1 Provider Manual 2017. 5/17. TABLE OF CONTENTS. Chapter 1: Managed Health Services (MHS).. 6. Chapter 2: Guidelines for 7. The Medical Covered Provider Assistance with Public Health HealthWatch (EPSDT)..7. Notification of Pregnancy (NOP).. 8. Service 8. Medicaid Rehabilitation Option (MRO) 8. State Plan Home and Community-Based 8. Dental Services (Hoosier Healthwise).. 8. Individualized Family Services Plan (IFSP) 8. Individualized Education Plan (IEP) 8. Pharmacy Services (Hoosier Healthwise).. 8. Pharmacy Services (Healthy Indiana Plan and Hoosier Care Connect).
2 8. Availability and 9. Appointment 9. After-Hours Telephone Accessibility 10. Out-of-Office 10. Provider Disenrollment from 10. Advance Provider -Member Member Panel Quality Improvement (QI) Chapter 3: Health Insurance Portability and Accountability Act (HIPAA).. 12. Privacy 12. Transactions and Code Sets 12. HIPAA-Regulated 12. HIPAA Electronic 12. HIPAA Required Code 13. Sending Protected Health Information 13. Federal, State and MCE Audits and 13. Fraud and 13. Chapter 4: General Claims Information and 14. Provider Information on 14. Updating Billing 14. Changing Your Tax Identification Number (TIN).
3 14. Mismatched Member 15. Billing the Member (HHW and Hoosier Care Connect only).. 15. Third Party Liability (TPL).. 15. Claims 16. Avoid Common 16. Claim Submissions Online at 17. Paper Claim 17. Coordination of Benefits (COB).. 17. MHS Secure Provider Portal 18. EDI 18. Claims with 19. Clean Claim and Non-Clean Claim 19. Code Auditing and Editing (Code Review)..20. 2 | MHS Provider Manual 2017 | Claims for Claims 21. Electronic Remittance Advice and Electronic Funds 21. PaySpan Health Benefits to 21. Claim Corrections and Resubmissions (Adjustments)..22. EPSDT Immunizations Transportation Getting Help with a Chapter 5: Claims Administrative Reviews and 24.
4 Informal Claim Formal Claim Dispute - Administrative Claim Administrative Claim Appeal Review and Claim Processing Following Determining Correct Appeal Procedure for Inpatient Chapter 6: Medical 26. Contact MHS Medical Referral and Prior Authorization (PA)..26. Referrals Prior Authorization List of Services Requiring Prior Authorization (PA)..29. Outpatient Inpatient and Observation Observation Bed Facility-to-Facility 31. Assistant 31. Continuity of 31. Dental 31. Emergency and Non-Emergency 31. Rendering Prior Authorization Utilization Management (UM) Review Peer-to-Peer Utilization Management Inpatient Authorization Review Routine, Urgent and Emergency Care Services Specialty Chapter 7: Medical Management 35.
5 Appeal Review Medical Necessity Receipt and Review Determination Expedited Medical Necessity Receipt and Review Determination External Independent 37. State Fair 37. Chapter 8: 38. Preferred Drug Non-Covered Mandatory Generic Prior Contacts for Medical | MHS Provider Manual 2017 | 3. Chapter 9: Preventive Healthcare Preventive Care 40. MHS CentAccount .. 40. MHS Healthy 40. 40. Bright 40. 41. 41. Vaccines for Children (VFC).. 41. Children & Hoosiers Immunization Registry Program (CHIRP) 41. Clinical Practice and Preventive Health Healthy Indiana Plan (HIP) Recommended Preventive Tobacco Cessation and the Indiana Tobacco Chapter 10: Case Management 43.
6 Start Smart for Your Baby ..43. MHS Special Start Smart for Your Baby Post-Partum First Year of Life Puff Free Pregnancy Smoking Cessation Disease Management 44. Lead Disease 44. Frequent Emergency Room Utilizers Management 44. Right Choices Program (RCP)..45. Children with Special Chapter 11: Behavioral Health 46. Cenpatico Intensive Case 46. Cenpatico Disease Behavioral/Physical Healthcare Billing for Behavioral Health Chapter 12: Quality 48. 48. Quality Improvement Delegated 51. Clinical Practice and Preventive Health Guidelines (CPGs).. 51. Chapter 13: Member Eligibility, Enrollment and PMP Selection/Panel 52.
7 Eligibility for Hoosier Healthwise (HHW) & Hoosier Care HHW & Hoosier Care Connect Member Open Enrollment and Plan Eligibility for Healthy Indiana Plan (HIP)..52. HIP Member Open Enrollment and Plan Presumptive Eligibility (PE)..53. Hospital Presumptive Eligibility (HPE) for Pregnancy and HIP Verifying Member Means for Verifying Member ID Member Member Enrollment Guidelines for MHS PMP Selection/Panel Adding a New Member to Your Full Panel 4 | MHS Provider Manual 2017 | Panel Hold Requests and Pre-birth Physician Disenrollments and Continuity of Member Valid Reasons for a Request for Chapter 14: Member Benefits, Services and 60.
8 HIP Medical Copays (HIP Basic, HIP State Plan Basic or HPE only).. 61. HIP Emergency Premiums and Contributions (HIP Plus or HIP State Plan Plus only)..62. Transportation Interpreter/Translation Nurse Advice Line 24/7 Nurse Ombudsman New Member Member 64. MemberConnections 64. Connections Plus Cell Phone 64. MHS Baby 64. Family Education Network (Hoosier Healthwise & Healthy Indiana Plan).. 64. MHS Education Network (Hoosier Care Connect)..65. Outcomes and US Med Management Online Mental Health Member Advisory Council (MAC)..65. Member Rights and 66. Chapter 15: Healthy Indiana Plan (HIP)/Power 67.
9 POWER Billing HIP 69. Pregnancy 69. ER 69. Chapter 16: Physician 70. Credentialing Credentialing Committee (CC)..70. Criteria for MHS Network Practitioner Criteria for MHS Network Organizational Provider 71. 71. Right to Review and Correct 71. Chapter 17: Medical Record Keeping and Documentation 72. Organization and Demographic Clinical Medical Records 73. Medical Records Transfer for New 73. Medical Records 73. Medical Records 73. Audit 73. Chapter 18: Provider 74. Assistance with Claims Provider Chapter 19: Frequently-Asked | MHS Provider Manual 2017 | 5. 1.
10 Chapter 1: Managed Health Services (MHS). Managed Health Services (MHS) is a managed care entity (MCE) that has contracted with the state of Indiana to serve Medicaid recipients enrolled in: Healthy Indiana Plan (HIP). Hoosier Healthwise, including children in the Children's Health Insurance Program (CHIP). Hoosier Care Connect The state of Indiana 's Family and Social Services Administration's (FSSA) department administers these state and federal benefit plans through the Indiana Health Coverage Programs (IHCP). Our Goals MHS' top priority is to promote healthy lifestyles through preventive healthcare.