P0216 (09/08) 2008 Indiana Health Coverage Program Seminar Prior Authorization/DME Presented by MDwise & MDwise Delivery Systems Provider Relations October 6-8,2008

Hoosier Healthwise Topics for today  MDwise Lines of Business  Prior Authorization Overview  Contacting Medical Management  Closed Network vs. Open Network  Claims Submission  Introduction of MDwise Delivery Systems Representatives/Medical Management  MDwise Delivery System Roundtable

Hoosier Healthwise MDwise Lines of Business Hoosier Healthwise Operations began January 1994 Statewide operations  Members Served  Package A, B, and C  Children  Pregnant Women (also from HIP)  Low income families (TANF)  Less than 150% FPL (Pkg A & B)  Between % FPL (Pkg C)

Hoosier Healthwise MDwise Lines of Business continued… Indiana Care Select Operations began November 2007 Statewide operations  Members Served  Aged, Blind, Disabled  Home and Community Based Waivers  Adoptive Services  M.E.D. Works  Wards and Foster Children

Hoosier Healthwise MDwise Lines of Business continued….. Healthy Indiana Plan- MDwise with AmeriChoice Operations began January 2008 Statewide operations  Members Served  Adults ages  Caretaker and Individuals  Uninsured for at least 6 months  No access to employer-sponsored insurance  Package H  % FPL

Hoosier Healthwise MDwise Currently serves 300,000 plus members statewide! ( all lines of business)

P0216 (09/08) Prior Authorization

Hoosier Healthwise Role of Medical Management  MDwise delegates medical management functions to the individual hospital delivery systems (see quick contact sheet).  Medical Management focuses on the outcome of treatment with an emphasis on:  Appropriate screening activities.  Reasonableness and necessity of all services.  Quality of care reflected by the choice of services provided, type of provider involved, and the setting in which the care was delivered.  Prospective and concurrent care management.  Evaluation of standards of care/guidelines for provision of care and  Best practice monitors.

Hoosier Healthwise Role of Medical Management  Medical Management service authorization activities conducted by the medical management staff include:  Preauthorization of inpatient and selected outpatient services, including pharmaceuticals referral management concurrent review retrospective review on selected inpatient and outpatient services authorization and denial notification

Hoosier Healthwise Contacting Medical Management  Contact members Medical Management department for services that require prior authorization or online (see quick contact sheet)  Prior authorization forms are available online or by contacting MDwise members medical management department

Hoosier Healthwise Closed Network vs. Open Network  The majority of MDwise and it’s delivery systems operate as a closed network.  MDwise Methodist  MDwise Wishard  MDwise St. Vincent  MDwise Select Health Network  MDwise St. Catherine  MDwise St. Margaret Mercy  MDwise ProHealth  MDwise St. Francis  MDwise Hoosier Alliance is the only delivery system that operates as a open network. Please contact Hoosier Alliance Medical Management department for services that require authorization

Hoosier Healthwise Referral to Specialist  A prior authorization number may not be required when referring to a in-network provider.  Please refer to the delivery system medical management or provider directory for assistance in location an in-network provider.  Retroactive authorizations for referrals is not guaranteed (contact members medical management department).

Hoosier Healthwise Out-of-Network Authorizations  Members of MDwise networks that require covered services not available within the network must have prior authorization from the delivery systems medical management department ( before services are rendered). * please see note on previous page for MDwise Hoosier Alliance

Hoosier Healthwise Prior Authorization for DME DME providers:  Please contact the members delivery system medical management department for DME prior authorization requirements.  Prior Authorization forms are available online at

Hoosier Healthwise Pharmacy Authorization All providers are specialist providing care to MDwise members are required to utilized the MDwise PDL. The PDL is updated on a regular basis. The PDL can is available hard copy and online at PerformRX

Hoosier Healthwise Claims Submission Providers are encouraged to submit their claims electronically  In-MDwise Network Providers must submit their claims to the delivery system claims department where the member is assigned.  Providers should contact the applicable delivery system for specific instruction on electronic claims submission  Please note that all electronic claims must be submitted using the HIPPA compliant transaction and codes sets  Providers may submit paper claims to the applicable delivery system address ( see quick contact sheet )

Hoosier Healthwise Claims dispute In and out of network- Call Delivery System to inquire about claim Delivery System must respond within 30 calendar days of inquiry Appeals – Must be in writing Provider has 60 calendar days  From receiving remittance advice denial or  After delivery system fails to make determination or  In-network appeals should be forward to members delivery system for resolution  Out-of-network appeals should be forward to MDwise Corporate at P.O. Box , Indianapolis, IN Attention: Grievance Coordinator Claims Dispute

Hoosier Healthwise Claims Filing Limit In-Network Providers have a filing limit that ranges from 90 to 180 days, depending on their contract with the Delivery System. Out-of-Network Providers have 365 days from the date of service to file a claim. It is the responsibility of ALL providers to check eligibility at the time of each visit.

Hoosier Healthwise Roundtable Discussion MDwise Delivery System Provider Relations Representatives/Medical Management

Hoosier Healthwise Thank You From