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					                              Mitchell E. Daniels, Jr., Governor
                                               State of Indiana

             Indiana Family and Social Services Administration

 2010 IHCP Annual Seminar
Indiana Care Select Program
                 Today’s Agenda

• October 1, 2010 Change in Scope
   – Restructured Program Goals
   – CMO’s, Member Eligibility & Opt-out Process
   – Disease Management
   – HP Continued Functions
   – Disease Management
• Prior Authorization Process
• Certification Code Policy
• Right Choices Program Referral Process
• 2010 Care Select Quality Measures
• CMO Updates
• Q&A
    Indiana Care Select Program
          Change in Scope
Restructured Program Goals
• Transition from a care management program to a disease
  management program focusing on members with chronic
• Re-designed to help patients with chronic illnesses lead
  healthier and more productive lives
• About 32,000 Medicaid members are eligible for the disease
  management program
• Members no longer eligible for Care Select were sent a letter
  in August 2010 informing them they are eligible for
  Traditional Medicaid and that their benefits will remain the

         Indiana Care Select Program
               Change in Scope
• Care Select Care Management Organizations (CMO’s)
  – ADVANTAGE Health Solutions,
  – MDwise, Inc.
• Statewide Populations Served
  – The aged, if not eligible for Medicare;
  – Blind members;
  – Physically and/or mentally disabled members (collectively known
    as “the ABD population”);
  – Wards of the court and foster children; or
  – Children on adoption assistance

            Indiana Care Select Program
                  Change in Scope
• Eligible Care Select Members (Conditions)
   –   Asthma
   –   Diabetes
   –   Congestive Heart Failure
   –   Coronary Heart Disease
   –   Hypertension
   –   Chronic Kidney Disease
   –   Severe Mental Illness (SMI) and Depression
   –   Serious Emotional Disturbance (SED)

         Indiana Care Select Program
               Change in Scope
• Statewide Populations not eligible for the Care Select
   – Dual-eligible members
   – The population on Home and Community Based Service (HCBS)
   – MED Works participants
   – Individuals receiving room and board assistance
   – Breast and Cervical Cancer Group
   – Individuals with QMB or SLMB only (not in combination with
     another aid category)

    Indiana Care Select Program
          Change in Scope
Member Opt-out Process
• Members can opt-out if they are eligible to participate in
  disease management programs that the Care Management
  Organizations (CMOs) provide for their chronic conditions
• Members who opt-out will be enrolled in Traditional
• HCBS waiver members will no longer be in Care Select and
  continue to receive case management services through the

            Care Select Member Opt-out
                 Process Overview
                              Member letter sent in
Member staying in Care                                      Member no longer in
       Select                                                  Care Select
                              Member new to Care
                                                            Member needs to do
                                                           nothing; Moves back to
                                   Call Maximus             Traditional Medicaid
      needs to do
        Can call
      Maximus to
       opt-out at        Opt-Out              Pick PMP &    May call Maximus if
       any time.                      OR
                                                 CMO          they have ?s.

        Indiana Care Select Program
              Change in Scope
Disease Management
• Members with a chronic condition will have access to
  additional health education resources with the CMO
• Increased compliance with disease management treatment
  plans including medication compliance and appropriate
  preventative care visits
• Disease specific assessments and care plans
• Goals: individualized & preventative care

        Indiana Care Select Program
              Change in Scope
HP’s Continued Functions
• Process claims for all services provided to Care Select
• Follow the IHCP Provider Manual
• The member must be eligible for Medicaid – check eligibility
  prior to providing services
• Web InterChange administration & maintenance
• Remittance advices and claims adjudication
• Claims resolution
• IHCP Provider Enrollment
• PMP Quarterly Certification Code Distribution

                      Prior Authorization

    • ADVANTAGE Health Solutions,
       – 1-800-784-3981 – Care Select PA
       – 1-800-269-5720 – Traditional FFS & MRO PA
    • ADVANTAGE was selected to function as the Traditional
      Medicaid fee–for–service and MRO Transformation PA
    • MDwise, Inc.
         – 1-866-440-2449 – Care Select PA
Note: All PA’s for prescription drugs are processed
by ACS and not the CMOs
               Prior Authorization

General Information
• The STATE plan requirements for Prior Authorization are the
  same for both Indiana Care Select and Traditional Medicaid

• The CMO’s PA departments use OMPP approved criteria in
  addition to the Indiana Administrative Code (IAC), PA
  guidelines, and Indiana Health Coverage Programs (IHCP)
  bulletins, banner pages, and newsletters when considering PA

• The CMO’s PA Departments review all medical, facility, or
  dental PA requests

                Prior Authorization

General Information
• Decisions to authorize, modify, or deny a PA is based on
  medical reasonableness, necessity, and other criteria outlined
  in 405 IAC 5-3 and reflects the current standards of practice in
  the provider community

• For a full detailed explanation of PA processes and
  procedures, please refer to Chapter 6 of the IHCP Provider

• Out-of-state providers must obtain PA prior to performing
  services (except emergencies & CMO contracted out-of-state
  PMPs performing services that don’t require PA)

                  Prior Authorization
PA Helpful Tips
• All prior authorizations (PA) are submitted to the member’s health
  plan on the date of request
• Fax the Indiana Prior Review and Authorization Request form
  along with supporting documents
• Web InterChange allows providers to submit non-pharmacy PA
  requests Note: Prior to contacting the CMO on PA status, providers
  should verify PA status using web interChange first
• Mail – Written requests for PA are submitted using an Indiana
  Prior Review and Authorization Request form along with
  supporting documents
• View fee schedule at to
  see if a covered service requires14PA
                 Prior Authorization
PA Helpful Tips (Cont.)
• New services require a new Prior Authorization request form
   – Reminder: Providers may not add new services to an existing
     PA request as this constitutes a new PA request
• Indiana Prior Review and Authorization Request Form, System
  Update Form and Dental Prior Review and Authorization
  Request Form
   – These forms are available on the Forms page, under the
     provider section of the IHCP Website at
   – View PA form completion information in Chapter Six
     of the IHCP Provider Manual at 15
                  Prior Authorization

PA Helpful Tips (Cont.)
• PA form information left open to interpretation
   – Please submit legible forms if mailing or faxing
   – Keep supporting documentation and PA request form
   – If faxing, please consider volume and use direct mail as an
     alternative (please do not batch faxes)
   – Make sure PA request form is signed by appropriate
     authorized provider

                  Prior Authorization
                           Web Interchange

• The following provider types can submit PA requests via Web
   – Chiropractor
   – Dentist
   – Doctor of Medicine
   – Doctor of Osteopathy
   – Home Health Agency (authorized agent)
   – Hospice
   – Hospitals
   – Optometrist
   – Podiatrist
   – Psychologist endorsed as a Health Service Practitioner in Psychology
   – Transportation providers
                   Prior Authorization

            Top PA Suspension/Denied Reasons
•   Certificate of medical necessity missing/incomplete
•   Home health plan of care missing/incomplete
•   Incomplete PA form
•   Missing physician orders
•   Clinical documentation missing
•   Incorrect form submitted

           Certification Code Policy

• The Care Select PMP is responsible for providing and/or
  overseeing a member’s care during the time the member is
  linked to that PMP through the PMP assignment process
• The PMP agrees to provide the necessary primary and
  preventive health services directly to their assigned members
  or agrees to refer the member to another health care provider
  for those services undeliverable by the PMP
• Each Care Select PMP is assigned a cert code on a quarterly
• This code, in addition to the PMP’s National Provider Identifier
  (NPI) is needed to allow a specialist or another provider’s
  claims to be paid when appropriate
           Certification Code Policy

Policy Description Statements
• While it is always preferable that the assigned PMP authorize
  treatment and provide their NPI and cert code, there may be
  occasions when this is not possible
• Appropriate and designated CMO staff will need to provide
  this information to another health care provider in order to
  allow the Care Select member access to appropriate and
  timely care
• The following are specific circumstances in which designated
  CMO staff may release to another health care provider a
  member’s PMP’s cert code and NPI before or after a service
  has been rendered as approved by the State

            Certification Code Policy
• PMP change is still pending after a member has selected a new
• Death of PMP
• PMP moves out of the region without proper notification to the
• Newly transitioned members into the program who are in need
  of treatment (i.e. EPSDT) within the first sixty (60) days of
• Member lives in an underserved area and is unable to select a
  PMP from that area
• Other urgent, emergent, or ongoing issues (i.e. dialysis or
  emergent ER admission) where the member is unable to access
  necessary services and the assigned PMP is unwilling or
  unable to provide services or the appropriate referral
         Right Choices Program (RCP)
               Referral Process

• ADVANTAGE Health Solutions identifies and monitors RCP
  members in both ADVANTAGE Care Select and Traditional
  fee-for-service Medicaid Programs

• MDwise Care Select identifies and monitors RCP members in
  the MDwise Care Select Program

• RCP includes members who have shown a pattern of potential
  mis-utilization or over-utilization of services (for example)
   – Non-emergent use of the ER
   – “drug seeking” behavior
   – Resistance to PCP interventions
          Right Choices Program (RCP)
                Referral Process
The RCP is:
• Not a loss of benefits
• Not a reduction in benefits
• Not a punitive action, but is a legal action

  Note: Members are still eligible for all medically necessary IHCP services.
  However, those services must be ordered or authorized in writing by the
  member’s assigned PMP

        Right Choices Program (RCP)
              Referral Process
• The RCP identifies members appropriate for assignment and
  subsequent “lock-in” to:
   – one Primary Medical Provider (PMP)
   – one pharmacy and
   – one hospital
• The goal of “lock-in” is to ensure members receive
  appropriate care and prevent members from mis-utilizing
• Specialty providers receive written authorization from the
• The CMO’s add those specialists to the member’s provider list
  in order for the specialty provider to be reimbursed
  Note: The RCP Program applies to both members
  in Traditional Medicaid and Indiana Care Select
       Right Choices Program (RCP)
             Referral Process
• The PMP manages the member’s care and determines
  whether a member requires evaluation or treatment by a
  specialty provider
   – Referrals are required by the PMP for most specialty
     medical providers (except self referral services)

   – Referrals should be based on medical necessity and not
     solely on the desire of the member to see a specialist

   – Emergency services for life threatening or life altering
     conditions are available at any hospital, but non-
     emergency services require a referral from the PMP

        Right Choices Program (RCP)
              Referral Process
      Adding Providers to a Right Choices Member’s
                       Lock In List
• Additional providers may be locked-in, either short-term or
  on an ongoing basis, if the PMP sends a written referral

• Providers may be locked-in for one specified date of service
  or for any defined duration of time, up to one year

       Right Choices Program (RCP)
             Referral Process
Self Referral
• Behavioral health (except
  prescriptions)                   • Home health care
• Chiropractic services            • Hospice
• Dental services (except          • Podiatric services (except
  prescriptions)                     prescriptions)
• Diabetes self-management         • Transportation
  services                         • Vision care (except surgery)
• Family planning services         • Waiver services
• HIV/AIDS targeted case

        Right Choices Program (RCP)
              Referral Process
Referral Guidelines for the PMP
• Referrals must be faxed or mailed
• Referrals may be handwritten on letterhead or a prescription
  pad, however, they must include the following information:
   – IHCP member’s name
   – IHCP member’s RID
   – First and last name and specialty of the physician to whom
     the member is being referred
   – Primary lock-in physician’s signature (not that of a staff
   – Date and duration of referral

    Right Choices Program (RCP)
          Referral Process
                   Contact Information
     ADVANTAGE                                   MDwise
ADVANTAGE Health Solutions –        MDwise Care Select
   Traditional FFS                  Attn: Care Management
Attn: Right Choices Program
P.O. Box 40789                      P.O. Box 44214
Indianapolis, IN 46240              Indianapolis, Indiana 46244-0214
1-800-784-3981                      Phone: 1-800-356-1204 or
Fax: 1-800-689-2759                 317-630-2831
ADVANTAGE Health Solutions -        Fax: 1-877-822-7187 or
   Care Select                      317-822-7517
Attn: Right Choices Program
P.O. Box 40789
Indianapolis, IN 46240
Fax: 1-800-689-2759
  2010 Care Select Quality Measures

The office of Medicaid Policy and Planning (OMPP) requires the
  CMOs to report their PMP’s performance in preventative
  service delivery.
• Annual HEDIS recommended preventative services are based
  on age and/or sex of the member

• Examples of preventative services that OMPP measures the
  CMOs on include:
   – Adolescent Well child Visits
   – Cholesterol Screening
   – Diabetes Screening
   – ER Bounce Back
2010 Care Select Quality Measures

            Step 4.
       Submit claim to HP                  Step 1.
                                      Identify care gap

       Step 3.
  Provide service to
      member                         Step 2.
                                 Notify member

                  CMO Updates

• State Mandated Preventative Services Guidelines will
  be made available at and

• To date ADVANTAGE and MDwise have paid out a
  total of approx. $400,000 in P4P programs paid to the
  PMP community for providing high quality
  preventative care

           Contact Information

ADVANTAGE Care Select:        MDwise Care Select:
   1-800-784-3981              1-800-356-1204


Thank you for attending!


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