MHS - Provider Manual 2021

1 Provider 7/212 | MHS Provider Manual 2021 | OF CONTENTSC hapter 1: Managed health Services (MHS) 6 Chapter 2: Guidelines for Providers 7 The Medical Home7 Covered Services 7 Provider Assistance with Public health Services7 HealthWatch (EPSDT)7 Notification of Pregnancy (NOP) 8 Service Carve-outs8 Pharmacy 8 Excluded Benefits - Hoosier Care Connect 8 Availability and Accessibility 9 Appointment Availability 9 After-Hours Telephone Accessibility Arrangement10 Out-of-Office Coverage10 Provider Disenrollment from IHCP10 Interpreter/Translation Services 10 Advance Directives 11 Provider -Member Communication 11 Member Panel Capacity 11 Quality Improvement (QI) Activities11 Chapter 3.

2 Compliance 12 health Insurance Portability and Accountability Act (HIPAA) 12 Privacy Regulation12 Transactions and Code Sets Regulation 12 HIPAA-Regulated Transactions 12 HIPAA Electronic Transactions12 HIPAA Required Code Sets13 Sending Protected health Information Securely13 Federal, State and MCE Audits and Investigations13 Fraud and Abuse 13 Chapter 4: General Claims Information and Guidelines14 Reimbursement14 Provider Information on File14 Updating Billing information14 Changing Your Tax Identification Number (TIN)14 Mismatched Member Information15 Billing the Member15 Third Party Liability (TPL) 15 Claims Submission 16 Avoid Common Errors16 Claim Submissions Online at Claim Submissions 17 Coordination of Benefits (COB)

3 17 MHS Secure Provider Portal Submission18 EDI Clearinghouse 1890 Day Provision for COB Billing Available Electronically 19 Claims with Attachments 19 Clean Claim and Non-Clean Claim Definitions19 Post-Processing Claims Audit 20 Code Auditing and Editing (Code Review)21 Claims for Newborns 21 Claims Payment22 Electronic Remittance Advice and Electronic Funds Transfer 22 PaySpan health Benefits to Providers .. | MHS Provider Manual 2021 | 3 Recoupments23 Claim Corrections and Resubmissions (Adjustments)23 EPSDT Billing 23 Immunizations Reimbursement 23 Private Stock for Vaccines 24 Getting Help with a Claim24 Chapter 5.

4 Claims Administrative Reviews and Appeals25 Informal Claim Dispute 25 Formal Claim Dispute - Administrative Claim Appeal 25 Administrative Claim Appeal Review and Determination26 Claim Processing Following Determination26 Determining Correct Appeal Procedure for Inpatient Denials 26 Chapter 6: Transportation 27 Nonemergency Transportation Services (Excluding Ambulance) 27 Nonemergency Transportation Claims27 Ambulance and Fixed Air Transportation 28 Contact MHS Medical Management28 Chapter 7: Medical Management 29 Contact MHS Medical Management29 Referral and Prior Authorization (PA)29 Referrals Requirements 30 Prior Authorization Requirements 31 List of Services Requiring Prior Authorization (PA)

5 31 Outpatient Facilities33 Inpatient and Observation Services33 Observation Bed Guidelines 33 Facility-to-Facility Transfers34 Post-Stabilization34 Late Notification 34 Assistant Surgeon 35 Continuity of Care 35 Dental Services35 Radiology, Diagnostic Imaging and Therapy35 Rendering Prior Authorization Decisions 36 Utilization Management (UM) Review Guidelines36 Peer-to-Peer Review37 Utilization Management Inpatient Authorization Review Process37 Routine, Urgent and Emergency Care Services Defined 38 Chapter 8: Medical Management Appeals 39 Appeal Review Guidelines39 Medical Necessity Appeal 39 Receipt and Review Timeline 39 Determination Timeline40 Expedited Medical Necessity Appeals 40 Receipt and Review Timeline40 Determination Timeline40 External Independent Review 41 State Fair Hearing 41 Chapter 9: Pharmacy42 Preferred Drug List42 Non-Covered Drugs42 Mandatory Generic Substitution 43 Prior Authorization 43 Specialty Medications43 Contacts for Appeals43.

6 4 | MHS Provider Manual 2021 | 10: Preventive Healthcare Programs 44 Preventive Care Outreach44My health Pays 44 MHS Healthy Celebration44 HealthWatch/EPSDT 44 Bright Futures44 MEDTOX 45 Immunizations 45 Vaccines for Children (VFC) 45 Children & Hoosiers Immunization Registry Program (CHIRP)/MyVaxIndiana45 Clinical Practice and Preventive health Guidelines46 Healthy Indiana Plan (HIP) Recommended Preventive Care/Incentive46 Tobacco Cessation and the Indiana Tobacco Quitline46 Chapter 11: Case Management Programs47 Prenatal and Well-Baby Programs47 Start Smart for Your Baby 47 MHS Special Deliveries47 Start Smart for Your Baby Post-Partum Program 47 First Year of Life Program 47 Referral to Case Management48 Disease Management Programs48 Lead Disease Management48 Frequent Emergency Room Utilizers Management Program 48 Right Choices Program (RCP)49 Children with Special Needs49 Chapter 12.

7 Behavioral health Services50 Behavioral health Case Management 50 Behavioral health Disease Management 50 Behavioral/Physical Healthcare Coordination50 Billing for Behavioral health Services53 Chapter 13: Quality Improvement54 Overview54 Quality Improvement Oversight 56 Delegated Activities/Services 57 Clinical Practice and Preventive health Guidelines (CPGs)57 Healthcare Effectiveness Data and Information Set (HEDIS) Annual Request for Information57 Chapter 14: Member Eligibility, Enrollment and PMP Selection/Panel Assignment 58 Eligibility for Hoosier Healthwise (HHW) & Hoosier Care Connect58 HHW & Hoosier Care Connect Member Open Enrollment and Plan Changes58 Eligibility for Healthy Indiana Plan (HIP)

8 58 HIP Member Open Enrollment and Plan Changes59 Pregnancy and HIP Members 60 Verifying Member Eligibility 60 Means for Verifying Eligibility61 Member ID Cards 62 Member Redetermination 62 Member Enrollment Guidelines for MHS Providers63 PMP Selection/Panel Assignments 63 Adding a New Member to Your Panel .63 Full Panel Additions63 Panel Hold Requests and Additions63 Pre-birth Selection 64 Physician Disenrollments and Continuity of Care 64 Member Disenrollment 64 Valid Reasons for a Request for Disenrollment.

9 Chapter 15: Member Benefits, Services and Copays 66 HIP Medical Copays (HIP Basic, HIP State Plan Basic or HPE only) 67 Important Notes on Copays for Medical Services68 HIP Emergency Copay68 Premiums and Contributions (HIP Plus or HIP State Plan Plus only) 69 HHW & CHIP Prescription Copays 69 HIP Prescription Copays69 Interpreter/Translation Services 7024/7 Free Nurse Advice Line 70 Ombudsman Program70 New Member Welcome70 Member Materials 71 MemberConnections Program71 Connections Plus and Safelink Cell Phone Program71 MHS Baby Showers 71 MHS Healthy Celebrations71 Family Education Network (Hoosier Healthwise & Healthy Indiana Plan)71 MHS Education Network (Hoosier Care Connect)72 Outcomes and US Med Management (USMM)

10 Partnership 72 Online Mental health Resources 72 Member Advisory Council (MAC)72 Other Benefits 72 Member Rights and Responsibilities73 Chapter 16: Healthy Indiana Plan (HIP)/Power Account74 POWER Account74 Billing HIP Members76 Benefits Information76 Pregnancy Services76ER Copayments76 Chapter 17: Credentialing77 Credentialing Requirements77 Credentialing Committee (CC) 77 Criteria for MHS Network Practitioner Participation 77 Criteria for MHS Network Organizational Provider Participation 78 Recredentialing 78 Right to Review and Correct Information78 Chapter 18: Provider Enrollment79 Directory Display 79 Address Limitations79 Updating Provider Information79 Chapter 19.