407 IAC 1-2-1 - Choice of provider and use of health care card

Authority: IC 12-17.6-2-11

Affected: IC 12-17.6

Sec. 1.

(a) The member shall select a physician as PMP who is responsible for coordinating the member's health care needs. If a member fails to select a PMP within a reasonable time after being furnished a list of managed care providers by the office or its contractor, the office or its contractor shall assign a PMP to the member. A CHIP member may not receive services from a provider other than the designated PMP, except in the following cases:

(1) Medical emergencies.

(2) Where the designated managed care provider has authorized referral services in writing.

(3) Where specific covered services can be accessed through self-referral by members.

(b) In the event that the office determines that a member has utilized any CHIP coverage service or supply at a frequency or amount not medically reasonable or necessary, the office may restrict the benefits available to the member in the same manner as such restrictions are imposed for Medicaid recipients under 405 IAC 1-1-2. Any member whose benefits have been restricted under this subsection may appeal the restriction. Member appeals are governed by the procedures and time limits for Medicaid recipients set out in 405 IAC 1.Sec. 1.

(c) Before providing any service covered by the CHIP, each provider shall verify the eligibility of the individual for whom the provider is performing the service. Failure to do so can result in denial of the provider's claim if the individual is not eligible or the service is not authorized. In checking the health care card, the provider must determine all of the following:

(1) The health care card is valid at the time the service is being provided.

(2) The individual whose name appears on the health care card is the same individual for whom the service is being performed.

(3) No restrictions have been imposed on the individual's benefits that would prohibit the provider from performing the requested service.

Notes

407 IAC 1-2-1

Office of the Children's Health Insurance Program; 407 IAC 1-2-1; filed May 3, 2000, 2:02 p.m.: 23 IR 2227; readopted filed May 22, 2006, 3:22 p.m.: 29 IR 3424; filed Jun 1, 2011, 2:28 p.m.: 20110629-IR-407100420FRA; readopted filed Jun 18, 2012, 11:23 a.m.: 20120718-IR-407120202RFA