HHW/HIP Provider Manual - MDwise

1 Provider ManualHoosier Healthwise and Healthy Indiana Plan (HIP)2020 MDwise Provider Manual | 2 HHW-HIPP0504 (12/18)ContentsWelcome to MDwiseProvider Responsibilities ..7 Provider Qualifications Credentialing and Enrollment Process Access and Quality Standards Provider Rights and ResponsibilitiesHoosier Healthwise Member Benefits ..24 Program Overview Eligibility Presumptive Eligibility (PE) Member Card Cost-Sharing and Copayments Program Benefits Service DescriptionsHealthy Indiana Plan Member Benefits ..35 Program Overview Eligibility Member Card POWER Account Contributions and Copayments Program Benefits Service Descriptions Preventive Care Package Claims ..49 Timelines Third Party Liability Inquiries, Disputes and AppealsPrior Authorization.

2 57 Services that require Prior Authorization PA Process Hoosier Healthwise Claim Submission Healthy Indiana Plan Claim Submission Dental Claims Pharmacy Claims Billing MDwise Members2020 MDwise Provider Manual | 3 medical Management ..59 Care Management Disease Management Care Coordination NURSEon-call EPSDT Right Choices Program (RCP) Payment for Outcomes (P4O) HEDIS Potential Quality Issues (PQI) and Concerns Clinical Practice Guidelines Preventive Health and Practice GuidelinesPharmacy ..89 Drug-Related medical Supplies and medical Devices Pharmacy Claims Prior Authorization Drug Utilization ReviewBehavioral Health ..95 Providers Benefits Coordination Prior Authorization Referrals Transportation.

3 104 Services and Limitations Transport Prior Authorizations Transportation ReservationsMember Rights and Responsibilities ..107 Overview Choosing and Changing Doctors Member Grievances and AppealsOutreach and Education ..116 Member Education Communication Resources Community Resources Special MDwise Programs MDwise Provider Resource Directory2020 MDwise Provider Manual | 4 Welcome to MDwise ! MDwise welcomes you as a Provider into the MDwise network. We are supplying you with this Provider Manual to inform you of all the different programs MDwise participates in, as well as MDwise guidelines and requirements, policies and procedures, and answers to questions you may have. MDwise hopes that you will find the Manual to be a valuable tool that assists you in caring for our members.

4 MDwise values its on-going partnership with our network providers. Communication is essential to making a partnership work. We update the Provider Manual annually, and more frequently if necessary, due to program changes. You will be notified via the MDwise Provider webpage as revisions or updates are added to the Manual , which is always available on the MDwise website at If new procedures and processes take effect after this Manual has been published, MDwise will provide updates through other means of distribution including posting on , quarterly newsletter article, special mailings, and email blasts. We will always give you at least 45 calendar days notice of any significant change that may affect your office practice or procedures.

5 A significant change in practice is determined by the impact of the policy on such issues as coverage criteria, authorization procedures, referral policies, subcontractors, Provider office site standards, medical record standards, or access standards. Notice of all significant changes are also posted on the MDwise you have questions, concerns, or complaints, you are encouraged to call your delivery system Provider relations representative directly at the telephone numbers listed in the directory at the end of this Manual . Or, you can always call the toll-free MDwise Customer Service line. MDwise Customer Service Representatives (CSRs) are available Monday through Friday from 8:00 to 8:00 Eastern Standard Time.

6 After regular business hours, MDwise contracts with a telephone answering service that is trained to respond to most Provider issues that arise after hours. For instance, the after-hours service handles many urgent pharmacy issues. If the answering service representative is unable to respond to a Provider call, information is forwarded to a MDwise Customer Service Representative to address the following business day. We look forward to our continued working relationship with you and welcome your comments and suggestions regarding the Manual and suggestions on other ways that we can better assist you in providing quality care to our members. If you have any questions about the content of this Manual , please contact MDwise Customer Service or your MDwise Hoosier Healthwise/Healthy Indiana Plan Provider relations with questions regarding this Manual can submit those to the MDwise Provider Relations Department at or by calling 317-822-7300 ext.

7 MDwise Provider Manual | 5 Who is MDwise ? MDwise is a not-for-profit corporation that began its operation in 1994, when it was established as the Central Indiana Managed Care Organization, Inc. (CIMCO). It was formed specifically to help several major Indianapolis hospitals and their affiliated physicians deliver a Provider -directed, cost-effective approach to managed care services for Hoosier Healthwise members. It became the fastest growing organization providing risk-based managed care for Hoosier Healthwise in central 2001, CIMCO teamed up with IU Health Plan (IUHP) and organized its affiliated providers under a new name, MDwise . In August 2007, MDwise was selected to begin negotiations to serve as an insurance Provider for the Healthy Indiana Plan (HIP).

8 Under the HIP program, the State of Indiana contracts with statewide, risk-bearing entities to deliver basic benefit packages offered through a deductible health plan paired with a personal health care account referred to as a POWER (Personal Wellness and Responsibility) Account. The program is designed to foster personal responsibility and promote preventive care and healthy lifestyles while encouraging participants to be value-conscious consumers of health care to help promote price and quality transparency. In 2018 , MDwise was purchased by Michigan based McLaren Health Care. McLaren is a fully integrated health system that includes 14 hospitals, ambulatory surgery centers, imaging centers, and an employed primary care physician network.

9 McLaren Health Plan, a subsidiary, provides health benefits to over 260,000 commercial, Medicaid and Medicare members across Michigan. McLaren s vision and mission are very similar to the MDwise vision and mission. Both MDwise and McLaren are committed to delivering high-quality health care benefits to Indiana Medicaid Mission and VisionThe MDwise Plan is a coordinated, comprehensive approach to managing the cost and utilization of health care services. Our mission is to enhance client satisfaction and lower total health care costs by improving the health status of members through the most efficient provision of quality health care Core values are trust, excellence, stewardship, innovation and five-fold Mission: Delivering consistent, high quality care.

10 Focusing on families and community in a culturally competent way. Shaping health policy and promoting innovation in Medicaid managed care. Ensuring financial viability through efficient and cost-effective operations. Involving providers in key decision making and nurturing local governance of the MDwise MDwise Provider Manual | 6 Maximizing value in health service delivery includes a focus on quality and access and ultimately depends on the collaborative relationships between the managed care entity, providers, and well-informed members. In delivering Hoosier Healthwise and Healthy Indiana Plan services across the full healthcare continuum, a primary focus of MDwise is to link primary care physicians, specialists, hospitals, and ancillary providers so all providers can administer and coordinate care more efficiently and effectively.