to: all indiana health coverage programs providers subject ... · the purpose of this section is to...

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 B U L L E T I N

B T 2 0 0 0 0 6 J A N U A R Y 2 0 , 2 0 0 0

To: All Indiana Health Coverage Programs Providers

Subject: Package C Claim Submission and CoverageInformation

Overview

The purpose of this bulletin is to provide information in regard toclaim submission guidelines and coverage information associated withthe implementation of the Hoosier Healthwise Package C– Children’sHealth Plan. The topics addressed in this bulletin include:

• Important Eligibility Verification Upgrade Information

• Hoosier Healthwise Package C Training Reminder

• Vaccines for Children (VFC) Update

• Claim Submission Information

• Updated Coverage and Limitation Benefit Chart and Benefit LevelClarifications

As a reminder, effective January 2000 the state of Indiana beganimplementing one of the most significant health care programs sincethe introduction of the Indiana Medical Assistance Programs in 1965,the Hoosier Healthwise Package C– Children’s Health Plan. The stateof Indiana and the Office of the Children’s Health Insurance Program(CHIP Office) remain dedicated to ensuring a smooth transition andminimizing the effect of any changes related to the implementation ofthis program to the provider community.

This bulletin is the fourth in a series and its main focus is to ensure allparties are educated on the new structure of the Indiana HealthCoverage Programs (IHCP) and Hoosier Healthwise Package C, sinceenrollment in Package C began January 1, 2000.

EDS 1P. O. Box 68420Indianapolis, IN 46268-0420

Eligibility Verification Upgrade Information

Providers were notified in bulletin BT199942, Package C EligibilityVerification System Upgrade, dated December 3, 1999, of changes tothe Eligibility Verification System (EVS) that include the AutomatedVoice Response (AVR), OMNI, and National Electronic ClaimsSubmission (NECS).

Specifically, providers are reminded that to activate the eligibilitychanges on the OMNI terminal, it is necessary to download theterminal on or after January 10, 2000.

Additionally, all NECS users should have received version 3.00 of theNECS software. This software must be installed to receive the neweligibility indicators associated with the implementation of Package C.If you have not received version 3.00 of NECS, please contact theElectronic Claims Help Desk at (317) 488-5160.

In bulletin BT200008, Upgrade to OMNI Eligibility System andNecessary OMNI Terminal Downloads, dated January 5, 2000,providers were notified of implementation dates associated with theOMNI terminal download. Specifically, this bulletin stated that allprevious versions of the OMNI software will not be allowed beginningFebruary 1, 2000.

Note: EDS has extended the grace period to March 1,2000, for using all previous versions. However,effective March 1, 2000, providers who have notdownloaded OMNI terminals or installed version3.00 of NECS will not be able to access theeligibility system.

Hoosier Healthwise Package C Training Reminder

Providers were notified in bulletin BT199929, Hoosier HealthwisePackage C Training Schedule, dated November 24, 1999, of a series ofIHCP training sessions developed by EDS, the CHIP Office, and theOffice of Medicaid Policy and Planning (OMPP). The HoosierHealthwise Package C training schedule began December 16, 1999,and will continue through March 21, 2000. These training sessionscover pertinent information in regard to the restructuring of the IHCPand the implementation of the Hoosier Healthwise Package C–Children’s Health Plan.

Indiana Health Coverage Programs Package C Claims Submission and Coverage InformationBT200006 January 20, 2000


Providers are strongly encouraged to take advantage of one of the 70training opportunities offered statewide. A registration form andcomplete schedule of workshop dates were included with bulletinBT199929 and are also available on the IHCP Web site atwww.indianamedicaid.com.

Vaccines for Children Update

The purpose of this section is to inform all Indiana Health CoveragePrograms providers of changes to the Vaccines for Children (VFC)Program. Detailed information regarding these changes wereforwarded to providers in Indiana Health Coverage Programs bannerpage article dated January 11, 2000, and bulletin, BT200007 datedJanuary 12, 2000.

The changes to the VFC Program include the following:

• The VFC Program will be transferred from the Indiana StateMedical Association (ISMA) to the Indiana State Department ofHealth (ISDH) effective January 1, 2000. All vaccine ordering,distribution, and accountability processes will remain unchanged,however, they will be administered through the ISDH.

• Vaccinations for Hoosier Healthwise Package C members havebeen added to the VFC delivery system.

• The Vaccine Order Form, Patient Eligibility Screening Record, andVaccine Accountability Tally Sheet have been revised toincorporate vaccines administered to children enrolled in HoosierHealthwise Package C, and includes a column to indicate thenumber of vaccines given to children enrolled in HoosierHealthwise Package C.

• The new address, phone numbers, and fax number for the VFCprogram are as follows:

Indiana Immunization ProgramIndiana State Department of Health2 North Meridian StreetIndianapolis, Indiana 46204Phone: (317) 233-7704 or 1-800-701-0704Fax: (317) 233-3719

Again, providers are reminded that bulletin BT200007 provides furtherinformation on these changes and VFC vaccine storage, reports andforms, claim submission, and third party liability.



Claim Submission Information

Billing policies and procedures are not significantly impacted by therestructuring of the IHCP and the implementation of the HoosierHealthwise Package C– Children’s Health Plan. For the most part itremains business as usual. The following information outlinesdeviations from standard policies and procedures. With the exceptionof the areas addressed below, providers should continue to applybilling procedures and coverage information as defined in the IHCPProvider Manual.

Prescription drugs

For Hoosier Healthwise Package C members, pharmacists maysubstitute the generic equivalent of a brand name drug only when theprescribing physician has indicated on the written or orallycommunicated prescription that the generic equivalent may besubstituted. If the prescribing physician has indicated that themedication should be dispensed as written, the pharmacist mustdispense the drug prescribed.

Copayments

Package C members’ families will be required to make copayments forsome services. Providers will be responsible for collecting copaymentsand the copayment amount will be deducted from the claim. Table 1.1describes the copayments required and the corresponding copaymentamount.

Note: Insulin does require a member copaymentaccording to Table 1.1.

Table 1.1 − Description of Copayments

Service Copayment

Prescription drugs-generic, compound and sole-source $3

Prescription drugs-brand name $10

Ambulance transportation $10

Emergency room visit that does not result in hospitalization $20



Transportation Services

Ambulance services are the only transportation services covered forHoosier Healthwise Package C members. Table 1.2 has beendeveloped to assist providers in the determination of which servicesare covered and which services are subject to member copayment. Thetable represents commonly billed codes to the IHCP. This table doesnot represent all billable or covered codes. Providers should refer tothe IHCP Provider Manual, Chapter 8, for additional informationregarding covered and billable transportation services.

Please note that member copayments will be systematically deductedfrom the ambulance base rate only. Providers must not includemember copay amounts on the claim form. Further, providers shouldcontinue to follow normal transportation claim guidelines whensubmitting claims to the IHCP for processing.

Table 1.2 − Transportation Covered Services and Copayments

Procedure Description Copayment

A0010 Ambulance service, basic life support (BLS) Yes

A0020 Ambulance service, BLS per mile, transport, one way No

A0070 Ambulance service, oxygen, administration and supplies, lifesustaining situation

No

A0220 Ambulance service, advanced life support (ALS) base rate, allinclusive services, emergency transportation, one way

Yes

A0221 Ambulance service, ALS per mile, transportation one way No

A0060 Ambulance service, waiting time, one half hour increments No

A0150 Nonemergency transportation, ambulance, base rate one way Yes

A0222 Ambulance service, return trip, transport Yes

Emergency Room Visits Resulting in a Hospitalization

There is a member copayment of $20 for emergency room visits thatdo not result in a hospital inpatient admission. However, if theemergency room visit results in an admission, the copaymentrequirement does not apply. The emergency room copayment will onlybe required for the hospital component of emergency room care. Thefacility where the services are rendered must indicate the admission byentering an occurrence code of 40 in locator 32 of the UB-92 claimform. Additionally, the admission date must be reflected in locator 32adjacent to the occurrence code 40. Entering this information allowsthe claim to systematically bypass the emergency room copaymentrequirement.



Claim Submission Guidelines

Providers must keep the following in mind when submitting claims forservices rendered to Hoosier Healthwise Package C members:

• Claims for services rendered to members must be submitted throughthe normal claim processing post office boxes listed in the IHCPProvider Manual, Chapter 1.

• Providers should use the same avenues for claim and programcoverage inquiries as indicated in the IHCP Provider Manual,Chapter 1.

• Claims processed for Hoosier Healthwise Package C members willbe processed and reflected on the same weekly remittance advicestatement as with the Traditional Medicaid program.

Explanation of Benefit Codes

Table 1.3 represents explanation of benefit (EOB) codes associatedwith denied claims for noncovered services rendered to membersenrolled in Hoosier Healthwise Package C. These EOB codes becameeffective January 1, 2000. Additional EOB codes associated withHoosier Healthwise Package C will be introduced in the secondquarter of 2000.

Table 1.3 − Explanation of Benefit Codes

Edit Codes for Package C

Code Description

2033 Package C member not eligible for claim type.

4062 Organ transplants are noncovered for Package C. Please verify and resubmit.

4082 Bed reservations rendered in an institution for mental health diseases are anoncovered service for Package C.

4083 Inpatient care rendered in an institution for mental health diseases arenoncovered for Package C.

4126 Over-the-counter and nonlegend drugs are noncovered for Package C.

Updated Coverage and Limitation Table and Benefit LevelClarifications

The IHCP issued bulletin BT199928, dated October 29, 1999,contained an overview of Hoosier Healthwise Package C. As a resultof further review, the following are clarifications to items published inbulletin BT199928.



• On page 4, under the heading of Qualified Medicare Beneficiaries,the first paragraph, second sentence should read, “NoncoveredMedicare services are not reimbursable by Medicaid.”

• On page 8, the fourth paragraph, last sentence should read, “If theprovider fails to contact the MCO, and obtain the appropriatereferral and prior authorizations prior to rendering the service, theprovider risks the denial of payment.”

• On page 12, under the heading Hoosier Healthwise Package B–Pregnancy Coverage Only, the definition should be added, “Act of1986 defines an Emergency Medical condition as a medicalcondition of sufficient severity (including severe pain) that theabsence of medical attention could result in placing the membershealth in serious jeopardy, serious impairment of bodily functions,or serious dysfunction of any organ or part.”

• On page 14, Table 1.6 − Description of Copayments, under theservice of emergency room visit that does not result in anhospitalization, please note the $20 copay only applies to thefacility where the services were rendered. Physician professionalservices and ancillary services, such as laboratory and radiology, donot require a member copay.

• On page 18, under the heading Billing Considerations, please addthe following paragraph:– Providers who are currently participating as IHCP providers and

newly enrolled providers will be automatically authorized toprovide services to Hoosier Healthwise Package C members.According to State law, providers cannot choose to provideservices only to non-Package C members or only to Package Cmembers.

The remainder of clarifications to bulletin BT199928 are highlighted inAppendix A: Hoosier Healthwise Benefit Package Comparison.Providers should disregard the Benefit Package Comparison Tableoriginally published in bulletin BT199928, as the OMPP and the CHIPOffice have provided additional clarifications. Appendix A is aconclusive and updated chart. When using the comparison table thefollowing should be considered:

• Updates since the original publication on October 29, 1999, are initalics.



Additional Information

If you have any questions regarding the information in this bulletin,please call EDS Customer Assistance at (317) 655-3240 in theIndianapolis local area or 1-800-577-1278.



Appendix A: Hoosier Healthwise Benefit Package ComparisonService Package A - Standard Plan Package B - Pregnancy

Coverage OnlyPackage C - Children's

Health PlanPackage D - Hoosier

Healthwise for PersonsWith Disabilities and

Chronic Illnesses

Package E - EmergencyServices Only

InpatientHospitalServices*

Inpatient services are coveredwhen such services areprovided or prescribed by aphysician and when theservices are medicallynecessary for the diagnosis ortreatment of the member'scondition. See CoveredServices and Limitations Rule405 IAC 5.

Coverage is limited toservices related to pregnancy(including prenatal, delivery,and postpartum services), aswell as conditions which maycomplicate the pregnancy orurgent care services.

Inpatient services are coveredwhen such services areprovided or prescribed by aphysician and when theservices are medicallynecessary for the diagnosis ortreatment of the member'scondition. See CoveredServices and Limitations Rule405 IAC 5.

Inpatient services arecovered when such servicesare provided or prescribed bya physician and when theservices are medicallynecessary for the diagnosisor treatment of the member'scondition. See CoveredServices and LimitationsRule 405 IAC 5.

Emergency services arecovered when such servicesare provided or prescribed bya physician and when theservices are medicallynecessary for the diagnosisor treatment of the member'sacute condition. Thisincludes labor and deliveryup to the time the mother isstable. See Covered Servicesand Limitations Rule 405IAC 5.

OutpatientHospitalServices*

Outpatient services arecovered when such servicesare provided or prescribed bya physician and when theservices are medicallynecessary for the diagnosis ortreatment of the member'scondition. See CoveredServices and Limitations Rule405 IAC 5.


Outpatient services are coveredwhen such services areprovided or prescribed by aphysician and when theservices are medicallynecessary for the diagnosis ortreatment of the member'scondition. See CoveredServices and Limitations Rule405 IAC 5.

Outpatient services arecovered when such servicesare provided or prescribed bya physician and when theservices are medicallynecessary for the diagnosisor treatment of the member'scondition. See CoveredServices and LimitationsRule 405 IAC 5.

Emergency services arecovered when such servicesare provided or prescribed bya physician and when theservices are medicallynecessary for the diagnosisor treatment of the member'sacute condition. Thisincludes labor and deliveryup to the time the mother isstable. See Covered Servicesand Limitations Rule 405IAC 5.

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EDS A-1P. O. Box 68420Indianapolis, IN 46268-0420

Service Package A - Standard Plan Package B - PregnancyCoverage Only

Package C - Children'sHealth Plan

Package D - HoosierHealthwise for PersonsWith Disabilities and

Chronic Illnesses


Rural HealthClinics

Reimbursement is availablefor services provided by aphysician, nurse practitioner,or appropriately licensed,certified, or registeredtherapist employed by therural health clinic.


Reimbursement is available forservices provided by aphysician, nurse practitioner, orappropriately licensed,certified, or registered therapistemployed by the rural healthclinic.

Reimbursement is availablefor services provided by aphysician, nurse practitioner,or appropriately licensed,certified, or registeredtherapist employed by therural health clinic.

Noncovered services

FederallyQualifiedHealthCenters(FQHCs)

Reimbursement is availablefor medically necessaryservices provided by licensedhealth care practitioners.


Reimbursement is available formedically necessary servicesprovided by licensed healthcare practitioners.

Reimbursement is availablefor medically necessaryservices provided by licensedhealth care practitioners.

Noncovered services

LaboratoryandRadiologyServices

Must be ordered by aphysician.

Coverage is limited toservices related to pregnancy(including prenatal, delivery,and postpartum services), andconditions which maycomplicate the pregnancy orurgent care services.



Noncovered services

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Chronic Illnesses


NursePractitioners

Reimbursement is availablefor medically necessaryservices or preventative healthcare services provided by alicensed, certified nursepractitioner within the scopeof the applicable license andcertification.


Reimbursement is available formedically necessary services orpreventative health careservices provided by a licensed,certified nurse practitionerwithin the scope of theapplicable license andcertification.

Reimbursement is availablefor medically necessaryservices or preventativehealth care services providedby a licensed, certified nursepractitioner within the scopeof the applicable license andcertification.

Noncovered services

NursingFacilityServices**

Coverage includes room andboard; nursing care; medicalsupplies; durable medicalequipment; and transportation.See Covered Services andLimitations Rule 405 IAC 5.

Coverage is limited toservices related to pregnancy(including prenatal, delivery,and postpartum services andconditions which maycomplicate the pregnancy orurgent care services.

Noncovered services Coverage includes room andboard; nursing care; medicalsupplies; durable medicalequipment; andtransportation. See CoveredServices and LimitationsRule 405 IAC 5.

Noncovered services

EarlyInterventionServices

Covers comprehensive healthand development history,comprehensive physicalexam, appropriateimmunizations, laboratorytests, health education, visionservices, dental services,hearing services, and othernecessary health care servicesin accordance with theHealthWatch EPSDTperiodicity and screeningschedule.


Covers immunizations, andinitial and periodic screeningsaccording to the HealthWatchEPSDT periodicity andscreening schedule. Coverageof treatment services is subjectto the Package C benefitpackage coverage limitations.

Covers comprehensive healthand development history,comprehensive physicalexam, appropriateimmunizations, laboratorytests, health education, visionservices, dental services,hearing services, and othernecessary health careservices in accordance withthe HealthWatch EPSDTperiodicity and screeningschedule.

Noncovered services

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Chronic Illnesses


Familyplanningservices andsupplies

Provided with limitations. SeeCovered Services andLimitations Rule 405 IAC 5.


Provided with limitations. SeeCovered Services andLimitations Rule 405 IAC 5.

Provided with limitations.See Covered Services andLimitations Rule 405 IAC 5.

Noncovered services

Physicians'surgical andmedicalservices*

Covers reasonable servicesprovided by a M.D. or D.O.for diagnostic, preventive,therapeutic, rehabilitative orpalliative services providedwithin scope of practice. PMPoffice visits limited to amaximum of 30 per year permember without priorauthorization. See CoveredServices and Limitations Rule405 IAC 5.


Covers reasonable servicesprovided by a M.D. or D.O. fordiagnostic, preventive,therapeutic, rehabilitative orpalliative services providedwithin scope of practice. PMPoffice visits limited to amaximum of 30 per year permember without priorauthorization. See CoveredServices and Limitations Rule405 IAC 5.

Covers reasonable servicesprovided by a M.D. or D.O.for diagnostic, preventive,therapeutic, rehabilitative orpalliative services providedwithin scope of practice.PMP office visits limited to amaximum of 30 per year permember without priorauthorization. See CoveredServices and LimitationsRule 405 IAC 5.

Emergency services arecovered when such servicesare provided or prescribedby a physician and when theservices are medicallynecessary for the diagnosisor treatment of the member'sacute condition. Thisincludes labor and deliveryup to the time the mother isstable. See Covered Servicesand Limitations Rule 405IAC 5.

(Continued)






Chronic Illnesses


Nurse-midwifeservices

Reimbursement is availablefor services rendered by acertified nurse-midwife whenreferred by a PMP. Coverageof certified nurse-midwifeservices is restricted toservices that the nurse-midwife is legally authorizedto perform.


Reimbursement is available forservices rendered by a certifiednurse-midwife when referredby a PMP. Coverage ofcertified nurse-midwifeservices is restricted to servicesthat the nurse-midwife islegally authorized to perform.

Reimbursement is availablefor services rendered by acertified nurse-midwife whenreferred by a PMP. Coverageof certified nurse-midwifeservices is restricted toservices that the nurse-midwife is legally authorizedto perform.

Noncovered services

Podiatrists Surgical procedures involvingthe foot, laboratory or x-rayservices, and hospital staysare covered when medicallynecessary. No more than sixroutine foot care visits peryear are covered.


Surgical procedures involvingthe foot, laboratory or x-rayservices, and hospital stays arecovered when medicallynecessary. Routine foot careservices and office visits arenot covered.

Surgical proceduresinvolving the foot, laboratoryor x-ray services, andhospital stays are coveredwhen medically necessary.No more than six routinefoot care visits per year arecovered.


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Chronic Illnesses


VisionServices

Reimbursement for the initialvision care examination willbe limited to one examinationper year for a member under19 years of age unless morefrequent care is medicallynecessary. Optical suppliesare covered when prescribedby an ophthalmologist oroptometrist.

Coverage is limited toservices related to pregnancy(including prenatal, delivery,and postpartum services), aswell as conditions which maycomplicate the pregnancy orurgent care services..

Reimbursement for the initialvision care examination will belimited to one examination peryear for a member under 19years of age unless morefrequent care is medicallynecessary. Optical supplies arecovered when prescribed by anophthalmologist or optometrist.

Reimbursement for the initialvision care examination willbe limited to oneexamination per year for amember under 19 years ofage unless more frequentcare is medically necessary.Optical supplies are coveredwhen prescribed by anophthalmologist oroptometrist.

Noncovered services

Eyeglasses Reimbursement foreyeglasses, including framesand lenses, will be limited to amaximum of one pair per yearfor members under 19 yearsof age except when a specifiedminimum prescription changemakes additional coveragemedically necessary or themember’s lenses and/orframes are lost, stolen, orbroken beyond repair. SeeCovered Services andLimitations Rule 405 IAC 5.


Reimbursement for eyeglasses,including frames and lenses,will be limited to a maximumof one pair per year formembers under 19 years of ageexcept when a specifiedminimum prescription changemakes additional coveragemedically necessary or themember’s lenses and/or framesare lost, stolen, or brokenbeyond repair. See CoveredServices and Limitations Rule405 IAC 5.

Reimbursement foreyeglasses, including framesand lenses, will be limited toa maximum of one pair peryear for members under 19years of age except when aspecified minimumprescription change makesadditional coveragemedically necessary or themember’s lenses and/orframes are lost, stolen, orbroken beyond repair. SeeCovered Services andLimitations Rule 405 IAC 5.

Noncovered services

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Chronic Illnesses


Chiropractors* Reimbursement is availablefor covered services providedby a licensed chiropractorwhen rendered within thescope of the practice ofchiropractic. Limited to fivevisits and 50 therapeuticphysical medicine treatmentsper member per year.


Reimbursement is available forcovered services provided by alicensed chiropractor whenrendered within the scope ofthe practice of chiropractic.Limited to five visits and 14therapeutic physical medicinetreatments per member peryear. An additional 36treatments may be covered ifprior approval is obtainedbased on medical necessity.There is a 50 treatment limitper calendar year.

Reimbursement is availablefor covered servicesprovided by a licensedchiropractor when renderedwithin the scope of thepractice of chiropractic.Limited to five visits and 50therapeutic physicalmedicine treatments permember per year.


Home HealthServices**

Reimbursement is available tohome health agencies formedically necessary skillednursing services provided by aregistered nurse or licensedpractical nurse; home healthaide services; physical,occupational, and respiratorytherapy services; speechpathology services; and renaldialysis for home-boundindividuals. See CoveredServices and Limitations Rule405 IAC 5.


Reimbursement is available tohome health agencies formedically necessary skillednursing services provided by aregistered nurse or licensedpractical nurse; home healthaide services; physical,occupational, and respiratorytherapy services; speechpathology services; and renaldialysis for home-boundindividuals. See CoveredServices and Limitations Rule405 IAC 5.

Reimbursement is availableto home health agencies formedically necessary skillednursing services provided bya registered nurse or licensedpractical nurse; home healthaide services; physical,occupational, and respiratorytherapy services; speechpathology services; and renaldialysis for home-boundindividuals. See CoveredServices and LimitationsRule 405 IAC 5.

Noncovered services

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Chronic Illnesses


Medicalsupplies andequipment(includesprostheticdevices,implants,hearing aids,dentures,etc.)**

Reimbursement is availablefor medical supplies,equipment, and appliancessuitable for use in the homewhen medically necessary.See Covered Services andLimitations Rule 405IAC 5.


Covered when medicallynecessary. Maximum benefit of$2,000 per year or $5,000 perlifetime for durable medicalequipment. Equipment may bepurchased or leased dependingon which is more cost-efficient.

Reimbursement is availablefor medical supplies,equipment, and appliancessuitable for use in the homewhen medically necessary.See Covered Services andLimitations Rule 405IAC 5.


DentalServices

In accordance with Federallaw, all medically necessarydental services are providedfor children under age 21 evenif the service is not otherwisecovered under Package A. SeeCovered Services andLimitations Rule 405 IAC 5.


All medically necessary dentalservices are provided forchildren enrolled in Package Ceven if the service is nototherwise covered under CHIP.See Covered Services andLimitations Rule 405 IAC 5.

In accordance with Federallaw, all medically necessarydental services are providedfor children under age 21even if the service is nototherwise covered underPackage A. See CoveredServices and LimitationsRule 405 IAC 5.

Only emergency servicesbilled with dental codeD0130 are covered formembers in this benefitpackage.

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Chronic Illnesses


PhysicalTherapy**

Must be ordered by a M.D. orD.O. and provided byqualified therapist or assistant.Prior authorization is notrequired for initialevaluations, or for servicesprovided within 30 daysfollowing discharge from ahospital when ordered by aphysician prior to discharge.See Covered Services andLimitations Rule 405 IAC 5.


Must be ordered by M.D. orD.O. and provided by qualifiedtherapist or assistant.Maximum of 50 visits per year,per type of therapy.

Must be ordered by M.D. orD.O. and provided byqualified therapist orassistant. Prior authorizationnot required for initialevaluations, or for servicesprovided within 30 daysfollowing discharge fromhospital when ordered byphysician prior to discharge.See Covered Services andLimitations Rule 405 IAC 5.

Noncovered services

Speech,Hearing andLanguageDisorders*

Must be ordered by a M.D. orD.O. and provided byqualified therapist or assistant.Prior authorization is notrequired for initialevaluations, or for servicesprovided within 30 daysfollowing discharge from ahospital when ordered byphysician prior to discharge.See Covered Services andLimitations Rule 405 IAC 5.


Must be ordered by a M.D. orD.O. and provided by qualifiedtherapist or assistant.Maximum of 50 visits perrolling year, per type oftherapy.

Must be ordered by a M.D.or D.O. and provided byqualified therapist orassistant. Prior authorizationis not required for initialevaluations, or for servicesprovided within 30 daysfollowing discharge from ahospital when ordered byphysician prior to discharge.See Covered Services andLimitations Rule 405 IAC 5.

Noncovered services

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Chronic Illnesses


OccupationalTherapy**

Must be ordered by a M.D. orD.O. and provided byqualified therapist or assistant.Prior authorization is notrequired for initialevaluations, or for servicesprovided within 30 daysfollowing discharge from ahospital when ordered byphysician prior to discharge.See Covered Services andLimitations Rule 405 IAC 5.



Must be ordered by a M.D.or D.O. and provided byqualified therapist orassistant. Prior authorizationis not required for initialevaluations, or for servicesprovided within 30 daysfollowing discharge from ahospital when ordered byphysician prior to discharge.Services are not to exceed 30hours/visits/sessions per 30days. See Covered Servicesand Limitations Rule 405IAC 5.

Noncovered services

RespiratoryTherapy*

Must be ordered by a M.D. orD.O. and provided byqualified therapist or assistant.Prior authorization is notrequired for inpatient oroutpatient hospital,emergency, oxygen in anursing facility, 30 daysfollowing discharge fromhospital when ordered byphysician prior to discharge.



Must be ordered by a M.D.or D.O. and provided byqualified therapist orassistant. Prior authorizationis not required for inpatientor outpatient hospital,emergency, oxygen in anursing facility, 30 daysfollowing discharge fromhospital when ordered byphysician prior to discharge.

Noncovered services

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Chronic Illnesses


Prescribed(Legend)Drugs

See Covered Services andLimitations Rule 405 IAC 5.





Over-the-counter (Non-legend) Drugs



Not covered except for insulin. See Covered Services andLimitations Rule 405 IAC 5.


(Continued)






Chronic Illnesses


InpatientRehabilitativeServices**



Covered up to 50 days percalendar year.



IntermediateCare Facilitiesfor theMentallyRetarded**

Preadmission diagnosis andevaluation required. Includesroom and board; mental healthservices; dental services;therapy and habilitationservices; durable medicalequipment; medical supplies;pharmaceutical products;transportation; optometricservices.


Noncovered services Preadmission diagnosis andevaluation required. Includesroom and board; mentalhealth services; dentalservices; therapy andhabilitation services; durablemedical equipment; medicalsupplies; pharmaceuticalproducts; transportation;optometric services.

Noncovered services

CommunityMental HealthRehabilitation

Includes outpatient mentalhealth services, partialhospitalization (group activityprogram) and casemanagement. See CoveredServices and Limitations Rule405 IAC 5.


Noncovered services Includes outpatient mentalhealth services, partialhospitalization (groupactivity program) and casemanagement. See CoveredServices and LimitationsRule 405 IAC 5.

Noncovered services

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Chronic Illnesses


Outpatientmental health/substanceabuse services

Includes mental healthservices provided byphysicians, psychiatric wingsof acute care hospitals,outpatient mental healthfacilities and psychologistsendorsed as Health ServicesProviders in Psychology.Office visits limited to amaximum of four per monthor 20 per year per memberwithout prior approval. SeeCovered Services andLimitations Rule 405 IAC 5.


Covers outpatient mentalhealth/substance abuse serviceswhen the services aremedically necessary for thediagnosis or treatment of themember's condition exceptwhen provided in an institutionfor mental diseases with morethan 16 beds. Office visitslimited to a maximum of 30 peryear per member without priorapproval to a maximum of 50visits per year.

Includes mental healthservices provided byphysicians, psychiatric wingsof acute care hospitals,outpatient mental healthfacilities and psychologistsendorsed as Health ServicesProviders in Psychology.Office visits limited to amaximum of four per monthor 20 per year per memberwithout prior approval. SeeCovered Services andLimitations Rule 405 IAC 5.

Noncovered services

Inpatientmental health/substanceabuseservices**

Each member admitted musthave an individuallydeveloped plan of caredeveloped by the physicianand interdisciplinary team.Plan of care must be reviewedand updated every 30 days bythe interdisciplinary team.Recertification is requiredevery 60 days.


Inpatient mentalhealth/substance abuse servicesare covered when the servicesare medically necessary for thediagnosis or treatment of themember's condition exceptwhen they are provided in aninstitution for mental diseaseswith more than 16 beds.

Each member admitted musthave an individuallydeveloped plan of caredeveloped by the physicianand interdisciplinary team.Plan of care must bereviewed and updated every30 days by theinterdisciplinary team.Recertification is requiredevery 60 days.

Noncovered services

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Chronic Illnesses


Hospicecare**

Must be expected to die fromillness within six months.Coverage of two consecutiveperiods of 90 days followedby an unlimited number ofperiods of 60 days.


Must be expected to die fromillness within six months.Coverage of two consecutiveperiods of 90 days followed byan unlimited number of periodsof 60 days.

Must be expected to die fromillness within six months.Coverage of two consecutiveperiods of 90 days followedby an unlimited number ofperiods of 60 days.


CaseManagementfor Personswith HIV**

Targeted case managementservices limited to no morethan 60 hours per quarter.


Noncovered service Targeted case managementservices limited to no morethan 60 hours per quarter.

Noncovered services

CaseManagementfor PregnantWomen**

Limited to one initialassessment, one reassessmentper trimester, and onepostpartum assessment.


Noncovered service Limited to one initialassessment, onereassessment per trimester,and one postpartumassessment.

Noncovered services

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Chronic Illnesses


CaseManagementfor Mentally Illor EmotionallyDisturbed

Targeted case managementservices limited to thoseprovided by or undersupervision of qualifiedmental health professionalswho are employees of aprovider agency approved bythe Department of MentalHealth.


Noncovered service Targeted case managementservices limited to thoseprovided by or undersupervision of qualifiedmental health professionalswho are employees of aprovider agency approved bythe Department of MentalHealth.

Noncovered service

Non-emergencyTransportation

Non-emergency travelavailable for up to 20 one-waytrips of less than 50 miles peryear without priorauthorization.


Ambulance services for non-emergencies between medicalfacilities are covered whenrequested by a participatingphysician.

Non-emergency travelavailable for up to 20 one-way trips of less than 50miles per year without priorauthorization.

Noncovered services

OrganTransplants

Covered in accordance withprevailing standards ofmedical care. Similarlysituated individuals are treatedalike.


Noncovered services Covered in accordance withprevailing standards ofmedical care. Similarlysituated individuals aretreated alike.

Emergency services arecovered when such servicesare provided or prescribed bya physician and when theservices are medicallynecessary for the diagnosis ortreatment of the member'sacute condition. This includeslabor and delivery up to thetime the mother is stable. SeeCovered Services andLimitations Rule 405 IAC 5.

(Continued)






Chronic Illnesses


EmergencyTransportation*

No limit or prior approval foremergency ambulance or tripsto/from hospital for inpatientadmission/discharge.


Covers emergency ambulancetransportation using the prudentlayperson standard as definedin state insurance law I.C. 27-13-1-11.7.

No limit or prior approval foremergency ambulance ortrips to/from hospital forinpatientadmission/discharge.

Emergency services arecovered when such servicesare provided or prescribed bya physician and when theservices are medicallynecessary for the diagnosis ortreatment of the member'sacute condition. This includeslabor and delivery up to thetime the mother is stable. SeeCovered Services andLimitations Rule 405 IAC 5.

Diabetes SelfManagementTrainingServices*

Limited to 16 units permember per year. Additionalunits may be prior authorized.


Limited to 16 units per memberper year. Additional units maybe prior authorized.

Limited to 16 units permember per year. Additionalunits may be priorauthorized.

Noncovered services

Orthodontics Covered when medicallynecessary.

Coverage is limited toservices related to pregnancy(including prenatal, delivery,and postpartum services), aswell as conditions which maycomplicate the pregnancy orurgent care services. SeeCovered Services andLimitations Rule 405 IAC 5.

Covered when medicallynecessary.

Covered when medicallynecessary.

Noncovered services

(Continued)






Chronic Illnesses


FoodSupplements,NutritionalSupplements,and InfantFormulas**

Covered only when no othermeans of nutrition is feasibleor reasonable. Not available incases of routine or ordinarynutritional needs.


Covered only when no othermeans of nutrition is feasible orreasonable. Not available incases of routine or ordinarynutritional needs.

Covered only when no othermeans of nutrition is feasibleor reasonable. Not availablein cases of routine orordinary nutritional needs.

Noncovered services

Out-of-stateMedicalServices**

Covers acute general hospitalcare; physician services;dental services; pharmacyservices; transportationservices; therapy services;podiatry services; chiropracticservices; durable medicalequipment and supplies. Priorauthorization is not requiredfor emergency servicesprovided out of state, but oncethe member is stable priorauthorization must beobtained.


Covers acute general hospitalcare; physician services; dentalservices; pharmacy services;transportation services; therapyservices; podiatry services;chiropractic services; durablemedical equipment andsupplies. Coverage is subject toany limitations included in theCHIP benefit package.

Covers acute general hospitalcare; physician services;dental services; pharmacyservices; transportationservices; therapy services;podiatry services;chiropractic services; durablemedical equipment andsupplies. Prior authorizationis not required for emergencyservices provided out ofstate, but once the member isstable prior authorizationmust be obtained.

Emergency services arecovered when such servicesare provided or prescribedby a physician and when theservices are medicallynecessary for the diagnosisor treatment of the member'sacute condition. Thisincludes labor and deliveryup to the time the mother isstable. See Covered Servicesand Limitations Rule 405IAC 5.**

**Prior approval always required

*Prior approval required under certain circumstances

Italics − Updates since the original publication on October 29, 1999.



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