How can I confirm that I will be reimbursed for a member's presumptive eligibility (PE) service?
The PE approval letter clearly indicates the date a member's coverage begins and ends and the plan to which the member belongs, if applicable. This letter serves as the member's identification card. In addition, a member's eligibility is available in real time and should be viewable in the Provider Healthcare Portal at the time the verification letter is printed and sent.
Where can a PE member receive services?
The member is not limited to receiving services only from the provider location where he or she was determined presumptively eligible. Presumptively eligible members can receive services covered under their benefit plan from any Indiana Health Coverage Programs (IHCP)-enrolled provider.
Note: Members determined eligible for Presumptive Eligibility - Adult before January 1, 2019, are covered under the managed care delivery system and must receive services from providers enrolled with the member's managed care entity (MCE) network.
What if a member's eligibility for services is denied via a pharmacy's point-of-sale system?
It may take up to 3 days for a member's eligibility status to be visible in all eligibility systems, such as in the eligibility system of the pharmacy benefit manager. During that time, the member is eligible to receive services. The PE approval letter clearly indicates the date a member's coverage begins and ends, and serves as a member's identification card.