405 IAC 1-1-2 - Choice of provider and use of Medicaid card
Authority: IC 12-13; IC 12-15
Affected: IC 12-13-2-3; IC 12-13-7-3; IC 12-15-12; IC 12-15-28-1
Sec. 2.
(a) The
member shall have free choice of providers for services provided in the state
of Indiana and for services provided outside the state on an emergency basis,
except as provided in subsections (b) and (c). Services to be provided outside
the state, except for those out-of-state areas that have been designated by the
office, which are not of an emergency nature, require prior authorization of
the office.
(b) If a member is
participating in a managed care program, the member shall select a managed care
provider who is responsible for coordinating the member's health care needs. If
a member fails to select a managed care provider within a reasonable time after
being furnished a list of managed care providers by the office, the office
shall assign a managed care provider to the member. A Medicaid member may not
receive services from a provider other than the designated managed care
provider except in the following cases:
(1)
Medical emergencies.
(2) Where the
managed care provider has authorized referral services in writing.
(3) Where specific services are excluded from
coverage under the managed care program.
(4) Where specific services covered under the
managed care program can be accessed through self-referral by members, as
designated in IC 12-15-12 et seq.
(c) In the event that the office determines
that a Medicaid member has utilized any Medicaid coverage service or supply at
a frequency or amount not medically necessary, the office may restrict the
benefits available to the Medicaid member for a period of two (2) years by
noting any restrictions on the face of the member's Medicaid card. The office
may restrict the Medicaid member's benefits by:
(1) requiring that the member only receive
benefits from the provider or providers noted on the Medicaid card, except as
specifically approved in advance by the office; or
(2) prohibiting the member from receiving:
(A) any specific services noted on the card;
or
(B) services from any specific
provider or providers noted on the card.
(d) Not later than two (2) years after a
Medicaid member's benefits have been restricted, the office will review the
Medicaid member's case and continue the Medicaid member's restricted benefits
if review of documented services indicates continued misutilization of Medicaid
coverage services or supplies. The continued period of restriction will again
be for a period of two (2) years, after which the Medicaid member's case will
be reviewed and the restriction may again be renewed.
(e) A Medicaid member affected by the initial
restriction under subsection (c) or continued restriction of benefits under
subsection (d) may appeal the restrictions. Member appeal rights shall be those
provided for in 42 CFR as required by IC 12-15-28-1, and the notice and hearing
will be in accordance with the requirements of
42 CFR
431.200 et seq. and
405 IAC 1.1-1-3.
(f) Before providing any Medicaid covered
service, each provider shall check the Medicaid card of the individual for whom
the provider is performing the service. Failure to do so shall result in denial
of the provider's claim if the individual is not eligible or the service is not
authorized. In checking the Medicaid card, the provider must determine all of
the following:
(1) The Medicaid card is valid
for the month in which the service is being provided.
(2) The individual whose name appears on the
Medicaid card is the same individual for whom the service is being
performed.
(3) No restriction or
restrictions appearing on the Medicaid card would prohibit the provider from
performing the requested service.
Notes
Transferred from the Division of Family and Children
(470 IAC 5-1-2) to the Office of
the Secretary of Family and Social Services (405 IAC 1-1-2) by P.L. 9-1991,
SECTION
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