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Glossary

Contains a list of several Medicaid-related terms and definitions with a shared meaning for all MCOs.

Carve-outs:
While the MCOs retain responsibility for the delivery and payment for most care for its members, certain services are not paid by the MCO. These services remain the financial responsibility of the State, are reimbursed on a FFS basis, and are billed to EDS. These service carve-outs include the following:

  • Dental services rendered by providers enrolled in an IHCP dental specialty. These specialties are endodontist, general dentistry practitioner, oral surgeon, orthodontist, pediatric dentist, periodontist, and prosthodontist.
  • Services provided by a school corporation as part of a student’s Individualized Education Plan (IEP).
  • Mental health services classified as Medicaid Rehabilitation Option (MRO) Services rendered by providers enrolled in the Indiana Health Coverage Programs with a mental health specialty.
 

Non-covered services:
Health care services to which Enrollees are not entitled under 405 IAC 5 in the Indiana Health Coverage Program Provider Manual. Covered services shall be no broader or narrower than the services provided to recipients under the state of Indiana Medicaid Program unless otherwise provided in the Medicaid Contract. Additionally, services must be medically necessary and most appropriate to treat the member’s diagnosis.

 

PMP (Primary Medical Providers):
A Primary Medical Provider (PMP) is a primary care provider who has enrolled in the IHCP and has signed an agreement with an MCO to be assigned a panel of Hoosier Healthwise members and has agreed to act as a gatekeeper for the member’s medical care. There are five primary care specialties that can elect to enroll as PMPs. They include family practitioner, general pediatrician, OB/GYN, general internal medicine practitioner, and general practitioner.

 

PMP Referral:
A PMP referral is a request to a specialist or ancillary provider for medically necessary services that the PMP cannot provide.

 

Prior Authorization:
A procedure governed by the Contract used to review and assess the medical necessity and appropriateness of elective hospital admissions and non-Emergency Care before the services are provided. Also called Pre-Certification and Pre-Authorization. 

 

Program Referral:
A PMP can refer a member to a number of programs available such as prenatal case management, disease management, smoking cessation, weight management, wellness information, health information for teens, as well as other community resources.

 
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