Page 11

Application for the State of Indiana Children’s Health Insurance Program Amendment #7

Effective Date:

11

Approval Date:

Area Description Medicaid Management Information System (MMIS) The MMIS contains a Surveillance and Utilization Review (SUR) subsystem that provides a comprehensive method for conducting utilization review and program management. Under this system, computerized reports are generated that provide a statistical profile of provider practices and recipient utilization. The system allows for the flagging of areas where there is deviation from peers. Rankings are made to indicate which individuals have the greatest amount of deviation. SUR analysts take action where warranted. The objective is for misuse of health services to be identified, investigated, and corrected. Provider desk reviews are conducted based upon Federal and State requirements, and prepayment review and other action is taken where warranted. Recipient restricted card procedures are implemented in cases of recipient over utilization. Programmatic (CHIP) Specific mechanisms designed to prevent over utilization are also built into the Phase II CHIP program. Limitations are placed on the benefit package and nominal copayments will be imposed for certain services. A more detailed discussion regarding benefits can be found in Section 6; and a more detailed discussion regarding copayments can be found in Section 8. Programmatic (Hoosier Healthwise) The managed care system established under Hoosier Healthwise also has some built in utilization controls. The PMP serves as a gatekeeper who provides or authorizes primary care services and makes referrals for specialty care (except those which may be self- referred) where appropriate. Referrals must be documented in the patient’s medical record. In addition, MCOs are required to have written utilization review (UR) programs in place. The program must include a utilization review committee directed by the Medical Director of the MCO; utilization management practices that conform to industry standards; and resources for evaluating, and, if necessary, modifying the UR process. In order for the State to track expenditures and service utilization in the RBMC program, shadow claims are required to be reported for patient encounters. The shadow claims provide details regarding diagnoses, procedures, place of services, billed amounts and providers.