MDwise Product Comparison

Transcription

1 Quick Contact Guide

2 MDwise Product Comparison Basic Information Members Served Customer Service Business Structure Claims/Reimbursement Authorization Required Other Program Responsibilities State Website Information Pharmacy Hoosier Healthwise Healthy Indiana Plan Indiana Care Select Operations began Jan Statewide operations MDwise.org/providers Packages A, B, C, & P Children Pregnant women Low income families (TANF) Less than 150% FPL (Package A & B) Between % FPL (Package C) Call or Administered by MDwise and its delivery systems throughout the state of Indiana Adjudicated by the delivery systems Checks issued by the delivery systems Claim filing limit: 90 days Remittance from delivery systems MDwise delivery systems closed network model Prior authorization required for services mandated by State and the delivery system Credentialing, quality improvement program, provider relations, hearings/ appeals, utilization management, claims adjudication, Right Choices program administration, behavioral health integration Operations began Jan Statewide operations MDwise.org/providers Package H Adults ages Parents of CHIP children Childless adults Uninsured for at least 6 months No access to employer-sponsored insurance Up to 138% FPL Call or Administered by MDwise and its delivery systems throughout the state of Indiana Checks issued by HIP delivery systems POWER Account managed by MDwise Claim filing limit: 90 days Remittance from HIP delivery system MDwise delivery systems Prior authorization required for services mandated by State and the delivery system Credentialing, quality improvement program, provider relations, hearings/ appeals, utilization management, claims adjudication, Right Choices program administration, behavioral health integration Operations began Nov Statewide operations MDwise.org/providers Aged, blind and disabled Children receiving adoptive services Wards of the court/ Foster children Call or Administered by MDwise corporate only Not a delivery system model Adjudicated by HP Checks issued by HP Claim filing limit: 365 days Remittance from HP Advantage Health Solutions Prior authorization required for services mandated by the State Credentialing, quality improvement program, provider relations, hearings/appeals, utilization management, Right Choices program administration, behavioral health integration, disease management indianamedicaid.com HIP.in.gov indianamedicaid.com in.gov/fssa/ompp/2546.htm Indiana Medicaid formulary Catamaran prior authorization/ drug rebate HP processes claims Formulary indianamedicaid.com, click Providers, then Pharmacy Services Indiana Medicaid formulary MedImpact prior authorization/ drug rebate Formulary MDwise.org/providers/hip/pharmacy select HIP Basic, HIP State or HIP Plus Indiana Medicaid formulary Catamaran prior authorization/ drug rebate HP processes claims Formulary indianamedicaid.com, click Providers, then Pharmacy Services Other Stakeholders Hoosier Healthwise Helpline: Anthem (MCE): MHS (MCE): Anthem HIP Plan: MHS HIP Plan: HIP Helpline:1-877-GET-HIP-9 Care Select Helpline: HP (fiscal agent): or ADVANTAGE Health Solutions, Inc. (CMO): (provider services) Catamaran (Care Select pharmacy):

3 MDwise Hoosier Healthwise and HIP Maternity Contact Information MDwise.org/providers General Information Customer Service/Transportation Fax: or Provider Services: Medical Services Fax: MDwise Hoosier Healthwise Customer Service P.O. Box Indianapolis, IN MDwise Hoosier Healthwise Provider Services 1200 Madison Avenue, Suite 400 Indianapolis, IN Provider Services: Behavioral Health Contracting and Credentialing Fax: MDwise.org/providers MDwise Hoosier Healthwise Behavioral Health 1200 Madison Ave.. Suite 400 Indianapolis, In Right Choices Program Fax: Preferred Drug List indianamedicaid.com (Choose Providers, then Pharmacy Services)/ Fraud & Abuse or Claims Disputes, Grievances & Appeals Behavioral Health ONLY Medical ONLY (contracted providers) Medical ONLY (non-contracted providers) MDwise P.O. Box Indianapolis, IN Attention: Grievances & Appeals Submit to member s delivery system, except MDwise Eskenazi Health, IU Health and Total Health delivery systems submit to: MDwise P.O. Box Indianapolis, IN Attention: Grievance Coordinator MDwise P.O. Box Indianapolis, IN Attention: Grievance Coordinator

4 MDwise Hoosier Healthwise and HIP Maternity Delivery Systems MDwise Hoosier Alliance Claims Inquiries Fax: Provider Representative Fax: Family Planning Claims MDwise St. Vincent MDwise Hoosier Alliance P.O. Box 7303 London, KY EDI Payer ID: mental/behavioral health eff MDwise Family Planning Claims McKesson/Relay Health Institutional Payer ID: 4976 Emdeon/WebMD Institutional Payer ID: 12K81 Claims Inquiries / / Fax: / Provider Representative Fax: Family Planning Claims MDwise St. Vincent P.O. Box Indianapolis, IN EDI Payer ID Relay Health: 2235 Emdeon: MDwise Family Planning Claims McKesson/Relay Health Institutional Payer ID: 4976 MDwise St. Catherine Claims Inquiries / (Hospital Auths Only) (Toll Free Prior Auth) (All Other Auths) Fax: Behavioral Health Fax: Provider Representative St. Mary Medical Center Providers Munster Community Hospital Providers (includes behavioral claims) Family Planning Claims St. Catherine Hospital Providers MDwise St. Catherine P.O. Box Indianapolis, IN Payer ID Emdeon Relay Health/McKesson 2235 mental/behavioral health eff MDwise Family Planning Claims McKesson/Relay Health Institutional Payer ID: 4976 Emdeon/WebMD Institutional Payer ID: 12K81 MDwise Eskenazi Health (formerly MDwise Wishard) Claims Inquiries Provider Representative / Fax: / MDwise Eskenazi Health All Medical Claims: Emdeon/WebMD Institutional Payer ID: 12K81 McKesson/Relay Health Institutional Payer ID:

5 MDwise SHN Claims Inquiries MDwise Total Health Claims Inquiries Phone and Fax: / Provider Representative Fax: Fax: Provider Representative Family Planning Claims MDwise Select Health Network P.O. Box Indianapolis, IN EDI Payer ID Relay Health: 6139 MDwise Family Planning Claims McKesson/Relay Health Institutional Payer ID: 4976 Emdeon/WebMD Institutional Payer ID: 12K81 MDwise Total Health All Medical Claims: Emdeon/WebMD Institutional Payer ID: 12K81 McKesson/Relay Health Institutional Payer ID: 4976 MDwise St. Margaret Claims Inquiries / Provider Representative (includes behavioral claims) Family Planning Claims Fax: x62309 MDwise St. Margaret P.O. Box Indianapolis, IN Payer ID Emdeon Relay Health/McKesson 2235 MDwise St. Anthony P.O. Box Indianapolis, IN MDwise Indiana University Health (formerly MDwise Methodist) MDwise Family Planning Claims McKesson/Relay Health Institutional Payer ID: 4976 Emdeon/WebMD Institutional Payer ID: 12K81 Professional Claims: SX172 Claims Inquiries Fax: Provider Representative MDwise IU Health Claim Disputes Address P.O. Box Indianapolis, IN Emdeon/WebMD Institutional Payer ID: 12K81 McKesson/Relay Health Institutional Payer ID: 4976

6 MDwise Healthy Indiana Plan (HIP) Contact Information MDwise.org/providers General Information Enrollment Broker Maximus GET-HIP-9 or Customer/Provider Service Fax: or MDwise Healthy Indiana Plan P.O. Box Indianapolis, IN Dental General Provider and Authorization line: Claims address: DENTAQUEST of IN-Claims N. Corporate Parkway Mequon, WI Electronic Claims should be sent: Direct entry on the web: dentaquest.com Or, Via Clearinghouse: Payer ID CX014 Include address on electronic claims: DentalQuest, LLC N Corporate Parkway Mequon, WI Right Choices Program Fax: Fraud & Abuse or Medical & Behavioral Health Claims Effective all HIP claims regardless of date of service should be mailed to: MDwise HIP Claims WebMD/Emdeon McKesson/Relay Health Institutional Payer ID: 12K81 Institutional Payer ID: 4976 Professional Payer ID: SX172 Professional Payer ID: 4481 Pharmacy Pharmacy Help Desk: : Fax: RxBIN: PCN: ASPROD1 RxGRP: MDW Preferred Drug List MDwise.org/providers/hip/pharmacy (select HIP Basic, HIP State or HIP Plus) 6

7 MDwise Healthy Indiana Plan Delivery Systems MDwise Eskenazi Health (formerly MDwise Wishard) MDwise Hoosier Alliance / Fax: / Fax: Provider Representative Provider Representative MDwise Indiana University Health (formerly MDwise Methodist) / Fax: Provider Representative (MDwise Indiana University Health) (HealthNet Providers) MDwise St. Margaret Provider Representative MDwise Total Health Fax: x62309 Phone and Fax: / MDwise St. Catherine (Hospital Auths Only) (Toll Free Prior Auth) (All Other Auths) Fax: Behavioral Health Fax: Provider Representative Fax: MDwise SHN Fax: Provider Representative Provider Representative St. Mary Medical Center Providers Munster Community Hospital Providers St. Catherine Hospital Providers MDwise St. Vincent / Fax: / Provider Representative Fax: Note: Medical Management and prior authorization for behavioral health Contact HIP member s delivery system

8 MDwise Care Select Contact Information MDwise.org/providers General Information Customer Service Members and providers may call customer service for all Care Select related questions Fax: or NURSEon-call:, Option #4 Indiana Relay services: MDwise Care Select Customer Service P.O. Box Indianapolis, Indiana Provider Services Fax: Advantage Health Solutions: HP Web interchange website: indianamedicaid.com Fax: MDwise Care Select Provider Services P.O. Box Indianapolis, Indiana Advantage Health Solutions Care Select Attn: Department P.O. Box Indianapolis, IN Care Management Fax: or Right Choices Program Fax: Disease Management Fax: or MDwise Care Select Care Management P.O. Box Indianapolis, Indiana MDwise Care Select Disease Management P.O. Box Indianapolis, Indiana Care Select Claims (UB04, CMS-1500, Pharmacy, Dental) Processed by Hewlett Packard Enterprise Services (HP), formerly EDS HP Customer Service Phone Number: or Fraud & Abuse or HP Electronic Solutions Help Desk (Not for eligibility or claim inquiry): or indianamedicaid.com Care Select Pharmacy and Pro-Dur Preferred Drug List Processed by Catamaran indianamedicaid.com (Preferred Drug List) Choose Providers, then Pharmacy Services 8

9 Services Requiring It is the responsibility of the provider to obtain PA for services from the (PA) Unit PRIOR to providing that service. Providers must check PA status using HP s web interchange at indianamedicaid.com. Institutional Services Inpatient substance abuse Psychiatric treatment facility (PRTF) Short-term nursing facility Inpatient surgical services Hospice (Traditional Medicaid only Member must be disenrolled from Care Select) Long-term acute care hospitalizations Non-Institutional Services Bariatric services Stem cell transplants Home health/certain types of therapy Reconstructive surgeries Reduction mammoplasties Sliding mandibular osteomies Surgical procedures Involving the foot Out of state services performed in non-designated areas (non-emergent) Blepharoplastics Brand name medically necessary drugs (Contact ACS) Intersex surgeries Maxillo-facial surgeries Rehabilitation inpatient admissions Stress electrocardiograms Dental Services Dentures Dental services rendered in a hospital Relines for dentures/partials for members > Age 21 Inpatient psychiatric admissions Emergency services that require PA in normal non-emergency situation Outpatient procedures rendered while inpatient Medically necessary office visits > 30 per year Certain durable medical equipment (DME) Bone marrow Genetic testing for detection of cancer Mastectomies for gynecomastia Organ transplants Rhinoplasty Submucus resection of nasal septum and septoplasty Podiatry services inpatient or outpatient Certain home medical equipment (HME) Transportation > 20 per year Drugs not on the state PDL Transportation > 50 miles one way Dental services rendered in an ambulatory surgical center (ASC) Repairs for dentures/partials for members > Age 21 Facility/anesthesia services in an ASC or hospital Dental and pharmacy services use the Indiana Prior Review and Authorization Request form located at indianamedicaid.com. All other PA requests must use the Universal PA form located at indianamedicaid.com unless the provider is submitting the PA request via web interchange (see the IHCP Provider Manual chapter 6, section 1, pages 6 8 for a list of providers who may submit PA requests via web interchange). All PA system updates must be submitted on the System Update Request form also located at indianamedicaid.com. New PA requests should not be submitted on a System Update Request form (i.e. modifying date ranges approved on a PA). All forms must be complete and signed. Advantage Health Solutions recommends faxing all PA information to Providers should submit PA requests to Advantage Health Solutions on the date of the request. Advantage Health Solutions will also process any requests for additional information related to a PA that is suspended and finalize that PA decision. Providers whose PA is suspended, have 30 days to respond to requests for additional information or that PA request will be denied. Physician authorization as well as PA may be required for some specialty services (see BT200804). Medicaid Rehabilitation Option Services PA are processed by Advantage Health Solutions. Certification Code Policy (For Care Select claims prior to January 1, 2011) It is the responsibility of each provider to verify the eligibility of each Care Select member PRIOR to providing services. The primary medical provider s (PMP) certification code and NPI are used by the PMP to authorize the referral of a Care Select member for necessary specialty services. Specialty providers must contact the member s PMP to seek the certification code PRIOR to providing services. (Please note: this includes non-emergency services provided in an emergency room in the hospital as well as all services related to an inpatient admission. Refer to BT located at indianamedicaid.com for a list of services by provider specialty that does not require the PMP s certification code.)

10 MDwise.org Last Updated February 4, 2015 APP0117 (10/12)