405 Ind. Admin. Code 14-4-2

Current through October 31, 2024

Section 405 IAC 14-4-2 - Provider enrollment, credentialing, and PMP requirements

Authority: IC 12-15-1-10

Affected: IC 12-15-12

Sec. 2.

(a) The office considers a provider eligible to participate in HCC when the provider enrolls with the IHCP.

(b) An HCC provider eligible and required to enroll with the office as a provider must first be enrolled with the office as a provider before providing services to members. After the provider enrolls with the office, the provider may contract with any MCO providing services to HCC members.

(c) An MCO shall have written credentialing, provisional credentialing, and recredentialing policies and procedures in place for ensuring that contracted providers hold current state licensure and are enrolled with the office.

(d) An MCO shall ensure access to an ongoing source of care appropriate to a member's clinical condition at least thirty (30) miles from the member's residence.

(e) If an MCO chooses to operate a PMP model for HCC, providers eligible to serve as a PMP may contract with more than one (1) MCO to serve as a PMP, or may serve as a PMP in at least one (1) MCO and as a specialist with at least one (1) other MCO.

(f) A PMP, if applicable, or provider that is otherwise a source of ongoing care, shall be available to see members at least three (3) days a week for at least twenty (20) hours a week at any combination of not more than two (2) locations.

(g) An MCO shall have a mechanism in place to ensure the MCO's contracted PMPs, if applicable, or providers that are otherwise a source of ongoing care:

(1) provide or arrange for covering covered services twenty-four (24) hours a day, seven (7) days a week;

(2) have a mechanism in place to offer members direct contact in English and Spanish with their provider, or the provider's qualified clinical designee, through a toll free telephone number twenty-four (24) hours a day, seven (7) days a week; and

(3) provide "live voice" coverage after normal business hours, which may include an answering service or a shared call system with other medical providers.

405 IAC 14-4-2

Office of the Secretary of Family and Social Services; 405 IAC 14-421; filed 8/30/2024, 11:42 a.m.: 20240925-IR-405240180FRA