The Right Choices Program (RCP) monitors member utilization and, when appropriate, implements restrictions for members who would benefit from increased case coordination. Member utilization review identifies members who use Indiana Health Coverage Programs (IHCP) services more extensively than their peers.
Any Medicaid member who meets the RCP criteria may be enrolled in RCP regardless of whether the member is in Hoosier Healthwise, Healthy Indiana Plan (HIP), Hoosier Care Connect, or Traditional Medicaid. Anthem, MHS, MDwise, CareSource, and Cooperative Managed Care Services (CMCS) administer the RCP for members in accordance with the State's policy and procedure guidelines.
Each RCP member is restricted to a physician, a pharmacy, and a hospital. In some situations, the member can be restricted to additional provider types, if such action is warranted. For example, the RCP member's lock-in physician can refer the member to a specialist. That specialist is then added to the member's list of providers. In an emergency, other providers can render services without the need for a referral.
Providers must verify member eligibility to determine to which IHCP program or plan the member belongs and whether RCP restrictions exist.
The provider is responsible for checking the eligibility of IHCP members before rendering services. If no restrictions are listed, the member is not restricted to any specific provider. If the eligibility response lists restrictions, the member is restricted to receiving specific types of services only from the specific providers indicated.
The IHCP reimburses only the providers to which the member is restricted unless a referral is on file with the entity to which the member is assigned, or if the service is for an emergency condition. The provider must notify the member, before rendering the service, that the services will not be covered by the IHCP and ask the member to sign a statement of understanding that he or she is responsible for payment. The provider can bill the member for the services not eligible for payment due to the RCP restrictions. Claims for nonemergency services to a Right Choices member that are rendered by a provider that is not assigned or referred are denied.
Providers may refer questions about RCP members to contacts as noted on the IHCP Quick Reference Guide.
For more information, see the following provider reference modules: