405 IAC 1-1-2 Choice of provider and use of Medicaid card

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.