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
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
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
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
Q: If a caseworker or provider has questions concerning the
Hoosier Healthwise Managed Care Program, whom should they
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
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)
Q: How long does it take to remove a member from an obstetric
PMP's panel when delivery and follow-up care has been
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.