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Provider Manual2020mhsindiana.com0920.PR.P.JB 9/20
TABLE OF CONTENTSChapter 1: Managed Health Services (MHS). 6Chapter 2: Guidelines for Providers. 7The Medical Home.7Covered Services.7Provider Assistance with Public Health Services.7HealthWatch (EPSDT).7Notification of Pregnancy (NOP). 8Service Carve-outs. 8Pharmacy. 8Excluded Benefits - Hoosier Care Connect. 8Availability and Accessibility. 9Appointment Availability. 9After-Hours Telephone Accessibility Arrangement. 10Out-of-Office Coverage. 10Provider Disenrollment from IHCP. 10Interpreter/Translation Services. 10Advance Directives.11Provider-Member Communication.11Member Panel Capacity.11Quality Improvement (QI) Activities.11Chapter 3: Compliance.12Health Insurance Portability and Accountability Act (HIPAA). 12Privacy Regulation. 12Transactions and Code Sets Regulation. 12HIPAA-Regulated Transactions. 12HIPAA Electronic Transactions. 12HIPAA Required Code Sets. 13Sending Protected Health Information Securely. 13Federal, State and MCE Audits and Investigations. 13Fraud and Abuse. 13Chapter 4: General Claims Information and Guidelines.14Reimbursement. 14Provider Information on File. 14Updating Billing information. 14Changing Your Tax Identification Number (TIN). 14Mismatched Member Information. 15Billing the Member. 15Third Party Liability (TPL). 15Claims Submission. 16Avoid Common Errors. 16Claim Submissions Online at mhsindiana.com/login. 17Paper Claim Submissions. 17Coordination of Benefits (COB). 17MHS Secure Provider Portal Submission. 18EDI – Clearinghouse. 1890 Day Provision for COB Billing Available Electronically. 19Claims with Attachments. 19Clean Claim and Non-Clean Claim Definitions. 19Code Auditing and Editing (Code Review).20Claims for Newborns.20Claims Payment. 21Electronic Remittance Advice and Electronic Funds Transfer. 212 MHS Provider Manual 2020 mhsindiana.com
PaySpan Health Benefits to Providers. 21Recoupments.22Claim Corrections and Resubmissions (Adjustments).22EPSDT Billing.22Immunizations Reimbursement.22Private Stock for Vaccines.23Transportation Claims.23Getting Help with a Claim.23Chapter 5: Claims Administrative Reviews and Appeals. 24Informal Claim Dispute/Reconsideration.24Formal Claim Dispute - Administrative Claim Appeal.24Administrative Claim Appeal Review and Determination.25Claim Processing Following Determination.25Determining Correct Appeal Procedure for Inpatient Denials.25Chapter 6: Medical Management. 26Contact MHS Medical Management.26Referral and Prior Authorization (PA).26Referrals Requirements.28Prior Authorization Requirements.28List of Services Requiring Prior Authorization (PA).28Outpatient Facilities.30Inpatient and Observation Services.30Observation Bed Guidelines.30Facility-to-Facility Transfers.30Post-Stabilization. 31Late Notification. 31Assistant Surgeon.32Continuity of Care.32Dental Services.32Emergency and Non-Emergency Transportation.32Radiology, Diagnostic Imaging and Therapy.33Rendering Prior Authorization Decisions.33Utilization Management (UM) Review Guidelines.34Peer-to-Peer Review.34Utilization Management Inpatient Authorization Review Process.34Routine, Urgent and Emergency Care Services Defined.35Chapter 7: Medical Management Appeals. 36Appeal Review Guidelines.36Medical Necessity Appeal.36Receipt and Review Timeline.36Determination Timeline. 37Expedited Medical Necessity Appeals. 37Receipt and Review Timeline. 37Determination Timeline. 37External Independent Review.38State Fair Hearing.38Chapter 8: Pharmacy. 39Preferred Drug List.39Non-Covered Drugs.39Mandatory Generic Substitution. 40Prior Authorization. 40Specialty Medications. 40Contacts for Appeals. 40mhsindiana.com MHS Provider Manual 2020 3
Chapter 9: Preventive Healthcare Programs.41Preventive Care Outreach. 41My Health Pays . 41MHS Healthy Celebration. 41HealthWatch/EPSDT. 41Bright Futures. 41MEDTOX.42Immunizations.42Vaccines for Children (VFC).42Children & Hoosiers Immunization Registry Program (CHIRP)/MyVaxIndiana.42Clinical Practice and Preventive Health Guidelines.43Healthy Indiana Plan (HIP) Recommended Preventive Care/Incentive.43Tobacco Cessation and the Indiana Tobacco Quitline.43Chapter 10: Case Management Programs.44Prenatal and Well-Baby Programs. 44Start Smart for Your Baby . 44MHS Special Deliveries. 44Start Smart for Your Baby Post-Partum Program. 44First Year of Life Program. 44Referral to Case Management.45Disease Management Programs.45Lead Disease Management.45Frequent Emergency Room Utilizers Management Program.45Right Choices Program (RCP). 46Children with Special Needs. 46Chapter 11: Behavioral Health Services. 47Intensive Case Management.47Behavioral Health Disease Management.47Behavioral/Physical Healthcare Coordination.47Billing for Behavioral Health Services. 48Chapter 12: Quality Improvement. 49Overview. 49Quality Improvement Oversight. 51Delegated Activities/Services.52Clinical Practice and Preventive Health Guidelines (CPGs).52Healthcare Effectiveness Data and Information Set (HEDIS) Annual Request for Information.52Chapter 13: Member Eligibility, Enrollment and PMP Selection/Panel Assignment. 53Eligibility for Hoosier Healthwise (HHW) & Hoosier Care Connect.53HHW & Hoosier Care Connect Member Open Enrollment and Plan Changes.53Eligibility for Healthy Indiana Plan (HIP).53HIP Member Open Enrollment and Plan Changes.54Pregnancy and HIP Members.55Verifying Member Eligibility.55Means for Verifying Eligibility.56Member ID Cards.57Member Redetermination.57Member Enrollment Guidelines for MHS Providers.58PMP Selection/Panel Assignments.58Adding a New Member to Your Panel.58Full Panel Additions.58Panel Hold Requests and Additions.58Pre-birth Selection.59Physician Disenrollments and Continuity of Care.59Member Disenrollment.59Valid Reasons for a Request for Disenrol
mhsindiana.com and the MHS Secure Provider Portal MHS’ website, mhsindiana.com, offers many useful features and information on the latest developments regarding IHCP. Providers may register online to access MHS’ Secure Provider Portal, where you can: Manage multiple practice
