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Index
Indiana Health Coverage Programs Provider Manual
I N D I A N A
H E A L T H
C O V E R A G E
P R O G R A M S
P R O V I D E R
M A N U A L
Index
Library Reference Number: PRPR10004
Published: June 2015
Version: 14.0, 14.1, and 15.0
1
Index
Indiana Health Coverage Programs Provider Manual
Index
1
100-day supply – maintenance medications 949
1099 reporting information .....................12-64
how it is determined ............................12-64
incorrect ..............................................12-64
2
270/271 ...................................................3-27
277 Claim Status Request and Response 8-138,
8-408
277 Health Care Claim Status Response 8-158
278 request..............................................6-29
278 response ...........................................6-36
278 transaction ........................................6-29
4
450B..........................................................14-9
5
590 Program authorizations ....................6-27
590 Program ...........................................1-9, 244
8
835 and RA
comparison ..........................................12-38
835 Remittance Advice ..........................8-138,
8-158, 8-408
837D .......................................................8-19, 8401, 8-407
837I .........................................................8-19, 8138
837P ........................................................8-19, 8158
A
AA modifier............................................8-185
abortion ...................................................8-471
abuse .......................................................13-10
acceptance of payment ............................13-37
access online forms................................14-9
accessories K0607 – K0609 PA criteria .6-68
accident-related services .........................5-9
accompanying attendant .........................8-374
accompanying parent ..............................8-374
accounts receivable .................................12-39
automatically established ....................12-39
control numbers ..................................12-39
definition .............................................12-39
Library Reference Number: PRPR10004
Published: June 2015
Version: 14.0, 14.1, and 15.0
establishing ........................................ 12-39
ICF/MR tax assessments .................... 12-46
liens against provider payments ......... 12-53
manually established .......................... 12-40
nonclaim-specific refunds .................. 12-52
payouts ............................................... 12-46
provider partial payments................... 12-48
reason codes ....................................... 12-40
recovery ............................................. 12-42
referrals .............................................. 12-42
transfer letter ...................................... 12-43
Acknowledgement of Receipt of Hysterectomy
Information ........................................ 8-485
action codes ........................................... 6-36
ADA Dental claim form fields............... 8-403
ADA Dental Claim Form....................... 8-404
ADA ...................................................... 4-63
adding a location ....................................4-56
additional attendant ................................8-375
additional diagnosis codes ..................... 8-82
add-on services ...................................... 7-35,
8-124
address changes ..................................... 4-58
addresses and telephone directory ......... 116
addresses for check and claim submission 116
addresses ................................................ 4-57
adjustment filing limitations .................. 11-12
adjustment form examples ..................... 11-11
adjustment reason codes ........................ 12-17
adjustment remark codes ....................... 12-18
adjustment request returned to provider 117
adjustment requests
where .................................................. 11-6
Adjustment/Finance Unit address .......... 5-14
adjustments
cannot be performed........................... 11-7
check-related ...................................... 11-6,
11-8
completing forms ............................... 11-10
expedite .............................................. 11-6
filing limitations ................................. 11-12
form examples .................................... 11-11
mass ................................................... 11-9
noncheck-related ................................ 11-6,
11-8
ordering forms .................................... 11-11
retroactive LTC rates ......................... 11-9
submitting for paid claims.................. 11-10
2
Index
timely processing guidelines ...............11-7
types ....................................................11-8
administration fee ...................................8-269
administrative fee on Remittance Advice
1254
administrative hearing ............................6-76
member appeals ..................................6-77
notification procedures ........................6-77
provider appeals ..................................6-76
administrative review and appeal procedures 675
administrative review responses ............10-34
administrative review .............................6-75,
10-33, 13-34
Administrative Simplification requirements 8144
Administrative Simplification ..................3-8, 467, 8-183
administrative .........................................7-43
admissions from other nursing facilities .14-10
ADRC .....................................................14-8,
14-40
Adult Protective Services .......................14-23
advanced practice nurse ..........................4-33
AEDs ......................................................6-67
agency review decision ...........................14-31
Aging and Disability Resource Center ...14-8,
14-40
alphabetic data to numeric data translation 329
ambulance services
emergency ...........................................8-376
ambulatory surgical center......................4-29, 733, 8-100
Americans with Disabilities Act .............4-63
anesthesia charges ...................................7-56
anesthesia services ..................................8-183
anesthesia
general, for dental procedures .............8-194
regional ...............................................8-194
vaginal or cesarean delivery................8-193
anesthesiology services ...........................7-39
antepartum care ......................................8-318
antepartum tests and screenings schedule
8320
antepartum visits .....................................8-333
Anthem HIP member card with Dentalvision
example...............................................2-10
Anthem HIP member card without Dentalvision
example...............................................2-10
apnea monitor .........................................8-238
appeal decision notification ....................14-31
appeal process .........................................4-28,
13-35, 14-31
Indiana Health Coverage Programs Provider Manual
application of corrective remedies ......... 14-33
apply for a Web interChange user ID .... 3-15
approval of nonspecific codes ............... 6-33
approval process .................................... 3-28
ARC ....................................................... 12-17
ASP ........................................................ 8-269
assistant surgeon modifier ..................... 7-39
attachments ............................................ 10-17
audiologist ............................................. 4-35
audiology services ................................. 8-262
audit procedures
minimum data set audit process ......... 14-28
augmentative communication devices ... 8-263
autoclosure billing ................................. 8-95
autoclosure of member Level of Care ... 14-35
automated attendant ............................... 6-16
automated letters .................................... 5-10
automated pharmacy prior authorization 9-47
automated questionnaires....................... 5-10
automated recovery................................ 5-10
Automated Voice Response (AVR) system 3-26
automatic crossovers............................. 10-22
automatic external defibrillators PA criteria 667
automatic external defibrillators ............ 6-67
automatically established accounts receivable
........................................................... 12-39
automation of pharmacy prior authorization for
fee-for-service claims ......................... 6-14
Average Sales Price ............................... 8-269
average wholesale price (AWP)............. 7-56
avoid reissues ......................................... 12-56
AVR .......................................................3-26
assignment code ................................. 3-55
call limitations ....................................3-27
check write option .............................. 3-51
claim status inquiry ............................ 3-60
date errors........................................... 3-31
entering alphabetic data ..................... 3-28
entering data ....................................... 3-29
general error messages ....................... 3-30
how to use .......................................... 3-26
initial options ..................................... 3-32, 3-33
location code errors ............................ 3-31
other insurance information ............... 3-45
prior authorization .............................. 3-52
provider ID number and location code errors
........................................................... 3-31
quick-entry techniques ....................... 3-28
RID errors .......................................... 3-31
service restrictions ............................. 3-41
special function keys .......................... 3-27
system assignment codes ................... 3-52
appeals ........................................10-34, 10-35, 13-35
other administrative reviews and appeals 10-34
Library Reference Number: PRPR10004
Published: June 2015
Version: 14.0, 14.1, and 15.0
3
Index
Indiana Health Coverage Programs Provider Manual
system walkthrough ............................3-30
telephone number ...............................3-26
B
B-Notice
definition .............................................12-65
process ................................................12-65
backup withholding on RA .....................12-65
backup withholding ................................12-65
how to stop ..........................................12-65
base relative value units ...........................8-193
batch ranges ...........................................10-11
bed hold payments .................................14-14
monitoring ..........................................14-15
behavioral health services .......................1-13
benefit limits ...........................................3-48
benefit package explanation ....................2-15, 2-32
benefit types
provided by EVS ................................5-12
bilateral procedures .................................8-360
billed amount limit...................................9-23
billing considerations ..............................14-35
billing exceptions ....................................4-61
billing for services rendered to Right Choices
Program members ...............................13-34
billing guidelines for bed hold days........14-15
billing IHCP members ............................13-37
billing instructions ..................................8-19
billing provider classification .................4-8
billing procedures...................................5-13
billing provider .......................................8-150
billing usual and customary charge ........9-26
birth weight codes ...................................8- 89
blanket denials .......................................5-14
botulinum toxin ......................................8-272
BPHC waiver liability...... ......................5-21
brand medically necessary ......................9-48
Breast and Cervical Cancer Program ......2-17
C
capital costs payment ..............................7-24
capital .....................................................7-43
capped rental items .................................8-218
Library Reference Number: PRPR10004
Published: June 2015
Version: 14.0, 14.1, and 15.0
Care Select administrative fee ............... 12-54
Care Select ............................................. 1-9, 1-11
2-41, 4-11, 4-24, 5-34, 6-8, 6-48, 6-57,
6-63, 6-69, 10-6, 10-36, 11-5, 12-6
carve-out ................................................ 13-32
case development ...................................13-21
case manager.......................................... 4-32
case mix index ....................................... 14-32
case mix reimbursement methodology .. 8-94
case mix reimbursement ........................ 7-43,
14-16
caseworker ............................................ 5-8
casting supplies ...................................... 8-223
Catamaran Corporation..........................1-19, 98
Certification of Need, Form 1261A ....... 8-89
certification type codes .......................... 6-30
change in eligibility status ..................... 8-77
change of address ................................... 4-58
change of EFT........................................ 4-58
change of ownership .............................. 4-56
change of provider file information ....... 4-58
charging members for noncovered services 4-61
check and claim submission addresses .. 1-16
check inquiry ......................................... 3-19
check write
information .........................................3-51
option ................................................. 3-51
check-related adjustments ...................... 11-6,
11-8
chemotherapy .........................................8-130
chickenpox ............................................. 8-388
Children’s Health Plan ............................. 2-15
Children’s Special Health Care Services ..2-19
chiropractic services PA ........................ 6-53
chiropractic services .............................. 8-195
chiropractor ............................................4-34
CHIRP ................................................... 8-390
CHOICE Program ..................................8-76
CHOW ................................................... 4-56
civil rights laws ......................................4-63
civil rights
requirements .......................................1-17
claim and check submission addresses .. 1-16
claim filing ............................................. 4-60
claim form explanation .......................... 8-19
claim inquiry .......................................... 3-18
claim reimbursement adjustments.......... 9-25
claim status inquiry ................................ 3-60
claim status ............................................ 1-25
claims administrative review ................ 10-33
4
Index
claims filing limit ....................................10-29,
10-30
claims for returned-to-stock prescriptions 925
claims processing ....................................10-8
claims returned to provider .....................10-14
claims submission ...................................3-17
claims that do not cross over automatically 1022
classification
billing provider ...................................4-8
dual provider .......................................4-9
group provider.....................................4-9
rendering provider ..............................4-9
classifications .........................................4-8
CLIA .......................................................8- 274
clinics......................................................4-32
closing a location ....................................4-56
CMS Civil Rights Compliance Policy Statement
............................................................1-18, 463
CMS-1500 billing instructions
hearing aids .........................................8-259
CMS-1500 claim form ............................8-19
example ...............................................8-157
CMS-1500 claims
submission address .............................8-146
CMS-1500 modifiers ..............................8-161
code sets..................................................4-67
coding guidelines ....................................8-81
coding of claims for premature newborns
889
common trends .......................................13-36
companion guides .................................3-26, 468, 8-26, 8-138, 8-158, 8-407
completing adjustment forms .................11-10
Compound Prescription Claim Form ......8-19
computerized tomography scans.............8-351
condition code 07....................................8-73
conditions of enrollment .........................4-8
consultation
office ...................................................8-246
consultations ...........................................8-245
continuation claim ..................................8-32, 878
Library Reference Number: PRPR10004
Published: June 2015
Version: 14.0, 14.1, and 15.0
Indiana Health Coverage Programs Provider Manual
continuous home hospice care
delivered in a nursing facility ............. 7-49
delivered in a private home ................ 7-49
continuous passive motion ..................... 8-223
contractor, county, and State responsibilities 119
contractors – fiscal agent ....................... 1-19
control numbers ..................................... 12-39
coordination with commercial plans ...... 5-25
copayment ..............................................2-53
ER nonemergency services................ 2-54
exempt services .................................. 2-55
exempt transportation services ........... 2-54
federal guidelines ............................... 2-53
Hoosier Healthwise Package C .......... 2-56
policies ............................................... 2-53
transportation ..................................... 2-53
transportation services ....................... 2-53
transportation services for Hoosier
Healthwise Package C..................... 2-56
corneal tissue ......................................... 8-103
corporate reorganization ........................ 4-56
cost avoidance ....................................... 5-8
bypass ................................................ 5-11
cost-avoidance requirement
exempt services ................................. 5-11
cosurgeon modifier ................................ 7-39
cosurgeons ............................................. 8-359
county, State, and contractor responsibilities 119
coverage ................................................ 2-14
covered and noncovered claim.............. 5-23
CPT codes .............................................. 7-56
credit balance letter ............................... 5-10
credit balance worksheet .......................5-10
critical care services ...............................8-246
crossover A claims ................................. 10-26
837I .................................................... 10-27
cross over automatically ........................ 10-22
crossover B claims ................................. 10-27
837P ................................................... 10-27
crossover C claims ................................. 10-27
837I .................................................... 10-27
crossover claims processing procedures 10-22
crossover claims..................................... 5-21, 755
UB-04 .................................................8-136
5
Index
crossovers
automatic ............................................10-22
C-section .................................................8-193
CSHCS ...................................................2-19
custom equipment ...................................8-217
Customer Assistance...............................1-23
telephone numbers and addresses .......1-16
D
data elements ..........................................6-30
certification type codes .......................6-30
facility type codes ...............................6-31
level of service codes ..........................6-31
release of information codes ...............6-31
service type codes ...............................6-30
data matches ...........................................5-8
date of service definition ........................8-25
decision letter ..........................................6-24
definition for other diagnoses .................8-82
definition of an accounts receivable .......12-39
delivery systems .....................................1-10
dental claim form field descriptions .......8-405
dental claim form ....................................8-19, 8401
dental coverage policy ............................8-416
dental extractions ....................................8-408
dental procedures at a hospital ...............6-54
dental procedures at an ASC...................6-54
dental service limitations ........................8-414
dental services PA ..................................6-53
dental services ........................................7-54
dentures ...............................................6- 53
partials .................................................6-54
partials for replacement of anterior teeth 654
dentist .....................................................4-38
denture relines ........................................6-54
denture repairs ........................................6-54
dentures ..................................................6-53, 8420, 8-425
Department of Health (ISDH) ................1-20
description of a CMS-1500 claim form ..8-151
description of fields on the UB-04 claim form
............................................................8-33
DESI .......................................................9-14
designated out-of-state areas...................6-73
detail .......................................................12-8
diabetes self-care management training ..8-207
diagnosis codes ......................................5-11
diagnosis segment ...................................6- 32
diagnosis-related group (DRG) system...7-16
diagnosis-related group methodology.....6-38
dialysis services ......................................8-131
direct care ...............................................7-42
Library Reference Number: PRPR10004
Published: June 2015
Version: 14.0, 14.1, and 15.0
Indiana Health Coverage Programs Provider Manual
disenrollment ......................................... 4-59
managed care ..................................... 4-59
dispensing fees ....................................... 9-17
DME and HME that do not require PA . 8-216
DME ...................................................... 6-65, 746, 7-49
PA ...................................................... 8-216
rent or purchase .................................. 8-215
DME/HME capped rental items............. 8-218
documentation.........................................10-31
requirements ...................................... 5-10
documenting physician authorization .... 13-30
DRG base rate for children’s hospitals .. 7-26
DRG base rate ........................................ 7-23
DRG inpatient hospital admission PA policy
requirements .......................................6-38
DRG methodology ................................. 6-38
DRG outlier payment policies ............... 7-23
DRG reimbursement system .................. 7-16
drug age precaution................................ 9-38
drug claim form ..................................... 8-19
drug claims
submission.......................................... 9-24
drug classes
billed amount limit ............................. 9-23
drug copayment ..................................... 9-21
drug disease alerts ..................................9-38
drug pregnancy alert .............................. 9-38
Drug Utilization Review ........................ 9-36
drug-drug interaction ............................. 9-38
drug-eluting stents ................................. 7-34
drugs
identical, related, or similar................ 9-14
less than effective ...............................9-14
dual provider classification .................... 4-9
dual ........................................................ 8-151
dually eligible member in nursing facility 876
dually eligible member in private home 8-76
duplicate requests ...................................6-33
DUR edits requiring PA......................... 9-47
DUR .......................................................9-36
durable medical equipment (DME)
reimbursement ....................................7-53
durable medical equipment .................... 4-36, 665, 8-213
E
e-450B.......................................................14-9
echography .............................................8-324
EDI ........................................................ 1-24, 3-8
edit 1024 ................................................ 14-37
edits and audits ....................................... 10-20
educational sessions ............................... 1-26
6
Index
EFT changes ...........................................4-58
EFT form
rejections .............................................12-60
EFT
how to enroll .......................................12-59
identifying receipt of funds .................12-60
receiving funds for rejected EFTs .......12-61
rejections .............................................12-60
electronic 450B........................................14-9
electronic data interchange .....................1-24
electronic funds transfer (EFT) ...............12-38, 12-59
electronic claims ....................................10-16
electronic PA requests ............................6-34
Electronic Solutions................................3-7
electronic transaction ..............................6-29
electronic voids and replacements.........11-12
eligibility verification
proof ....................................................2-13
eligibility
how to verify .......................................2-14
member ...............................................2-12
provider ...............................................4-8
retroactive ...........................................2-57, 460
retroactive Medicare ..........................5-16
verification ..........................................2-12
verification methods............................2-14
eliminate healthcare abuse and fraud ......13-15
emergency admission
PA policy ............................................6-48
PA policy RBMC ................................6-49
PA required .........................................6-48
emergency department physicians ..........8-243
emergency hospice services ....................7-50
emergency service ..................................6-48
emergency supply ...................................9-48
emergency ...............................................2-37
ambulance services .............................8-376
end-stage renal disease clinic ..................4-39
end-stage renal disease ...........................8-131
Enhanced Services Plan ..........................2-45
enrollment specifics
MCE ...................................................4-25
enrollment steps ......................................4-16
enrollment tips ........................................4-22
enrollment updates ..................................4-55
enrollment
provider ...............................................1-22
enteral therapy ........................................8-224
Library Reference Number: PRPR10004
Published: June 2015
Version: 14.0, 14.1, and 15.0
Indiana Health Coverage Programs Provider Manual
entering alphabetic data ......................... 3-28
entering data in the AVR system ........... 3-29
EPSDT Program .................................... 8-256
ER services ............................................ 13-31
error message ......................................... 3-30
ESP HIP member card
example.............................................2-11
ESRD ..................................................... 8-131
establishing accounts receivable ............ 12-39
estimated acquisition cost (EAC)........... 7-56
evaluation and management services requiring
PA ...................................................... 6-52
evaluation and management services ..... 8-244
examples of IHCP RA statements.......... 12-21
examples of system update requests ...... 6-25
exceptions to the DRG and LOC reimbursement
systems for Package C members ........ 7-30
exempt from the copayment .................. 2-54, 2-55
exempt services
prenatal care ....................................... 5-11
preventative pediatric care ................. 5-11
exempted hospital discharge ................. 14-22
exemption from cost avoidance............. 5-11
expedite adjustment processing ............. 11-6
explanation of benefits codes ................. 12-16, 12-17
extended care facilities........................... 4-30
eye examinations ................................... 8-340
F
facility type codes .................................. 6-31
family member transportation provider . 8-385
family planning diagnosis codes ............ 8-248
family planning services ........................ 8-248
fax PA requests ...................................... 6-24
federal DESI Program............................ 9-14
federal rebate program ........................... 9-14
federal requirements .............................. 13-9
federal TPL regulations.......................... 5-7
Federally Qualified Health Centers ....... 8-250
Fee Schedule ..........................................8-412, 8-486
fee-for-service Care Select..................... 6-13
fee-for-service ........................................1-10, 232, 6-8, 7-34
FFS reimbursement methodology ...... 7-34
FFS Medicaid contractor roles ............... 9-12
FFS ........................................................ 2-32, 6-8
field consultants ..................................... 1-26
file maintenance
HIPAA ............................................... 4-69
filing administrative review....................10-33
filing claims ........................................... 4-60
filing limit waiver ................................. 10-31
filing limit ............................................. 10-29, 10-30
financial adjustment reason codes ......... 12-18
7
Index
financial record retention ........................13-15
financial services ....................................12-6
fiscal agent contractors ...........................1-19
Form 450B ..............................................14-8
forms request ..........................................1-25,
8-23
frames .....................................................8-343
fraud or abuse .........................................13-9
fraud .......................................................13-10
free vaccines ...........................................8-386
FTP .........................................................10-19
full overpayment adjustment ..................11-8
full-time equivalent (FTE) ......................7-27
G
general anesthesia provided in the dentist’s office
............................................................8-418
general anesthesia ...................................8-418
dental procedures ................................8-194
general information ................................10-6
general inpatient hospice care.................7-50
geographic practice cost index................7-38
group provider classification ..................4-9
group .......................................................8-151
grouper ....................................................7-22
groups .....................................................4-56
H
habilitation services.................................7-46
HCBS......................................................5-11
HCPCS Code J3300................................8-337
HCPCS codes requiring attachments ......8-486
header .....................................................12-8
health plan eligibility...............................2-14
HealthWatch ...........................................8-256
Healthy Indiana Plan ..............................1-9, 113, 2-45, 4-11, 4-24, 5-35, 9-8
member identification card.................2-8
hearing aid dealer....................................4-35
hearing aid purchase ...............................8-259
hearing aids.............................................8-259
HER2 protein ..........................................8- 271
HercepTest® .............................................8-271
high and low dose alerts .........................9-38
high-risk pregnancies ..............................8- 329
HIP prior authorization criteria ...............6-13
HIP ..........................................................1-9, 113, 2-45, 9-8
HIP 2.0.....................................................9-20
HIPAA Administrative Simplification
requirements
entities affected ...................................4-68
HIPAA compliance.................................3-8
HIPAA information ................................4-67
Library Reference Number: PRPR10004
Published: June 2015
Version: 14.0, 14.1, and 15.0
Indiana Health Coverage Programs Provider Manual
HIPAA ................................................... 4-67, 629, 7-56, 8-144
file maintenance ................................. 4-69
HME ...................................................... 6-65, 749
hold ....................................................... 10-21
Home and Community-Based Services . 8-265
home and community-based waiver services
authorizations ..................................... 6-27
Home and Community-Based Waiver services
........................................................... 5-11
home health agencies ............................. 4-32
home health claims ................................ 8-62
home health nursing services ................. 6-14, 658
home health PA policy requirements ..... 6-57
home health revenue codes/HCPCS codes 8-62
home health services .............................. 7-48,
8-62
RBMC ................................................ 6-62
home health
hospital discharge............................... 8-66
multiple visit billing ........................... 8-64
overhead rate ...................................... 8-63
partial units of service ........................ 8-65
unit of service ..................................... 8-63
home health/nursing/therapy PA policy
requirements
Hoosier Healthwise considerations .... 6-61
home health/nursing/therapy services
RBMC ................................................ 6-62
home infusion and enteral therapy
services/supplies ................................ 8-66
home medical equipment ....................... 4-36, 665, 8-213
home PA policy requirements
Hoosier Healthwise considerations .... 6-61
Hoosier Health Card .............................. 2-8
Hoosier Healthwise benefit package explanation
........................................................... 2-15
Hoosier Healthwise considerations ........ 10-32,
7-9
Hoosier Healthwise MCE
enrollment specifics ........................... 4-25
Hoosier Healthwise ................................ 1-9, 4-11,
4-24, 5-34, 14-39
coverage...............................................2-15
member eligibility................................2-15
Open Enrollment..................................2-16
Package A
standard plan ....................................... 2-16
8
Index
Indiana Health Coverage Programs Provider Manual
Package C
member copayment policies ............2-56
transportation copayment.................2-56
Package P
Presumptive Eligibility......................2-20
premium comparison .........................2-17
program comparison...........................2-21
RBMC .................................................5-35
hospice care coverage .............................8-69
hospice care in group homes...................7-50
hospice claims ........................................8-69
hospice contracts.....................................8-74
hospice member residing in nursing facility 8-76
hospice PA policy parameters ................6-44
hospice provider reimbursement.............8-78
hospice services ......................................7-49
hospice ....................................................4-32
emergency services .............................8-75
nonterminal condition .........................8-73
revenue codes......................................8-70
hospital discharge ...................................8-246
hospital observation or inpatient care services 8-246
hospital outpatient services .....................7-33
Hospital Presumptive Eligibility.............1-10, 5-35
hospital role ............................................13-31
hospital selection ....................................13-31
hospital services ......................................13-31
hospital-acquired conditions ...................8-83
hospitalization .........................................7-47
hospitals ..................................................4-29
how to cancel EFT participation .............12-61
how to enroll in the electronic funds transfer
option ..................................................12-59
how to identify receipt of an EFT ...........12-60
how to process a reissue request .............12-55
how to request a reissue ..........................12-55
how to use the AVR system....................3-26
how to use this manual ...........................1-7
how to verify member eigibility .............2-14
HP audit procedures
minimum data set audit process ..........14-28
HP Long Term Care Review Unit ..........14-30
HP nursing home claims .........................8- 93
HP ...........................................................1-19
HPE..........................................................1-10, 5-35
hysterectomy ...........................................8-475, 8-482
I
ICES .......................................................2-8
ICF/IID tax assessments .......................12-46
ICF/IID... ..................................................8-97
ICN .........................................................10-8
identical, related, or similar ....................9-14
identification ...........................................5-12
Library Reference Number: PRPR10004
Published: June 2015
Version: 14.0, 14.1, and 15.0
IHCP Fee Schedule ................................ 7-40
IHCP payment check processing ........... 12-55
IHCP Program Integrity Department......13-35
IHCP stay ...............................................7-23
IHCP
as primary payer................................. 5-10
payer of last resort.............................. 5-7
Third Party Liability ...........................5-7
implantable DME................................... 8-102
implantable loop recorder ...................... 8-115
incontinence supplies ............................. 6-64, 665, 8-227
incontinence, ostomy, and urological mail order
supplies .............................................. 8-227
incorrect 1099 information .................... 12-64
independent-based RHCs....................... 8-254
Indiana Administrative Code ................. 8-19
Indiana Client Eligibility System ........... 2-8, 894
Indiana Health Coverage Programs ....... 1-6, 212
Indiana Hoosier Health Card ................. 2-8
example ............................................. 2-9
indianamedicaid.com..............................1-6
Indiana Medicaid DUR Board ............... 9-36
Indiana Pre-Admission Screening Procedures
........................................................... 14-7
Indiana Prior Review and Authorization Dental
Request Form
instructions ......................................... 6-20
Indiana Health Coverage Programs Prior
Authorization Request Form
instructions ......................................... 6-17
Indiana State Department of Health (ISDH) 1-20
indirect care ........................................... 7-43
information in EVS................................ 5-12
informed consent ................................... 8-478,
8-482
initial options for AVR system .............. 3-32
injections ................................................8-269
inpatient blood factor claims ..................8-82
inpatient care services or hospital observation
........................................................... 8-246
inpatient consultation ............................. 8-246
inpatient hospital claims ........................ 8-80
inpatient hospital DRG admission PA policy
requirements .......................................6-38
inpatient hospital services ...................... 8-80
inpatient psychiatric admission PA policy
parameters, distinct part inpatient psychiatric
services in acute care hospitals .......... 6-39
inpatient psychiatric admission PA policy
parameters, inpatient psychiatric services in
freestanding psychiatric hospitals ...... 6-41
9
Index
inpatient psychiatric admission prior
authorization policy parameters ..........6-39
inpatient psychiatric admissions .............8-88
inpatient respite hospice care ..................7-50
inpatient services ....................................7-15
inpatient stays less than 24 hours............7-29
inquiries ..................................................5-28
institutional crossovers ...........................7-55
institutional PA policy requirements ......6-38
intermediate care facilities for individuals with
intellectual disability.............................7-45
intermediate care facility for individuals with
intellectual disability services.............8-97
internal control number ..........................10-8
examples .............................................10-12
Internal Revenue Service reporting requirements
.............................................................12-64
intraocular lenses ....................................8-117
introduction to prior authorization ..........6-8
introduction.............................................1-6, 2-8, 9-8,
10-6
involuntary termination ..........................4-59
IRS ..........................................................9-14
items requiring frequent or substantial servicing
............................................................8-220
IV sedation..............................................8-418
J
Julian dates .............................................10-10
K
K0607 – replacement battery .................6-68
K0608 – replacement garment ................6-68
K0609 – replacement electrodes .............6-68
L
laboratory services ..................................7-51, 8128, 8-274, 8-348
laboratory ................................................4- 38
last menstrual period ...............................8-318
leave days ...............................................7-45, 747, 8-94, 8-97
legend drug coverage ..............................9-13
legend drug reimbursement ....................9-16
lenses ......................................................8-341
less than 24-hour inpatient stay..............7-32
less than effective ...................................9-14
Level of Care outlier payment policies ........725
Level of Care payment rates ...................7-25
Level of Care reimbursement system .....7-24
burn cases............................................7-24
outlier payment policies ......................7-24
payment rates ......................................7-24
psychiatric cases .................................7-24
rehabilitation cases ..............................7-24
Library Reference Number: PRPR10004
Published: June 2015
Version: 14.0, 14.1, and 15.0
Indiana Health Coverage Programs Provider Manual
Level of Care review ............................. 14-8
level-of-care information and the LTC pharmacy
........................................................... 9-35
level-of-service codes ............................ 6-31
liability insurance .................................. 5-9
licensure renewal ................................... 4-27
liens against provider payments ............. 12-53
limitations................................................2-59, 6-9
on AVR calls ...................................... 3-27
on benefit ........................................... 3-48
LMP ....................................................... 8-318
LOC reimbursement system .................. 7-16
local codes ............................................. 6-14, 8-62,
8-486
local offices of Division of Family Resources
directory ............................................. 1-16, 1-19
locating information............................... 1-7
location
adding .................................................4-56
closing ................................................ 4-56
lock-in hospitals and other acute care facilities
........................................................... 13-35
Long Term Care..................................... 14-7
agency review decision ...................... 14-31
appeal decision notification................ 14-31
appeal process .................................... 14-31
application of corrective remedies ..... 14-33
billing considerations ......................... 14-35
case mix index ....................................14-32
case mix reimbursement..................... 14-16
e-450B completion and certification...14-9
edit 1024 ............................................ 14-37
Form 450B ......................................... 14-8
Hoosier Healthwise ............................ 14-39
Level of Care review .......................... 14-8
MDS field audit.................................. 14-32
member Level of Care appeal process 14-30
member patient liability ..................... 14-35
PASRR Level II exclusions and categorical
determinations .................................... 14-22
personal resource contribution ........... 14-35
Pre-admission Screening Resident Review
........................................................... 14-22
RBMC ................................................ 14-39
resident changes from private-pay to IHCP
member...............................................14-10
respite short-term 30-day....................14-23
10
Index
retro-rate adjustments ..........................14-37
review objective ..................................14-8
short-term nursing ...............................14-39
transfers between nursing facilties......14-11
transfers from hospital to nursing facilities
..........................................................14-11
long-term acute care facilities .................8-93
Long-Term Acute Care reimbursement ...7-30
long-term care facility services ...............7-42
long-term care .........................................8-93
long-term nursing facility placement ......14-40
LTE.........................................................9- 14
M
maintain records .....................................4-10
maintenance medications ........................9-49
malpractice expense ................................7-38
managed care considerations..................10-36
managed care disenrollment ...................4-59
managed care entity ................................6-8
7-9, 10-6, 13-8
managed care members with hospice
........................................................... .....6-45
managed care ..........................................4-24, 527, 10-6¸11-5, 12-6, 13-8
administrative payment .......................12-54
mandatory substitution ...........................9-14
manual revisions .....................................1-7
manually established accounts receivable...
12-40
manually priced supplies.........................8-214
manuals
ordering ...............................................1-8
supplemental .......................................1-7
mapper ....................................................7-23
mass adjustments ....................................11-9
MCE PMP provider types ......................4-24
MCE .......................................................424, 6-8, 10-6, 13-8
enrollment specifics ............................4-25
MDS field audit ......................................14-32
MDS .......................................................8-94
MDwise HIP member card
example..............................................2-10
ME..........................................................8-150
Medicaid Covered Services and Limitations Rule
............................................................1-6
Medicaid Program
Traditional ...........................................2-31
Medicaid Rehabilitation Option services 8280
Medicaid Second Opinion Form .............6-23
Medicaid TPL Questionnaire..................5-8
medical and financial record retention....13-15
medical and nonmedical supplies and equipment..9-34
Library Reference Number: PRPR10004
Published: June 2015
Version: 14.0, 14.1, and 15.0
Indiana Health Coverage Programs Provider Manual
medical and nonmedical supplies .......... 7-50
medical and surgical supplies ................ 8-273
medical clearance forms ........................ 6-23
procedures .......................................... 6-23
medical education
under the DRG system ....................... 7-27
under the Level of Care system .......... 7-27
medical record retention ........................ 13-15
Medical Review Team.............................2-50
billing procedures ...............................8-391
medical services PA ............................... 6-51
medical services .....................................7-50
medical supplies and DME .................... 9-20
medical supplies and durable medical equipment
........................................................... 6-63
medical supplies and equipment PA policy
requirements .......................................6-63
medical supplies and equipment
Care Select ......................................... 6-69
RBMC ................................................ 6-69
risk-based managed care .................... 6-69
medical supplies..................................... 6-64
medically high-risk pregnancy............... 8-329
Medically Unlikely Edit..........................8-150
Medicare Clinical Laboratory Fee Schedule7-39
Medicare Crossover Claims Payment Policy
Changes ..............................................14-17
Medicare crossover claims..................... 8-96
Medicare denied details for crossover claims 1026
Medicare denied services ....................... 8-138
Medicare eligibility - retroactive ........... 5-16
Medicare exhaust claims ........................7-31¸ 8-86
Medicare noncovered services ............... 5-22
Medicare Prescription Drug Coverage.. 9-32
Medicare Remittance Notice ................. 10-23
Medicare retroactive recovery inquiry procedures..5-30
Medicare/IHCP-related reimbursement . 5-20
medications returned to the dispensing pharmacy
...............................................................9-35
Member and Provider Relations ............ 1-22
member appeals ..................................... 6-77
member billing exceptions......................4-62
member eligibility ................................ 2-12,6-13
member identification card ................... 2-8
member identification number .............. 2-8
member identification ........................... 2-8
member initiating PMP change ..............13-33
member Level of Care appeal process ... 14-30
member liability .....................................8-94
member patient liability ......................... 14-35
member TPL update procedures............. 5-18
member update procedures..................... 5-18
11
Index
mental health counselor and therapist ....5-30
mental health outpatient services ............6-62
mental health provider ............................4-33
mental health services .............................7-46,
8-275
message segment ....................................6-33
modifiers .............................................6-33
MHS HIP member card example............2-11
minimum data set audit process ..............14-28
minimum data set....................................8-94
modifier 54 .............................................8-359
modifier 55 .............................................8-359
modifier 57 .............................................8-356
modifier type ..........................................8-160
modifiers - PET scan ..............................8-179
modifiers affecting payment ...................7-39
modifiers for transportation ....................8-179
modifiers .................................................6- 33,
8-24
monies forwarded to the IRS ..................12-65
monies owed to the Indiana Medicaid Program...
12-62
monitored anesthesia ..............................8-194
monitoring cycle
rolling 12-month .................................2-59
MRN .......................................................10-23
MRO services .........................................5-11
MRO .......................................................5-10,
5-11
MRT .......................................................2-50,
8-391
MUE.......................................................8-150
multiple passengers.................................8-374
multiple restorations ...............................8-427
multiple surgical procedures ...................7-41
Mutually Exclusive edits.......................8-150
Indiana Health Coverage Programs Provider Manual
nonemergency services rendered in the
emergency department....................... 2-54
nonemergency
Care Select member ........................... 2-54
non-IHCP PA requests ...........................6-27
non-institutional PA policy parameters ...651
nonmaintenance medications ................. 9-49
nonrequired provider documents ........... 4-48
nonpharmacy PA.....................................6-18
NOP inquiry ........................................... 3-19
NOP ....................................................... 8-100, 8335
Notification of Pregnancy
billing ................................................. 8-100
process ............................................... 8-335
NPI .........................................................4-68, 820
nursing care............................................ 7-46
nursing facility billing ........................... 14-35
nursing facility room and board ............ 14-18
nursing facility services ......................... 7-42
nursing homes ........................................ 8-372
nursing policy requirements
Hoosier Healthwise considerations .... 6-61
nursing services ..................................... 6-14, 6-58
RBMC ................................................ 6-62
O
observation period ................................. 8-86
obstetrical services ................................. 8-318
obtaining physician authorization .......... 13-30
occupancy rate ....................................... 14-14
office consultation ................................. 8-246
N
National Correct Coding Initiative....7-57, 8-21, 8-146
National Drug Code (NDC) ....................9-14, 8-25
National Provider Identifier (NPI) ..........3-7, 468, 8-20
NCCI..................................................7-57, 8-21,
8-146
NCCI claim appeals................................10-35
NCCI claims administrative review........10-34
NDC ........................................................8-25, 9-14
nebulizer with compressor ......................8-236
NeuroCybernetic Prosthesis System .......8-118
new requests for PA................................6-19
nitrous oxide analgesia ...........................8-418
noncheck-related adjustments .................11-6, 11-8
nonclaim-specific refunds .......................12-52
noncovered bed-hold revenue codes.........8-95
OMPP 450B State Authorization/Data
Entry .................................................. 14-8
on-site review ........................................ 13-21
on-site reviews ....................................... 13-17
OOS provider provisions ....................... 4-64
ophthalmological services...................... 8-336
OPR provider requirements.....................4-49
optician .................................................. 4-35
optometrist ............................................. 4-35
optometry services ................................. 7-50
ordering claim forms.............................. 8-20
ordering manuals ................................... 1-8
ordering paid claim adjustment forms ... 11-11
noncovered services
charging members ...............................4-61
Library Reference Number: PRPR10004
Published: June 2015
Version: 14.0, 14.1, and 15.0
12
Index
ordering, prescribing, or referring providers...4-49
original check received after a reissue request is
made ....................................................12-56
orthodontics ............................................8-414
orthopedic or therapeutic footwear .........8-231
OTC Drug Formulary .............................9-19
other administrative reviews and appeals.10-34
other insurance indicator ........................9-29
other resources .......................................5-23
out-of-state areas.....................................4-65
out-of-state PA policy parameters ..........6-73
out-of-state PA policy
service coverage ..................................6-73
service restrictions ..............................6-74
out-of-state physicians ............................13-34
out-of-state provider provisions ..............4-64
out-of-state services
PA requirements .................................6-73
out-of-state suppliers of medical equipment 674
out-of-state
healthcare providers ............................4-64
home health and hospice providers .....4-64
reimbursement methodologies ............4-66
service restrictions ..............................4-64
services provided ................................4-64
outpatient claims .....................................8-99
outpatient hospital chemotherapy and radiation
treatment services ...............................8-130
outpatient mental health PA policy requirements
............................................................6-62
outpatient mental health services ............6-62
outpatient mental health..........................6-63,
8-134
risk-based managed care .....................6-63
outpatient pricing ....................................7-33
outpatient service within three days of an
inpatient stay .......................................7-29
outpatient services ..................................8-98
outpatient surgeries .................................7-33
outstanding prior authorizations for nonpharmacy services ...............................6-11
over and under-use precaution ................9-38
overpayment adjustment .........................11-8
over-the-counter (OTC) formulary .........7-57
over-the-counter......................................9-18
overview .................................................9-8
oximetry ..................................................8-233
oxygen and home oxygen equipment .....8-233
oxygen
portable systems ..................................8-236
Library Reference Number: PRPR10004
Published: June 2015
Version: 14.0, 14.1, and 15.0
Indiana Health Coverage Programs Provider Manual
P
PA administrative review and appeal procedures
........................................................... 6-75
PA and Medicare ................................... 6-28
PA and third party .................................. 6-28
PA inquiry.............................................. 6-20
PA institutional policy requirements ..... 6-38
PA policy requirements
practitioner ......................................... 6-51
PA policy
parameters for non-institutional ......... 6-51
PA procedures.....................................6-13
PA requests through Web interChange.6-10
PA therapy policy requirements............. 6-60
PA update decision form........................ 6-26
decision description............................ 6-26
PA .......................................................... 4-60, 5-13, 5-22
PACE ......................................................1-10, 2-49, 14-7
pacemakers ............................................ 8-103
Package A .............................................. 2-15, 2-32
Package C – Inpatient Mental Health/Substance
Abuse Services ................................... 8-89
Package C .............................................. 2-15
children's health plan..........................2-17
cost sharing..................... ....................2-17
enrollment.......................................... 2-17
Package E
emergency services only .................... 2-37
Package E
cost sharing........................................ 2-20
enrollment.......................................... 2-20
paid claim adjustment request forms ..... 11-11
paid claim adjustment request
when ................................................... 11-5
paid claim adjustment requests .............. 11-5
paper attachment .................................... 8-26
paper attachments with electronic claims
8-26
paper attachments .................................. 6-34
paper claim billing processes .................10-12
paper claim ............................................ 10-13
paper drug claims ................................... 9-24
parenteral and enteral pumps ................. 8-225
partial dentures....................................... 6-54
repairs................................................. 6-54
replacement of anterior teeth .............. 6-54
partial units ............................................ 8-25
partials ................................................... 8-420, 8-425
patient counseling .................................. 9-37
patient information ..................................9-37
Patient Protection and Affordable Care Act..13-14
patient status code 63 ............................. 8-93
patient-activated event recorder ............. 8-115
payer of last resort ................................. 5-7, 8-75
payment acceptance................................. 13-37
13
Index
Payment and Recoupment Agreement....12-50
payment differentials for nonphysician
practitioners ........................................7-40
payment for services ...............................4-28
payment programs ..................................7-15
payouts....................................................12-46
PEPW .....................................................1-10, 1-14
2-15, 8-297
PEN pumps .............................................8-225
periodontal root planing and scaling .......8-416
personal injury claims ............................5-17
personal resource contribution ................14-35
PET .........................................................8- 351
pharmaceutical products .........................7-50
pharmacies ..............................................13-35
pharmacy audit .......................................9-42
pharmacy claim FTP submission ............10-19
pharmacy contact information ................9-9
pharmacy copayment ..............................2-57
pharmacy coverage and reimbursement ....
9-13
pharmacy POS claim submission ...........10-19
pharmacy program ..................................9-8
pharmacy reimbursement........................7-56
pharmacy services copayments for Hoosier
Healthwise Package C members.........2-60
pharmacy services...................................7-56
pharmacy ................................................4-35, 611
billing usual and customary charge .....9-26
labeler number ....................................9-14
mandatory substitution ........................9-14
manufacturers ......................................9-14
return of medications ..........................9-34
therapeutic screenings .........................9-38
pharmacy-related Web sites....................9-11
phototherapy ...........................................8-237
phrenic nerve stimulator (breathing pacemaker)
............................................................8-107
physician crossovers ...............................7-55
physician internal referrals .....................13-30
physician referrals to secondary pharmacies 1330
physician services PA .............................6-51
physician signature stamps .....................6-10
physician work ........................................7-37
physician .................................................4- 39
physicians, limited license practitioners, and
other nonphysician medical practitioners 737
PMF.........................................................4-12
Library Reference Number: PRPR10004
Published: June 2015
Version: 14.0, 14.1, and 15.0
Indiana Health Coverage Programs Provider Manual
PMP ....................................................... 2-15,
14-38
pneumatic artificial voicing system ....... 8-264
pneumograms .........................................8-237
podiatric services ................................... 8-346
podiatrist ................................................ 4-34
podiatry services PA .............................. 6-52
point of sale
alert process ....................................... 9-38
response process................................. 9-38
portable oxygen system ......................... 8-236
POS claim format .................................. 9-24
POS ........................................................ 10-19
Positron Emission Tomography............. 8-351
postoperative epidural ............................ 8-195
postoperative services ............................ 7-40
postpartum care ...................................... 8-326
PPACA...................................................13-14
practice expense .....................................7-38
practitioner PA policy parameters ......... 6-57
Hoosier Healthwise considerations .... 6-57
RBMC ................................................ 6-57
risk-based managed care .................... 6-57
practitioner PA policy requirements ...... 6-51
Pre-Admission Screening Resident Review
forms ................................................. 14-24
Pre-Admission Screening Resident Review 14-22
Preferred Drug List ................................ 9-46
pregnancy care ....................................... 5-11
pregnancy coverage only ....................... 2-15
pregnancy
high risk ............................................. 8-329
premium comparison ............................. 2-17
prenatal care .......................................... 5-11
prenatal risk assessment ......................... 8-328
preoperative care only............................ 7-40
preoperative services ............................. 7-39
prepayment review................................. 13-19
prescriber identifier ................................ 9-28
prescriptions upon discharge from hospital 1331
present on admission indicators ............. 8-83
Presumptive Eligibility for Pregnant Women 1-10,
1-14
Presumptive Eligibility .......................... 2-15, 5-35
Package P ........................................... 8-305
preterm labor risk assessment ................ 8-324
preventative pediatric care ..................... 5-11
preventing stale-dated checks ................ 12-57
previous certification identification segment 632
pricing methodologies ........................... 7-9
primary lock-in hospital ......................... 13-31
14
Index
primary lock-in pharmacy.......................13-29
primary lock-in physician .......................13-28
primary medical provider (PMP) ............2-54,
14-38
primary sources of information ..............5-8
principal diagnosis ..................................8-81
prior authorization appeals.....................10-36
prior authorization criteria ......................6-13
prior authorization denial appeal process...9-50
Prior Authorization Department telephone
numbers ...............................................6-15
prior authorization ..................................3-52, 460, 4-65, 5-13, 5-22, 8-69, 8-345
dental ...................................................8-422
inquiry using member ID mumber ......3-55
inquiry using PA number ....................3-53
prior-authorized physician services ........8-74
problem resolution ..................................1-16
procedure code A0422 ............................8-378
procedure codes – vaginal/cesarean delivery CPT
............................................................8-193
procedures segment ................................6-32
units.....................................................6-33
procedures when the RVU is not appropriate 7-38
procedures when the RVU is not available 7-38
procedures ...............................................6-13
process suspended claims .......................10-21
pro-DUR ..................................................9-36
Program for All-Inclusive Care to the Elderly..1-10,
2-49, 14-7
programs overview .................................1-8
Program Integrity.................. .................13-9, 13-36
proof of eligibility verification ...............2-13
prophylaxis .............................................8-415
proprietary large private and small intermediate
care facilities for the mentally retarded
7-45
Prospective Drug Utilization Review .....9-36
prosthetic devices ...................................8-237
provider appeals......................................6-76
provider avenues of resolution ................1-27
provider-based RHC...............................8-254
provider classifications ...........................4-8
provider eligibility maintenance .............4-27
provider eligibility ..................................4-8
provider enrollment file ..........................4-53
Provider Enrollment website ..................1-23
provider enrollment ................................1-22
procedures ...........................................4-12
requirements........................................4-12
provider groups .......................................4-56
provider file information changes ...........4-58
provider manual
suggestions ..........................................1-8
Library Reference Number: PRPR10004
Published: June 2015
Version: 14.0, 14.1, and 15.0
Indiana Health Coverage Programs Provider Manual
provider manuals
supplemental ...................................... 1-7
provider master file ................................ 4-12
provider partial payments ...................... 12-48
provider profile maintenance ................. 4-53, 455
provider records ..................................... 4-10
Provider Relations ................................. 1-26
provider Remittance Advice .................. 12-8
provider reorganization .......................... 4-56
provider requirements
provider type and specialty ................ 4-29
provider responsibilities ........................ 10-29, 4-9
Provider Services.....................................1-22
provider termination .............................. 4-27,
13-32
provider utilization review results ......... 13-17
provider utilization review ..................... 13-10,
13-16
provider ................................................. 5-8
file addresses ...................................... 4-57
provider-based RHC .............................. 8-256
providers allowed to submit PA and electronic
278 requests ....................................... 6-10
providers using the 837P transactions....8-144
providers using the CMS-1500 claim form 8-144
providers using the UB-04 claim form .. 8-31
providers
out-of-state ......................................... 4-64
providing services to members .............. 4-11
PRTF ......................................................6-42
psychiatric residential treatment facility 6-42
public health agency .............................. 4-34
Q
QDWI.....................................................2-34
QI............................................................2-34
QMB ...................................................... 2-34
with spend-down ................................ 2-35
qualification for medical education payments..7-27
qualified Medicare beneficiaries ............ 2-34
quick-entry techniques ........................... 3-28
R
RA example
ARC code descriptions .......................12-35
dental claims paid .............................. 12-22
extended care facility claims paid.......12-30
EOB code descriptions ....................... 12-34
financial transactions.......................... 12-33
home health claims paid ..................... 12-29
inpatient claims paid .......................... 12-27
Medicare Crossover Part A claims paid 12-31
Medicare Crossover Part B claims paid 12-32
outpatient claims paid ........................ 12-28
15
Index
Indiana Health Coverage Programs Provider Manual
professional service claims paid .........12-23
professional services claims denied ....12-24
professional services claims in process
1225
professional services void/replacements 1226
summary .............................................12-36, 1237
RA inquiry ..............................................3-19
radiation ..................................................8-130
radiographs .............................................8-419
radiological procedures ...........................7-39
radiology services ...................................8-129,
8-349
radiology .................................................4-39
radionuclide bone scans ..........................8-351
RBMC members .....................................2-55
RBMC ....................................................1-12, 535, 6-8, 6-57, 6-63, 6-69, 10-6,
10-36, 13-8, 14-39
RBRVS reimbursement methodology ....7-38
RCP ........................................................13-8
RCP appeals............................................13-26
readmission to a nursing facility from a hospital
............................................................14-9
readmission .............................................7-29
receiving funds for rejected EFTs...........12-61
record review criteria ..............................13-16
records
maintain ..............................................4-10
recoupment .............................................13-19
recoveries ...............................................5-10
recovery of accounts receivable..............12-42
referral physicians...................................13-34
refunds to the IHCP ................................12-62
refunds ....................................................8-151
refusing or restricting services to members 4-63
region codes ...........................................10-9
regional anesthesia ..................................8-194
rehabilitation facilities ............................4-32
reimburse IHCP member ........................5-16
reimbursement for capital costs ..............7-26
reimbursement for medical educational costs 7-16,
7-26
reimbursement methodologies ................7-9
for long-term care facilities .................7-42
Reimbursement policy ............................10-30
reimbursement ........................................4-8
reissued check on RA .............................12-56
reject reason codes ..................................6-37
rejected PA request .................................6-14
rejection of request .................................6-33
relative weights .......................................7-23
release of information codes ...................6-31
Library Reference Number: PRPR10004
Published: June 2015
Version: 14.0, 14.1, and 15.0
Remittance Advice (RA).........................12-6
example .............................................. 12-21
field definitions .................................. 12-10
sorting sequence ................................. 12-10
summary page .................................... 12-19
Remittance Advice definitions............... 12-11
Remittance Advice information ............. 5-15
Remittance Advice section descriptions 12-9
renal dialysis physician services ............ 8-352
renal dialysis .......................................... 8-372
rendering provider classification............ 4-9
rendering provider ................................. 8-151
repairs to partial dentures....................... 6-54
repeated services modifiers .................... 6-34
replacement battery ................................ 6-68
replacement electrodes ...........................6-68
replacement eyeglasses .......................... 8-344
replacement garment .............................. 6-68
reporting individual cases of varicella (chickenpox)..8-388
report fraud, waste, and abuse.............. 13-8
reporting personal injury claims ............ 5-17
request claims review ........................... 10-30
request form ........................................... 6-16
requests of additional information ......... 6-14
resident changes from private-pay to IHCP member.14-10
resident review process ......................... 14-28
resolution avenues ................................. 1-27
resolution of problems ........................... 1-16
resource data .......................................... 5-10
resource-based relative value scale components
........................................................... 7-37
respite short-term 30-day ...................... 14-23
responsibilities – contractor, county, and State.1-19
responsibilities ....................................... 4-9
restorations .............................................8-427
restricted utilization ............................... 2-54
restricting or refusing services to members 4-63
restrictions
outside Indiana ................................... 4-64
retaining forms in records ...................... 14-16
retroactive eligibility ..............................2-57, 460
retroactive Medicare eligibility .............. 5-16
retroactive PA requests .......................... 6-35
retroactive PA ........................................ 6-28
retroactive prior authorization ............... 6-35
retroactive rate adjustments for long-term care
facilities .............................................. 11-9
retro-rate adjustments ............................ 14-37
Retrospective Drug Utilization Review . 9-40
retrospective reviews ............................. 13-21
16
Index
return of medications ..............................9-34
return to provider letter ...........................8-411
returned medications ..............................11-7
revenue code 101 ....................................8-93
revenue code 183 ....................................8-70
revenue code 185 ....................................8-70
revenue code 651 ....................................8-70
revenue code 652 ....................................8-70
revenue code 653 ....................................8-71
revenue code 654 ....................................8-71
revenue code 655 ....................................8-71
revenue code 656 ....................................8-72
revenue code 657 ....................................8-72, 874
revenue code 659 ....................................8-72
revenue codes with descriptions .............8-44
reviews
other administrative reviews and appeals 1034
revisions to manual .................................1-7
RID .........................................................2-8
Right Choices Program ...........................13-7, 2-52
risk-based managed care dental services 7-54
risk-based managed care prior authorization
criteria .................................................6-13
risk-based managed care .........................1-12, 535, 6-8, 6-57, 6-63, 6-69, 7-34, 10-6,
10-36, 11-5, 12-6, 13-8, 14-39
roles of contractors for FFS Medicaid ....9-12
rolling 12-month monitoring cycle... ......2-59
room and board .......................................7-46
routine home hospice care
delivered in a nursing facility .............7-49
delivered in a private home .................7-49
RTP .........................................................8- 411
RUG-III ..................................................8-94
rural health clinics ..................................8-250
RxCLAIM................................................9-32
S
salivary estriol test ..................................8- 324
scheduled workshops ..............................1-26
school corporation services.....................8-353
school corporation ..................................4-34
sealants ...................................................8-426
sedation for children ...............................8-418
segments .................................................6-32
diagnosis .............................................6-32
message ...............................................6-33
previous certification identification ....6-32
procedures ...........................................6-32
self-referral services ...............................1-13, 13-32
Library Reference Number: PRPR10004
Published: June 2015
Version: 14.0, 14.1, and 15.0
Indiana Health Coverage Programs Provider Manual
seminars and workshops ........................ 1-26
service coverage..................................... 6-73
service limitations .................................. 2-59
service restrictions ................................. 3-40, 674
service type codes .................................. 630
service units ........................................... 6-33
services billed on each claim form......... 8-22
services provided outside the state ......... 4-64
services
refusing or restricting ......................... 4-63
shoes and supportive devices ................. 8-231
short-term nursing ..................................14-39
signature stamps..................................... 6-10
site of service adjustment .......................7-41
SLMB......................................................2-34
SmartPA .................................................6-14, 9-48
solicitation ............................................. 4-11
sonography .............................................8-324
special payment situations ..................... 7-39
special processing required for HCBS
overlapping hospice Level of Care or longterm care discharge dates ................... 8-432
spend-down members ........................... 5-21
spend-down or waiver liability............... 5-21
8-413
with QMB .......................................... 2-40
spinal cord stimulators.............................8-110
stale-dated checks .................................. 12-56
stand-alone services ............................... 7-35, 8-126
Standard Plan ......................................... 2-15, 2-32
State responsibility................................. 1-19
State, county, contractor responsibilities 1-19
state-operated intermediate care facilities for the
intellectually disabled......................... 7-47
status of IHCP members ........................ 13-27
steps taken prior to the administrative review
process................................................10-33
sterilization and related services ............ 8-479
Sterilization Consent Form .................... 8-478
sterilization ............................................ 8-475
stop backup withholding ........................ 12-65
stop pay and reissue
how to avoid ....................................... 12-56
how to request .................................... 12-55
original check received after reissue requested
........................................................... 12-56
stop payment and reissue
time frames for requesting ................. 12-55
when to request .................................. 12-55
submission of duplicate form 450Bs ..... 14-13
Submission Summary Report..................10-37
description............................................10-37
submitting paid claim adjustments......... 11-10
submitting paper UB-04 crossover claims 8-136
subsequent payment ............................... 5-14
17
Index
subsequent Third Party Liability payment..5-14
suggestions for manual updates ..............1-8
summary page .........................................12-19
supernumerary tooth extractions.............8-419
supplemental provider manuals ..............1-7, 819
surgical services......................................8-356
surveillance and utilization review .........13-36
appeals.................................................10-36
suspended ...............................................4-42
suspended claim resolution ....................10-20
suspended claim
add/change ..........................................10-21
deny .....................................................10-21
force/override ......................................10-21
guidelines for processing ....................10-21
resubmit ..............................................10-21
route ....................................................10-21
suspended claims processing .................10-21
suspended compound claims ..................9-39
suspended PA request .............................6-14
suspended ...............................................10-20
suspension ..............................................6-14
system update requests ...........................6-25
T
tamper-resistant prescriptions .................9-15
tax assessment ........................................7-47
telemedicine ............................................8- 140
telephone and address directory..............1-16
telephone authorizations .........................6-15
telephone inquiry ...................................5-28
telephone PA services .............................6-15
telephone requests for PA .......................6-25
telephone
automated attendant ............................6-16
termination
involuntary ..........................................4-59
voluntary .............................................4-59
ThAIRapy Vest™ ...................................8-237
therapeutic duplication ...........................9-38
therapeutic leave of absence ...................7-47
therapeutic screenings .............................9-38
therapeutic shoes.....................................8-231
therapist ..................................................4-35
therapy PA policy requirements .............6-60
Hoosier Healthwise considerations .....6-61
therapy services ......................................6-60, 746, 8-360
RBMC .................................................6-62
therapy ....................................................7-44
third-party liability ..................................5-7, 9-28
time parameters ......................................6-19
timely filing limit....................................10-31
Library Reference Number: PRPR10004
Published: June 2015
Version: 14.0, 14.1, and 15.0
Indiana Health Coverage Programs Provider Manual
timely processing guidelines .................. 11-7
tocolytic infusion therapy ...................... 8-67
tooth numbers ........................................ 8-426
tooth surface procedure codes................ 8-426
topical fluoride treatment .......................8-416
total parenteral nutrition......................... 8-224
TPL resources ........................................ 5-23
TPL Unit................................................ 5-18
TPL ........................................................ 5-7
and PA................................................ 6-28
trading partner........................................ 4-69
Traditional Medicaid ............................. 1-9, 2-31
Standard Plan ..................................... 2-32
Traditional Medicaid benefit package explanation
............................................................ 2-32
transaction ..............................................4-67
transfer cases.......................................... 7-27
transfer letter .......................................... 12-43
transfers between nursing facilities........14-11
transfers from hospital to nursing facilties.14-11
transportation PA policy requirements .. 6-69
Care Select ......................................... 6-71
RBMC ................................................ 6-71
risk-based managed care .................... 6-71
transportation services copayment ......... 2-53
Hoosier Healthwise Package C .......... 2-56
transportation services ........................... 6-36, 669, 8-134, 8-365
request ................................................ 6-36
transportation ......................................... 4-36, 7-46
copayment .......................................... 2-53
treatment room visits ............................. 7-34, 8-123
trend event monitoring ........................... 8-238
TRICARE regions 2 and 5 claims processing....5-24
TRICARE .............................................. 5-24
trip limitation ......................................... 8-372
type 01 ................................................... 4-29
type 02 ................................................... 4-29
type 03 ................................................... 4-30
type 04 ................................................... 4-32
type 05 ................................................... 4-32
type 06 ................................................... 4-32
type 08 ................................................... 4-32
type 09 ................................................... 4-33
type 11 ................................................... 4-33
type 12 ................................................... 4-34
type 13 ................................................... 4-34
type 14 ................................................... 4-34
type 15 ................................................... 4-34
type 17 ................................................... 4-35
type 18 ................................................... 4-35
type 19 ................................................... 4-35
18
Index
Indiana Health Coverage Programs Provider Manual
type 20 ....................................................4-35
type 21 ....................................................4-35
type 22 ....................................................4-35
type 24 ....................................................4-35
type 25 ....................................................4-36
type 26 ....................................................4-36
type 27 ....................................................4-38
type 28 ....................................................4-38
type 29 ....................................................4-39
type 30 ....................................................4-39
type 31 ....................................................4-39
type 32 ....................................................4-41
types of adjustments ...............................11-8
varicella ................................................. 8-388
ventricular assist devices ....................... 8-238
verify member eligibility ....................... 2-12, 310
VFC ....................................................... 8-269,
8-385
violation of civil rights laws .................. 4-63
vision services and managed care .......... 8-346
vision ..................................................... 8-337
vocational and habilitation services ....... 7-49, 750
voiding a check ...................................... 12-57
voiding an IHCP payment check ........... 12-57
voluntary termination............................. 4-59
volunteer physician services .................. 8-75
U
W
U modifier ..............................................8-182
UB-04 claim form...................................8-19
fields ...................................................8-33
locators and descriptions .....................8-34
WAC ...................................................... 8-269
waiting time ........................................... 8-376
waive filing limit .................................... 10-30
waiver programs .................................... 4-45
waiver .................................................... 2-36, 4-41, 8-265
waiver liability.........................................2-32
WCD ...................................................... 6-67
wearable cardioverter defibrillators PA criteria
........................................................... 6-67
wearable cardioverter defibrillators ....... 6-67
Web interChange ................................... 3-13, 610
wheelchairs ............................................ 8-240
where to send checks ............................. 12-63
Wholesale Acquisition Cost................... 8-269
why an adjustment cannot be performed 11-7
workshops and seminars ........................ 1-26
wraparound services .............................. 2-19
Written Correspondence ........................ 1-24, 8344
written inquiry procedures .................... 5-28
written requests for PA .......................... 6-16
written system update requests .............. 6-25
UB-04
occurrence code ..................................8-63
underpayment adjustment .......................11-8
unit dose..................................................9-34
update procedures ...................................5-18
upper gastrointestinal studies..................8-351
usual and customary charge ....................7-57
usual and customary ...............................9-19
utilization review
activities ..............................................13-7
administrative review and appeal process 1338
fraud or abuse......................................13-9
monitoring ...........................................
13-7
on-site reviews ....................................13-17
provider ...............................................13-10,
13-16
provider results ...................................13-17
recoupment .........................................13-19
reporting avenues ................................13-13
retrospective reviews ..........................13-21
status of IHCP members .....................13-27
tips ......................................................13-15
trends ...................................................13-36
X
X-ray services ........................................ 8-348
V
vaccine storage .......................................8-386
Vaccines for Children Program ..............8-385
Vaccines for Children .............................8-269
vaginal and cesarean delivery CPT codes
8193
vaginal delivery ......................................8-193
vagus nerve stimulator ............................8-118
Library Reference Number: PRPR10004
Published: June 2015
Version: 14.0, 14.1, and 15.0
19