Section 405 IAC 14-5-2 - Provider enrollment and credentialingAuthority: IC 12-15-1-10; IC 12-17.6-2-11
Affected: IC 12-15-12; IC 12-17.6-2
Sec. 2.
(a) The office considers a provider eligible to participate in HHW when the provider enrolls with the office.(b) A HHW provider eligible and required to enroll with the office as a provider must first be enrolled with the office as a provider before providing services to members. After the provider enrolls with the office, the provider may contract with any MCO providing services to HHW members.(c) An MCO shall have written credentialing, provisional credentialing, and recredentialing policies and procedures in place for ensuring all contracted providers hold current state licensure and are enrolled with the office.(d) An MCO shall demonstrate compliance with 42 CFR 438.208, specifically in ensuring that each member has a PMP responsible for providing an ongoing source of primary care appropriate to a member's needs, including coordinating each member's physical and behavioral health care and making necessary referrals.(e) A referral from a member's PMP is required when the member receives physician services from a provider other than their PMP, unless the service is a self-referral or direct access service as set forth in sections 5 and 6 of this rule.(f) The MCO shall ensure access to a PMP at least thirty (30) miles from the member's residence.(g) Provider types that may serve as HHW PMPs include:(1) internal medicine physicians;(2) general practitioners;(3) family medicine physicians;(7) endocrinologists, if primarily engaged in internal medicine; and(8) physician assistants.(h) Providers eligible to serve as a PMP may contract with more than one (1) MCO to serve as a PMP, or may serve as a PMP in at least one (1) MCO and as a specialist with at least one (1) other MCO.(i) An MCO shall have a mechanism in place to ensure the MCO's contracted PMPs: (1) provide or arrange for covering covered services twenty-four (24) hours a day, seven (7) days a week;(2) have a mechanism in place to offer members direct contact in English and Spanish with their PMP, or the PMP's qualified clinical designee, through a toll free telephone number twenty-four (24) hours a day, seven (7) days a week; and(3) provide "live voice" coverage after normal business hours, which may include an answering service or a shared call system with other medical providers.Office of the Secretary of Family and Social Services; 405 IAC 14-5-2; filed 8/30/2024, 11:42 a.m.: 20240925-IR-405240180FRA