Overview
The Right Choices Program (RCP) is the lock-in program developed by the Indiana Health Coverage Programs (IHCP) in accordance with Code of Federal Regulations 42 CFR Sections 455 and 456 and Indiana Administrative Code 405 IAC 1-1-2(c).
Members are selected for review based on their behavior patterns and utilization practices compared with other members of the same population within each IHCP program. Reviews may also be initiated by referral, based on reports of potential overuse or abuse from various sources such as IHCP providers or other agencies. After the review process, if it is determined that the member is overusing or abusing services, the member is placed in the RCP, which includes increased care coordination, provider assignment, member education and interventions. The member is locked in to a single primary medical provider (PMP) and a single pharmacy. If the member requires services from a different provider, such as a specialist, the PMP must submit a referral; otherwise, the services will not be reimbursed. (A few services are exempt from this requirement, as noted later on this page, under Billing and Reimbursement.)
Any IHCP member who meets the RCP criteria may be placed in the RCP, including members enrolled in Hoosier Healthwise, Healthy Indiana Plan (HIP), Hoosier Care Connect or Traditional Medicaid.
The RCP program is administered, in accordance to the state's policy and procedure guidelines, by the managed care entities (Anthem, CareSource, Managed Health Services [MHS], MDwise and UnitedHealthcare) for managed care members, and by Acentra Health for fee-for-service (FFS) Traditional Medicaid members.
Checking Eligibility
Before rendering services, providers must verify member eligibility to determine the individual's enrollment status for the date of service, including whether RCP restrictions exist and, if so, which providers are included on the member's lock-in list.
Billing and Reimbursement
For professional and pharmacy claims, the IHCP reimburses only the lock-in and approved referral providers to which the member is restricted.
Note: An exception exists for hospital-based services and other designated services that are carved out of the RCP, as indicated in the Right Choices Program provider reference module. Referrals are not required for these services. However, with the exception of hospital services, it is recommended that referrals be made even for these carved-out services, because prescriptions will only be allowed if the prescriber is on the member’s lock-in list.
If the provider is not a lock-in or approved referral provider for the member, the provider must notify the member that the services will not be covered by the IHCP. If, before services are rendered, the member signs a statement of understanding for the responsibility for payment, the provider can bill the member directly for services not eligible for reimbursement due to RCP restrictions.
Contacts
Providers may refer questions about RCP members to the appropriate RCP Administrator. For contact information, see the Care Management – Right Choices Program section of the IHCP Quick Reference Guide.
More Information
For more information, see the following provider reference modules: