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Eligibility Verification

It is important that providers verify member eligibility on the date of service every time they provide services. Viewing a member's ID card alone does not ensure member eligibility, and neither does having prior authorization on file.

The Indiana Health Coverage Programs (IHCP) member identification card, called the Hoosier Health Card, is used to identify enrollment in IHCP fee-for-service (FFS) programs, including Traditional Medicaid, Emergency Services Only, Medicare Savings Programs and the Family Planning Eligibility Program. For managed care programs, the managed care entities (MCEs) issue cards for their enrolled members. MCE cards are issued as new members enroll in the plan or as lost cards are replaced. The MCE cards include the member's IHCP Member ID for eligibility verification purposes. See the Member Eligibility and Benefit Coverage provider reference module for more information.

If providers fail to verify eligibility on the date of service, they risk claim denial if, for example, the member was not eligible on the date of service, or the service provided was outside the member's scope of coverage.

The following eligibility verification tools can be used to verify the status of a member's eligibility for current and past dates of service.

IHCP Provider Healthcare Portal

The IHCP Provider Healthcare Portal (Portal) is a secure website that allows providers to perform multiple functions including obtaining eligibility information and filing FFS claims. The Portal is fast and easy to use, and online help is available through the eligibility verification process. For more information, see the Provider Healthcare Portal provider reference module.

Interactive Voice Response (IVR) System

The Interactive Voice Response (IVR) System enables providers to obtain member eligibility information, basic FFS claim status and other routine information through the use of a touch-tone telephone. For instructions about how to use the IVR System, see the Interactive Voice Response System provider reference module.

270/271 Eligibility Inquiry and Response Transaction - Batch or Interactive

The 270/271 eligibility benefit request and response is a Health Insurance Portability and Accountability Act (HIPAA)-compliant electronic transaction for use by registered trading partners. For more information about electronic transactions, see the Electronic Data Interchange (EDI) Solutions webpage.

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