P0216 (09/08)

2008 Indiana Health Coverage Program SeminarPrior Authorization/DME

2008 Indiana Health Coverage Program SeminarPrior Authorization/DME

Presented by MDwise & MDwise Delivery Systems Provider RelationsOctober 6-8,2008

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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

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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 150-200% FPL (Pkg C)

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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

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MDwise Lines of Business continued…..

Healthy Indiana Plan- MDwise with AmeriChoice Operations began January 2008 Statewide operations

Members Served Adults ages 19-64 Caretaker and Individuals Uninsured for at least 6 months No access to employer-sponsored insurance Package H 22-200% FPL

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MDwise Currently serves300,000 plus members

statewide!( all lines of business)

P0216 (09/08)

Prior AuthorizationPrior Authorization

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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.

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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

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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

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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

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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).

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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

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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 www.mdwise.org

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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 www.mdwise.org. PerformRX 800-558-1655

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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)

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Claims disputeIn and out of network- Call Delivery System to inquire about claimDelivery System must respond within 30 calendar days of inquiryAppeals – Must be in writingProvider 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 441423, Indianapolis, IN 46244-1423Attention: Grievance Coordinator

Claims Dispute

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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.

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Roundtable Discussion

MDwise Delivery System Provider Relations Representatives/Medical Management

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Thank You From