare providers.

Q: Who is eligible to be a PMP for this program?

A: Hoosier Healthwise has five standard PMP categories - family practice, general practice, internist, pediatrician, and OB/GYN.

Q: Will I need to complete an application or contract?

A: To serve as a PMP for MCO members, you must first enroll as an IHCP provider with one of the five standard PMP categories. After successfully enrolling in the IHCP, you must contract with one or more MCO to provide primary care services for risk-based managed care (RBMC) members.

Q: What are the differences between prior authorization and PMP authorization in RBMC?

A: Prior authorization (PA) and PMP referral are two different processes. A Care Select PMP provides PMP referral by giving a certificate code to other providers, which authorizes the provider to provide services to the member as specified by the PMP. Self-referral services do not require the member's PMP approval but may require PA. The care management organizations (CMOs) make the PA determinations for Care Select members.

PMPs contracted with an MCO may be allowed to make referrals to in-network specialists without written referrals, other than medical record documentation. MCOs may have different policies for handling referrals within their networks.

Each MCO provides PA determinations for its members. Most often, services for MCO members provided by out-of-network providers (providers who do not have a contract with the member's MCO) require PA. Contact the member's MCO for information on services requiring PA.

NOTE: PA is not a guarantee of reimbursement, and providers must continue to verify member eligibility and program assignment through the eligibility verification system (EVS).

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. The member's MCO is responsible for the payment of self-referral services.

Q: Can a PMP be in more than one program at a time?

A: PMPs can have patients active in any or all of the three programs (Care Select, RBMC, or MCO, and traditional fee-for-service) simultaneously.

Q: If a caseworker or provider has questions concerning the Hoosier Healthwise Managed Care Program, whom should they call?

A: If you don't know who to contact, call the Hoosier Healthwise Helpline at 1-800-889-9949 and select Option 3 for Provider Services. Those who wish to speak to a benefit advocate should call the same number and select Option 2 for Member Services. If the customer service representative cannot answer a case worker or provider's questions, the representative refers the caller to the appropriate number. For example, claims questions are referred to the appropriate MCO or EDS.

Q: Do Hoosier Healthwise members have third-party liability (TPL)?

A: Yes, Hoosier Healthwise members in Package A and B can have TPL. This information is available from one of the eligibility verification systems - Web interChange, Automated Voice Response (AVR), or Omni - based on the eligibility information the member provided. Hoosier Healthwise Package C members may not have commercial insurance coverage, but may also be enrolled in the First Steps and Children with Special Health Care Services (CSHCS) programs.

Q: How long does it take to remove a member from an obstetric PMP's panel when delivery and follow-up care has been completed?

A: Members enrolled in a pregnancy-only aid category (Package B) generally lose eligibility 60 days after delivery. However, some pregnant members are enrolled in other aid categories and may remain eligible for benefits beyond 60 days after delivery (Package A members). In these cases, the member must contact the Hoosier Healthwise Helpline or a local benefit advocate to choose another PMP to provide care that is not related to pregnancy care.

Q: Who handles RBMC claims disputes?

A: Providers must send MCO claim disputes to the member's MCO (Anthem, Managed Health Services (MHS), or MDwise). Medicaid rule 405 IAC 1-1.6 outlines the MCO claims dispute process for out-of-network providers. Although a provider may make verbal inquiries at any time, the rule requires the provider to send an informal, written objection to the MCO within 60 days of the provider's receipt of claim payment or denial. If the matter is not resolved to the provider's satisfaction within 30 days of the commencement of the informal process, the provider has 60 days to submit a formal appeal to the MCO. Contracted providers have a similar dispute process in their contracts with the MCO.