Provider Manual - MDwise

1 HCCP0036 (4/15) Provider Manual Blank Intentionally TABLE OF CONTENTS Introduction .. 1 Chapter 1 - Welcome to MDwise .. 2 MDwise Mission .. 3 MDwise Focus and Goals .. 3 Chapter 2 - Overview of MDwise Programs .. 4 Hoosier Care Connect Program Overview .. 5 Members Covered by the Hoosier Care Connect Program .. 5 Member Eligibility .. 5 Provider Enrollment .. 5 Chapter 3 - Hoosier Care Connect Benefits Overview .. 9 Self-Referral Services .. 14 Emergency Services .. 15 Prior Authorization for Emergency Services .. 16 Non-Emergency Services .. 16 Excluded Services .. 17 Chapter 4 - Member Eligibility .. 19 How Members Become Eligible for Hoosier Care Connect .. 19 The MDwise ID Card .. 19 How to Verify Eligibility .. 20 You can use the HP Web Interchange ( ) to check eligibility.

2 20 Hoosier Care Connect Eligibility Redetermination .. 20 Hoosier Care Connect Member Disenrollment Process .. 21 Chapter 5 - Provider Enrollment & Disenrollment .. 22 Hoosier Care Connect PMP Enrollment Updates and Changes .. 22 Hoosier Care Connect PMP Disenrollment Procedures .. 23 PMP Panel Size Selection and Changes in Panel Size .. 23 Panel Modifications and Panel Hold Requests .. 23 Chapter 6 - The Primary medical Provider s Role .. 25 Specific PMP Duties .. 25 Provision of Covered Services .. 27 Provider Access Guidelines .. 27 PMP Access 28 Specialist Access .. 28 Physician Response Time .. 28 Office Appointment Waiting Times .. 29 Office Telephone Answering Time .. 29 Accessibility and Availability Audits .. 29 Missed Appointments.

3 29 Confidentiality of Member Information .. 30 medical Records .. 31 Cultural Sensitivity .. 31 Interpretive Services .. 33 Hearing Impaired Members .. 34 Use of Physician Extenders .. 34 Chapter 7 - Choosing or Changing Doctors .. 36 Helping Members To Change 36 PMP Change Policy .. 36 Pregnancy Related Postpartum PMP Change .. 37 Open Enrollment for Hoosier Care Connect Members .. 37 Chapter 8 - Claims and Submission for Hoosier Care Connect .. 38 Claim Submission Deadlines .. 39 Claims Submission Forms .. 39 Third Party Liability .. 40 90 Day Rule .. 40 Third Party Liability and Prior Authorization .. 41 General Dispute Information .. 42 Chapter 9 - Member Cost Sharing Responsibilities .. 43 Hoosier Care Connect Member Copayments.

4 43 Chapter 10 - Care Management for the MDwise Hoosier Care Connect 44 Care Management Team .. 45 Member Assessment & Stratification .. 45 Assessment Tools .. 46 Member Classification and Prioritization .. 47 Care Plan Development & Implementation .. 47 Care Plan Development Process .. 47 Member Centered Approach .. 48 Ongoing Assessment & Evaluation .. 48 Chapter 11 - medical Management .. 49 Scope and Approach .. 49 Goals and Objectives .. 50 Integration with QI .. 50 MDwise MM Authority, Responsibility and Committee Oversight .. 51 Key medical Management Program Components .. 51 Confidentiality .. 52 Coordination and Continuity of Care .. 52 Data Analysis of Health Service Access and Utilization .. 53 NURSEon-call .. 54 Prior Authorization and Referral Process.

5 54 General Information .. 54 Prior Authorization Requests and Referrals .. 55 General Authorization Procedural Guidelines .. 55 General Referral Guidelines .. 55 Prior Authorization Request /Referral Procedure Reference Guide .. 56 Emergency Room .. 58 Provider Responsibilities upon Receiving Referral .. 62 Chapter 12 - Disease Management Program .. 63 Program Development .. 63 Core Program Elements and Requirements .. 64 Identification of Program Participants and Interventions .. 64 Short-Term Placements in Less Acute Settings .. 66 Discharge Planning .. 67 Coordination of medical and Behavioral Health Care .. 67 Informing and Educating Providers .. 68 Chapter 13 - Behavioral Health Care .. 69 Behavioral Health Care 69 Behavioral Health Care Benefits.

6 70 MRO Services and 1915(i) Services .. 70 Behavioral Health Care Referrals .. 71 PMP Referrals .. 71 Member Referral .. 72 Behavioral Health Care Authorization .. 72 Prior Authorization Process .. 72 Behavioral and Physical Health Coordination .. 73 Care Coordination and Case Management .. 75 Behavioral Health Coordination with the PMP .. 76 medical Records .. 76 Behavioral Health Access Standards .. 77 Chapter 14 - Pharmacy Services for Hoosier Care Connect Members .. 78 Preferred Drug List .. 78 Prior Authorization .. 79 Drug Utilization Review Edits that Require PA .. 79 Mandatory Generic Substitution/Brand Medically Necessary .. 79 Emergency Supply .. 79 90-Day Supply for Maintenance Medications .. 80 Tamper Resistant Prescription Pads.

7 80 Drug Copayment .. 80 Chapter 15 - Preventive Health and Practice Guidelines .. 81 Health Care Decisions for Preventive Health and Clinical Services .. 81 Development and Monitoring .. 81 Outreach to Members .. 82 Chapter 16 - Quality Improvement .. 83 Components of Quality Improvement 84 QI Program Scope .. 85 QI Program Goals .. 85 QI Program Oversight .. 85 QI Program Approach and Implementation .. 86 QI Program Activities/Initiatives .. 86 Performance Monitoring .. 87 Clinical Practice 88 Preventive Health Services/EPSDT .. 89 Potential Quality Concerns/Issues .. 89 Access to Clinical Care Services .. 89 Provider Performance Feedback .. 90 Member and Provider Satisfaction .. 91 Chapter 17 Transportation Services .. 92 Non-Emergent Transportation.

8 92 Transportation Considerations .. 92 Transportation Reservations .. 92 Prior Authorization (PA) for Transportation Services .. 92 Emergent Transportation .. 93 Chapter 18 - Member Outreach and Education Programs .. 94 New Member Materials .. 94 Toll-Free Member Phone Line .. 94 Member Newsletter .. 94 Special MDwise Programs .. 95 Emergency Room Use .. 97 Reach Out and Read (ROR) Program .. 99 Member Compliance Interventions .. 99 MDwise Website .. 100 Language Services .. 100 Special Needs of MDwise Members .. 101 Agency and Community Service Providers .. 101 About Special Kids! ASK: 1-800-964-4746 .. 101 (CSHCS)First Steps Program: 1-800-441-7837 (STEP).. 101 Children s Special Health Care Services (CSHCS) Program: 1-800-475-1355.

9 102 Linking Members with Additional Community Resources .. 102 MDwise Health Advocates .. 102 Coordinating Care for Members with Special Health Needs .. 102 Chapter 19 - Member Rights and Responsibilities .. 104 Member Rights .. 104 Member Responsibilities .. 105 Chapter 20 - Member Grievance and Appeals .. 107 Grievances .. 107 Appeals .. 108 External Review .. 109 FSSA Fair 109 Chapter 21 - Right Choices Program .. 111 RCP Mission .. 111 RCP Goals .. 111 RCP Philosophy .. 111 Identification of members for 111 Member referrals for Right Choices Program .. 112 PMP Selection and PMP Role .. 112 Referral requirements .. 113 Chapter 22 - Dental Services .. 115 DentaQuest Eligibility Systems .. 115 Dispute Resolution / Provider Appeals Procedure.

10 118 Submitting Authorization or Claims with X-Rays .. 119 Electronic Claim Submission Utilizing DentaQuest s Internet Website .. 119 Electronic Authorization Submission Utilizing DentaQuest's Internet Website .. 120 Coordination of Benefits (COB) .. 122 Filing Limits .. 122 Appendix A: EPSDT Screening Schedule .. 124 Appendix B: medical Records Audit Guidelines .. 129 Appendix C: Physician Office Site Standards .. 131 Appendix D: HIPAA .. 134 Appendix E: MDwise Practice Guidelines .. 136 Appendix F: CHIRP - Children and Hoosiers Immunization Registry Program .. 137 Appendix G: Behavioral Health SymptomsIdentification .. 138 Introduction MDwise welcomes you as a Provider into the MDwise network. We are supplying you with this Provider Manual to inform you of the MDwise guidelines and requirements, policies and procedures, and answers to questions you may have.