HCBS Provider Frequently Asked Questions

Health coverage in PathWays starts July 1, 2024.

Individuals identified in the population groups listed above will be notified of the transition to PathWays for Aging in February and March 2024. Please remind individuals to update their address (if it has changed since their Medicaid enrollment) with the Division of Family Resources. Benefits Portal (in.gov)

The MCEs are not allowed to contact waiver clients and future enrollees. FSSA will be sending information to current waiver clients to help them through the MCE selection process.

Once individuals select an MCE, the MCE will reach out to each individual and provide a “welcome packet” around June 2024. All materials sent to individuals by MCEs have been reviewed and approved by FSSA.

Each person eligible to enroll in PathWays will receive a notice in the mail in February and March 2024. The notices will include information about the PathWays for Aging program and how to select an MCE. Individuals will also be able to call the enrollment broker to discuss their plan options at 87-PATHWAY-4 (1-877-284-9294).

We encourage anyone who missed the roundtables in the spring to obtain the information that was handed out via this link: http://www.advancingstates.org/mcehcbs-provider-roundtable-events. There is also general information about the program at in.gov/pathways. The MCEs also participated in a contracting webinar that you can access at https://www.in.gov/pathways/stakeholder-engagement/ as well as future webinars FSSA will be holding with the MCEs.

FSSA will be doing extensive stakeholder outreach to all individuals who will transition to PathWays to support them in selecting an MCE. This outreach will include many methods such as TV commercials, radio ads, mailed notices, townhalls, phone calls, etc. The MCEs will only perform direct outreach to individuals who have selected that specific MCE as their plan.

If a member did not choose a plan by the end of April, they were assigned to a plan. The Enrollment Broker (Maximus) will assist members in selecting and changing their MCE. The Enrollment Broker is independent and not affiliated with any MCE.

Providers should direct their clients to the Enrollment Broker (Maximus) to support them in choosing a health plan. Individuals will be able to call Maximus at 87-PATHWAY-4 (1-877-284-9294) for support beginning in November 2023. Providers should remain impartial and not attempt to influence MCE selection.

Yes. Individuals will have the chance to change their MCE: within ninety (90) days of starting coverage; at any time their Medicare and Medicaid plans become unaligned (e.g. member disenrolls from one MA plan to another during quarterly Special Enrollment Period (SEP); once per calendar year for any reason; at any time using the just process; and Additionally, during a plan selection period which will be aligned with the Medicare open enrollment window (mid-October to mid-December) to be effective the following calendar year.

Each MCE will offer value-added benefits. These are benefits that the MCEs pay for out of their pocket; the state does not pay them to provide. The value-added benefits may include things like meal delivery services (Hello Fresh) and over-the-counter (OTC) pharmacy allowance. FSSA is creating a side-by-side comparison chart that each eligible person will receive with their notice to select an MCE.

No, members will select a plan with the help of the Enrollment Broker (Maximus). Individuals will be able to call Maximus at 87-PATHWAY-4 (1-877-284-9294) for support beginning in November 2023.

Individuals will receive an eligibility assessment by an Area Agency on Aging (AAA) until July 2025. If the individual qualifies, the AAA will provide a warm handoff to the Enrollment Broker (Maximus) for MCE selection. Beginning in July 2025, the Level of Care Assessment Representative (LCAR) with Maximus will complete the front-end level of care assessments for the Aging & Disability waiver and PASRR function. If the individual qualifies for PathWays, the enrollment broker will assist the member in selecting an MCE.

Yes. A person can be eligible for both Medicaid and Medicare and receive benefits from both programs at the same time. A Dual Eligible Special Needs Plan is a type of health insurance plan. It’s for people who have both Medicaid and Medicare. If that’s you, you’re “dual-eligible.”

To get information on D-SNPs, contact the State Health Insurance Assistance Program (SHIP) at (800) 452-4800 to speak to a counselor. SHIP is a free counseling program for people with Medicare. You can get one-on-one assistance in person, on the phone, or virtual.

If an individual receives Medicaid or both Medicaid and Medicare, they should expect to receive a letter from the Enrollment Broker (Maximus) 90 days before their 60th birthday.  This letter will inform them that they are eligible for the PathWays. If the individual receives services through the Aged and Disabled Waiver, they will transition to PathWays when they turn 60 years of age. Individuals who are in a federally recognized tribe as well as those receiving hospice services have the choice to opt-into PathWays.

Members under 60 will not be enrolled in the PathWays program and can remain with their current providers.

Providers can find assigned MCE by verifying the members Medicaid eligibility. The eligibility record includes information on MCE enrollment. IHCP requires providers to verify member eligibility on the date of service, using the Eligibility Verification on the IHCP Portal, or through Interactive Voice Response system, or through approved vendor software for 270/271 batch. At a minimum LTSS providers should verify member eligibility at the beginning of each calendar month.

Members will begin receiving welcome packets from their assigned MCE during the month of June. Providers can check with the individuals they serve to confirm MCE assignment.

As part of the Comprehensive Health Assessment process, the MCE will work with the member and collect and review medical and educational information, as well as family and caregiver input, as appropriate, to identify the member’s care strengths, health needs and available resources. The Comprehensive Health Assessment may include, but is not limited to, a review of the member’s claims history and contact with the member and/or member’s family, their informal caregiver, PMP (if applicable), or other significant providers with the consent of the member.

Providers will check their patients’ Medicaid eligibility and MCE enrollment using the IHCP portal. Member MCE enrollment changes are effective on the first of the month. IHCP requires providers to verify member eligibility on the date of service, using the Eligibility Verification on the IHCP Portal, or through Interactive Voice Response system, or through approved vendor software for 270/271 batch. At a minimum LTSS providers should verify member eligibility and enrollment at the beginning of each calendar month.

Providers must be an approved IHCP provider before they can contract with an MCE.  However, the State encourages providers to reach out to the MCEs in the interim to discuss the contracting process.

An atypical provider refers to those that provide home and community-based services.  Not all atypical providers will have an NPI and in those instances the LPI will be acceptable as part of contracting with the MCEs.

Each MCE is required to have Provider Representatives and Provider Claims Educators for HCBS and LTSS providers, and a dedicated provider services helpline. MCEs have different staffing and support models to fulfill these requirements. Some MCEs may assign an account manager and others will have different contact methods for providers.

The MCEs will work with members to identify providers in their community and make referrals to those providers.

All home modifications must be approved by the MCE prior to services rendered. Home modification providers will be paid for services approved on the service plan once the participant and/or IDT sign off on the home modification work.

The client will get a letter 90 days before their 60th birthday. This letter will tell them that they are eligible for the PathWays program. It will also include information on how to select a health plan.

Service plans are reviewed at least every 90 days and on an annual basis. Members are assessed upon enrollment with an MCE and are reassessed when there is a change in status and annually based on their NFLOC redetermination date. Changes and updates to an individual’s service plan are determined on the results of the individual’s assessment and reassessment.

The helpline is open M-F 8am-7pm. Outbound calls can be made any time the helpline is open, and will be dependent on their inbound call volume.

It does not affect the individual’s Medicare benefits. PathWays is a Medicaid managed care program designed to better coordinate care with an individual’s Medicare plan.

Yes, providers will have access to care plans with services they are authorized to provide.

Yes. The same Indiana Medicaid ID will be used.

There are no decreases to a member’s authorized services for the first 90 days of the PathWays program. Members can request to change their authorized hours and services.

IHCC is not going away and MCEs have to contract with at least one IHCC provider. Providers delivering IHCC services have an opportunity to share data about how this service supports individuals in reducing the number of medication errors, missed doctor’s appointments and hospitalizations.

Each MCE will have their own methods of communication with providers enrolled in their network.

There will be no copayments for members in the Indiana PathWays for Aging program. However, members may have copayments as part of their Medicare plan.

Yes, family members can be paid providers in the Structured Family Caregiving (SFC) program. There are also self-direction options or they could become an employee of a provider agency to provide care if they are not a legally responsible individual.

Medicaid eligibility requirements remain the same.

Structured Family Caregiving will not change; the Service Coordinators will complete quarterly visits.

Each MCE is required to submit a workforce development plan and will hire a workforce development administrator. Contact the MCE to learn about how to support in their workforce efforts.

There will be no decreases to authorized service plans for 6 months. However, new assessments/authorizations will be completed during that time.

Each MCE will have their own methods of communication with providers enrolled in their network.

PathWays MCEs will be responsible for payment of Medicare cost share.  Indiana Medicaid sets a minimum fee schedule. MCEs set their own reimbursement at or above that level, so any crossover payment is dependent on each MCE’s reimbursement. For members remaining in FFS, IHCP recently updated our Professional Fee Schedule to be set at 100% of the Medicare rate. See bulletin BT2023149.

OMPP does not have any interaction or involvement with Medicare plans that are not D-SNPs. MCEs are required to coordinate with members’ Medicare plans regardless of the plan type, including ACOs. In addition to any services or benefits provided by the ACO, the PathWays MCE should also be managing care and coordinating services.

Yes. Dual eligibles under the age of 60 will not be in PathWays. PathWays is only for individuals 60 years and older who are eligible for full Medicaid benefits including individuals receiving HCBS services through the Aged and Disabled Waiver, individuals residing in nursing facility, and individuals receiving full Medicare benefits.

PathWays MCEs will deduct the full amount of patient liability from the first claim for a month if the claim amount satisfies the patient liability.

Sometimes. Patient liability is calculated as part of the eligibility determination process. However, patient liability can change based on changes in an eligible’ s circumstances. When an eligible’ s patient liability increases, the eligible must be given notice, and the change is effective the first of the month after the date of the notice of action, so is prospective and would not require claim reprocessing. When an eligible’ s patient liability decreases, the new amount is normally effective the first of the month following reporting and verification and is intended to be prospective. However, there is a cutoff date near the end of the month for processing these changes. If the verification occurs after the cutoff date for processing the change, the effective date of the new amount is unaffected, but the change would be processed and implemented after the effective date and could result in the need to re-process claims.

Yes. If the claim denial was based on an error on the initially submitted claim, a provider can submit a corrected claim as soon as they learn of the denial.

There is no requirement for MCEs to allow such overrides of timely filing requirements and they may use the date stamp from the clearinghouse to enforce timely filing requirements.

The service location name and address where the patient was seen are required and the address must match the service location address currently on file with the MCEs for the group or billing provider. Provider name is not a requirement to process the claim.

Providers can check the status of a submitted claim in the MCEs’ Provider Portals.

Please contact the PathWays MCEs to determine whether any re-enrollment is needed; whether separate FTE enrollment is required for the Medicaid PathWays MCE and the aligned Medicare D-SNP, and whether an entity can have more than on bank set up to receive EFT payments.

Anthem: Email: INMLTSSProviderRelations@anthem.com; Phone: 833-310-3775

Humana: Email: InMedicaidProviderRelations@humana.com; Phone: 866-274-5888

UnitedHealthcare: Email: in_providerservices@uhc.com; Phone: 877-610-9785

MCEs are required to pay all claims using the NPI number. As long as the provider’s profile is accurate, the EFT payment will align with the provider’s NPI.

Yes. Please refer to the IHCP FQHC Provider Reference Module here.

Providers can input a date range on a claim. This cannot be a future date range.

Yes. Providers can register for and use the MCE’s Provider Portals to monitor claims status even if they do not use the portals to submit claims.

Yes. Non-network providers can register for and use the Pathways MCEs’ Provider Portals.

When authorization is required, the process depends on the member’s status.

• For Medicaid only non-dual eligible PathWays enrollees, the provider will need to follow the PathWays MCE prior authorization process.
• For dual eligible enrollees with aligned enrollment (in the same PathWays MCE for both their Medicare and Medicaid coverage), the provider will submit one authorization request for both Medicare and Medicaid following the MCE prior authorization process.
• For dual eligible enrollee with non-aligned enrollment (enrolled in a PathWays MCE for Medicaid benefits but another payor for Medicare benefits), the provider will need to submit authorization requests to the Medicare payor for Medicare covered benefits, and authorization requests to the PathWays MCE for services only covered by Medicaid.

Contact the provider relations representative at each MCE. The contact information can be found above.

For the first two years of the PathWays program, MCEs must accept claims from both contracted and not contracted providers. This is referred to as an open network. During this period, even if a provider does not contract with an MCE, the provider will be able to bill and get paid for covered services. After the 2nd year, MCEs can request to close their network if they meet network adequacy and only allow participation by contracted providers. FSSA will review such requests and either approve or deny them. If FSSA approves network closure, enrollees will need to get services from contracted providers in their PathWays MCE’s provider network.
Although contracting with the MCEs is not required for the first two years, there are benefits to contracting:

• Faster access to provider portals
• Will appear in the provider directory
• Members will be encouraged to use network providers
• Dedicated Provider Education and Outreach representatives that are available to assist providers with day-to-day program inquiries

Additionally, for the first three years of the PathWays program, MCEs must contract with any willing LTSS provider who meets licensure and IHCP enrollment criteria and is willing to accept the provisions of the MCE’s contract. Following the end of the third year of PathWays, the MCEs may implement selective contracting, though still must meet network adequacy standards.

FSSA will review each of the MCE’s processes and policies regarding processing claims as part of readiness review. FSSA also requires the MCEs to submit monthly reports regarding claims processing timeliness.

The Contractor must have written Provider Claims Dispute Resolution policies and procedures for responding to claims disputes for both in-network and out-of-network providers, in accordance with the rules for the claims dispute resolution process for non-contracted providers outlined in Indiana law, 405 IAC 1-1.6. Informal claim disputes must be resolved by the MCE within 30 days.  In the event the matter is not resolved to the provider's satisfaction within thirty (30) days after the provider commenced the informal process, the provider shall have sixty (60) days after the end of the thirty (30) day period to submit a formal appeal notice to the MCE.

Yes, MCEs will be able to receive claims through EDI. An EDI is the electronic interchange of business information using a standardized format; a process which allows a company to send information to another company electronically.

No. Providers can contract with MCEs any time after PathWays go-live.

The current contract includes Year One pay-for-outcomes measures for the MCEs. The State is in the process of developing additional Value-Based Payment (VBP) measures that will be implemented across all PathWays MCEs, which will take at least two years. This process requires provider feedback, public comment and approval by CMS. The State will share details for VBP once we are further along with planning.

Each MCE will offer training; contact the MCE’s designated provider relations representative for training information.

Yes, each MCE will have their own contracts.

Each MCE must contract with any willing provider for at least 3 years. For HCBS providers, they must be approved through the Indiana Health Coverage Programs (IHCP) and be certified by the Division of Aging prior to contracting with any MCE.

Yes, each MCE is required to participate in readiness review. Readiness review is a systematic large-scale review, where FSSA reviews the MCEs’ processes, polices, procedures, etc.  As part of readiness review, each MCE must demonstrate to FSSA that they are able to process claims.

MCEs have the contact information for providers who attended the MCE/HCBS Provider  roundtable events hosted by ADvancing States and are allowed to contact providers now. FSSA also encourages providers to do proactive outreach with the PathWays MCEs directly, if they are interested in becoming a provider in their network. Information from the roundtable events including MCE here: http://www.advancingstates.org/mcehcbs-provider-roundtable-events

Yes. All three MCEs are required to operate statewide.

The State determines the Medicaid rate and rate structures for Structured Family Caregiving (SFC). Each MCE is required to pay at least the established Medicaid rate.

MCEs can employ service coordinators directly and/or contract with AAAs and ICMs to provide service coordination.

MCEs have their own portal, FSSA is working together with all three MCEs to develop unified operations. While portals may be different, MCEs are aligning as much as possible with operations.

You can ensure the ability to continue serving your current waiver clients regardless of which MCE they are enrolled.

The state determines the Medicaid rate and rate structures for all waiver services. Each MCE is required to pay at least the established Medicaid rate.

The MCE will be authorizing all waiver services, and the MCEs are required to follow the regulations outlined in each waiver service. The PathWays Waiver carries over services from the Aged and Disabled Waiver. The bid requirement for home modifications does not change.

Providers will have to contract with each MCE separately. It is recommended that providers contract with all three MCEs to assure that they can continue to serve existing clients.

No. Waiver Providers do not need to get an NPI. PathWays MCEs will support claim submission by Waiver Providers as atypical providers who do not need an NPI. Waiver providers will use their Legacy Provider Identifier (LPI) on claims to identify themselves.

No. Order Referring Physician is an optional field on the claim form and the PathWays MCEs will not deny claims if this field is left blank.

Diagnosis code is a required field for claim submission. If the actual diagnosis code is not known, the provider should enter R69 in field 21, line A as the diagnosis for waiver members. This information can be found in the IHCP Home and Community Based Billing Guidelines Manual found here. On the CMS 1500 claim form, field 21A-L providers are required to enter an ICD diagnosis codes in priority order. A total of 12 codes can be entered. Though not required, it is best practice to include an accurate diagnosis code on claims. Waiver providers can find a patient’s diagnosis on their Notice of Action (NOA).

An atypical provider is one that provides home and community-based services. Not all atypical providers will have an NPI and in those instances the Legacy Provider Identifier (LPI) will be acceptable as part of contracting with the MCEs and should be included on claims.

Each of the PathWays MCEs offers multiple claims submission options including:

• Paper claims submission
• Electronic submission via data entry in the MCEs’ Provider Portals
• Electronic EDI submission through an EDI Clearinghouse,

Where providers submit claims for PathWays enrollees depends on whether an enrollee has Medicare coverage, and if they do, where an enrollee gets their Medicare coverage:

• If an enrollee does not have Medicare coverage, providers will submit claims for Medicaid covered services to the enrollee’s PathWays MCE.
• If an enrollee is in the same MCE for both Medicare and Medicaid coverage, providers will submit claims to the enrollee’s PathWays MCE, and the MCE will process it in consideration of Medicare and Medicaid coverage combined. However, providers will need to bill certain services on separate claims specifying whether the bill is for a Medicare covered service or a Medicaid covered service.
• If an enrollee is enrolled in a PathWays MCE for only their Medicaid coverage and receives their Medicare benefits through Medicare fee-for-service, in most cases providers will submit claims for Medicare covered services to Medicare, and PathWays MCEs will receive and process Medicare Crossover Claims from the Medicare Administrative Contractor. Providers will submit claims for services only covered by Medicaid to the PathWays MCE.
• If an enrollee is enrolled in a Medicare Advantage Plan or a non-PathWays D-SNP, providers will submit claims for Medicare covered services to the Medicare Advantage Plan or non-PathWays D-SNP and submit a claim to the PathWays MCE for any crossover amounts accompanied by the Medicare EOB. Providers will submit claims for services only covered by Medicaid to the PathWays MCE.
  • Non-PathWays D-SNPs are only an option through 2024. In 2025 people who had received their Medicare coverage through a non-PathWays D-SNP will have to elect another option. Their options include:
    • A PathWays aligned D-SNP
    • Medicare Fee-for-Service
    • A Medicare Advantage Plan
• All 1915i waiver services, Medicaid Rehabilitation Option (MRO) services, and Money Follows the Person (MFP) services are carved out of PathWays Managed Care plans, and claims for those services should be billed to Gainwell.

The PathWays MCE Payor IDs are:

• Anthem= 00130 – 837I and 00630–837P
• Humana= 61101
• United Healthcare= 87726

Use these Payor IDs regardless of whether a service is covered by Medicare or Medicaid, or both.

Whether there is a Medicare Crossover Claim depends on where an enrollee gets their Medicare coverage:

• If an enrollee has aligned enrollment, is enrolled in the same PathWays MCE for both their Medicare and Medicaid coverage, there is no Medicare Crossover Claim. Providers will submit a single claim to the PathWays MCE, and the MCE will process it in consideration of Medicare and Medicaid coverage combined.
• If an enrollee is enrolled in a PathWays MCE for only their Medicaid coverage and receives their Medicare benefits through Medicare fee-for-service, in most cases the PathWays MCEs will receive and process Medicare Crossover Claims from the Medicare Administrative Contractor.
• If an enrollee is enrolled in a Medicare Advantage Plan or a non-PathWays D-SNP for their Medicare benefit, the provider needs to submit a crossover claim to the PathWays MCE accompanied by the EOB from the Medicare Advantage plan or non-PathWays D-SNP.

While an Assisted Living Facility can bill on the 2nd of the month using the monthly rate, OMPP advises that ALFs submit claims on or after the 15^th of the month. Waiting to submit claims avoids situations where a person is away from the ALF for enough days that the rate needs to be changed from the monthly rate to a daily rate.

When a hospice election is revoked, for any reason, the Medicaid eligible individual will be enrolled in a PathWays MCE. If they then re-elect hospice, they will remain enrolled in the PathWays MCE.

If a person is QMB Only, then they are not eligible for PathWays enrollment.

If the individual is a Full Benefit Dually Eligible individual, then billing depends on whether they have aligned or non-aligned PathWays enrollment.

If the individual has aligned enrollment, meaning they are enrolled in the same plan for both their Medicare and Medicaid coverage, the provider will submit a single claim for services and the PathWays MCE will adjudicate the claim applying Medicare and Medicaid rules.

If the individual has non-aligned enrollment, meaning they are in a PathWays MCE for their Medicaid coverage but have elected to get the Medicare coverage from a different payor, the provider submits claims to the Medicare payor as primary for Medicare covered services. If Medicare pays the claims, deductible and copayment amounts should automatically cross over to the PathWays MCE. If the Medicare payor denies the claim, the provider would need to submit the Medicare denial with a PathWays claim for the service.

No. Eligibility cannot be verified for future dates because eligibility cannot be guaranteed before the date of service.

OMPP is sending letters to these D-SNP enrollees in September and October letting them know that their plan will be discontinued effective December 31, 2024, and that they will need to select a new source for their Medicare coverage during annual open enrollment. They can select the D-SNP plan aligned with their PathWays enrollment, or a Medicare Advantage Plan, or Traditional Fee-for-Service Medicare.

Current processes for SSBG/CHOICES will remain the same.

Each MCE is responsible for meeting network adequacy requirements and have their own transportation providers. FSSA requires MCEs to frequently and consistently monitor provider networks to proactively identify any network deficiencies, filling gaps and reporting on those metrics. MCEs are required to review of analytics reports to determine any network gaps, conduct ongoing monitoring of network access, network composition (including cultural and linguistic competency), provider compliance with access standards through surveys and member complaints, monitoring of single-case agreements (SCAs) to identify barriers with current providers and identification of new providers to include in the network. FSSA requires MCEs to have key staff positions for network development, dedicated Provider Relations team, and contracting experts across provider types who work in tandem with cross-functional leaders to assure the MCEs network strategy aligns with the comprehensive and complex needs of members.

The PathWays program provide specialized medical equipment identical to the specialized medical equipment service on the Aged and Disabled Waiver. Individuals who have a need for medical alert systems, such as, a personal emergency response pendant, Google Home or other adaptive technology may have access to those items on through their MCE. As long as it is a member enhanced benefit provided by the MCE, it can be accessible based on member need.

The monthly capitation rate for each member varies based on eligibility status.

Medicare only providers must be IHCP attested as provider type 37, specialty 370 – Medicare-Only Provider. Once a Medicare only provider is IHCP attested, they can bill the PathWays MCEs for Medicare deductible and coinsurance amounts owed by Medicaid.

Consistent with 42 CFR 447.45, MCEs must process electronically submitted clean claims, and issue payment within 21 days from receipt. MCEs must process electronically submitted clean HCBS claims, and issue payment within 7 business days from receipt. MCEs must process all clean paper claims and issue payment within 30 days from receipt.

No. Providers do not need to include patient liability amounts on a claim. The PathWays MCEs have patient liability information from Core MMIS and can apply this to claims received.rom receipt. MCEs must process all clean paper claims and issue payment within 30 days from receipt.

PathWays MCEs will deduct the full amount of patient liability from the first claim for a month if the claim amount satisfies the patient liability.

Yes. For the PathWays MCEs, the TIN is required on the 1500 and UB04 as part of the unified billing format.

No. This is an optional field on the claim form and the MCEs will not deny claims if the NOA/Prior Auth number is not included on the claim.

Please review BT2024113 for guidance on the correct Type of Bill codes to use when Medicaid is the primary payer and billing for hospice, home health, and nursing facility services. When Medicare is the primary payer use 21X for Medicare skilled stays.

Sandata is FSSA’s electronic visit verification (EVV) platform. If a provider uses the Sandata State-sponsored EVV platform, then no, Sandata will not send the provider’s claims to the PathWays MCE, and a provider will need to submit their claims to the MCE or through an electronic clearinghouse. If a provider uses a different EVV vendor/platform the provider should engage with their vendor to determine whether that vendor offers claims submission.

Yes. A provider can use a third-party billing company for some billing services, but bill other services in-house for the PathWays program.

The billing requirements for this service are not changing. IHCC must be part of the individual’s person centered service plan for the claim to pay.

PathWays MCEs use the definitions of clean claim at IC 12-15-13-0.5 and IC-15-13-0.6 for nursing facilities. These definitions comply with the federal definition of clean claim at 42 CFR447.45 that specifies that, “Clean claim means one that can be processed without obtaining additional information from the provider of the service or from a third party. It includes a claim with errors originating in a State's claims system. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity.”

Yes.  All PathWays MCEs must require the same information on the claim forms. The MCEs are developing a training resource that will include the following:

1. The fields required to submit for adjudication and
2. The information required for each required field. Please also refer to each MCE’s specific submission requirements and options.

An electronic remittance advice, or ERA, is an explanation from a health plan to a provider about a claim payment. An ERA explains how a health plan has adjusted claim charges based on factors like:

• Contracts
• Secondary payers
• Benefits
• Expected copays and co-insurance
  Under HIPAA, all payers, including Medicare, are required to use claims adjustment reason codes (CARCs) and remittance advice remark codes (RARCs) approved by X12 recognized code sets. Payers are not allowed to use their own proprietary codes to explain any adjustment in the claim payment.
  The Department of Health and Human Services (HHS) has adopted one standard for ERA transactions: X12 835 TR3 TRN Segment, for data content of the Addenda Record of the CCD+.
  Health plans are required to input the X12 835 TR3 TRN Segment into Field 3 of the Addenda Record of the CCD+. The TRN Segment in the Addenda Record of the CCD+ should match the TRN Segment in the associated ERA that describes the payment. Using the same TRN Segment helps to match the payment to the correct remittance advice, a process called re-association.
  Each PathWays MCE can provide guidance and instruction on what is on their Remittance Advice and how to read it. Further information can be found on the CMS and HHS websites:
• Health Care Payment and Remittance Advice - https://www.cms.gov/medicare/coding-billing/electronic-billing/health-care-payment-remittance-advice
• Understanding Your Remittance Advice Reports - https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/ICNMLN8788099-final_0.pdf
• Remittance Advice Resources and FAQs - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ICN905367TextOnly.pdf

PathWays enrollees that also have Medicare have several options for how they get coverage of their Medicare benefits.

• They can choose to enroll in the aligned PathWays MCE’s D-SNP plan to maximize coordination and streamline their interactions with health plans
• They can choose to receive the Medicare through traditional Medicare (fee-for-service)
• They can choose to enroll in a Medicare Advantage plan
• If they already in a non-PathWays MCE’s D-SNP they can stay in that plan through 2024 and will need to choose another option for their Medicare benefits for 2025

Yes. All PathWays enrollees will get their Medicaid covered benefits through their PathWays MCE. PathWays enrollees that also have Medicare have several options for how they get coverage of their Medicare benefits.

• They can choose to enroll in the aligned PathWays MCE’s D-SNP plan to maximize coordination and streamline their interactions with health plans
• They can choose to receive the Medicare through traditional Medicare (fee-for-service)
• They can choose to enroll in a Medicare Advantage plan
• If they already in a non-PathWays MCE’s D-SNP they can stay in that plan through 2024 and will need to choose another option for their Medicare benefits for 2025

Yes. Dual eligibles under the age of 60 will not be in PathWays. PathWays is only for individuals 60 years and older who are eligible for full Medicaid benefits including individuals receiving HCBS services through the Aged and Disabled Waiver, individuals residing in nursing facility, and individuals receiving full Medicare benefits.

No. Some populations 60 and over are excluded from PathWays. These include:

• Partial dually eligible Medicare beneficiaries
• DDRS waiver recipients
• TBI waiver recipients,
• ICF/IDD residents
• PACE members
• RCAP members
• Anyone not eligible for full Medicaid benefits, for example, Package E Medicaid which only covers emergent services
  There are also some populations 60 and over who can opt-in to PathWays such as American Natives and Alaska Native and individuals receiving hospice services prior to age 60.

The Enrollment Broker’s helpline is open M-F 8am-7pm. Outbound calls can be made any time the helpline is open and will be dependent on their inbound call volume.

Yes. If a Medicaid eligible person is not eligible for full Medicare benefits but meets the other PathWays eligibility criteria, they will be enrolled in PathWays.

Service plans are reviewed at least every 90 days and on an annual basis. Members are assessed upon enrollment with an MCE and are reassessed when there is a change in status and annually based on their NFLOC redetermination date. Changes and updates to an individual’s service plan are based on the results of an individual’s assessment and reassessment.

A provider must be an approved IHCP provider before they can execute a contract with an MCE. However, the State encourages providers to reach out to the MCEs in the interim to discuss the contracting process.

In accordance with 405 IAC 1-14.7-7(b), FSSA has designated facilities that have received approval to operate a qualified Ventilator program. The list of facilities with approved Medicaid Ventilator Programs and the add on rate for the period of 7/1/2023 through 6/30/25 is located here.

Providers will check their patients’ Medicaid eligibility and MCE enrollment using the IHCP portal. Member MCE enrollment changes are effective on the first of the month. IHCP requires providers to verify member eligibility on the date of service, using the Eligibility Verification on the IHCP Portal, or through Interactive Voice Response system, or through approved vendor software for 270/271 batch. At a minimum LTSS providers should verify member eligibility and enrollment at the beginning of each calendar month.

Yes. If a Medicaid eligible person is not eligible for full Medicare benefits but meets the other PathWays eligibility criteria, they will be enrolled in PathWays.

Until July, 2025, enrollment processes will remain the same where individuals receive an eligibility assessment from their AAA. If the individual qualifies, the AAA will provide a warm handoff to the Enrollment Broker (Maximus) for MCE selection. Beginning in July 2025, the Level of Care Assessment Representative (LCAR) with Maximus will complete the front-end level of care assessments for the Aging & Disability waiver and PASRR function. If the individual qualifies for PathWays, the enrollment broker will assist the member in selecting a MCE.

AAAs can decide to contract with the MCE to provide service coordination services as subcontractors. It is also possible the MCE may employ independent service coordinators not affiliated with an AAA. MCEs are not required or recommended to utilize a pick list, as members in the PathWays program are encouraged to have choice in choosing their providers along with education about provider selection to ensure there is a good match between member and provider.

The client will get a letter 90 days before their 60th birthday. This letter will tell them that they are eligible for the PathWays program. It will also include information on how to select a health plan.

Ninety days before a Medicaid eligible turns 60 years old, they will receive a letter telling them that they are about to become eligible for the PathWays program and giving them information about MCE options and how to select a plan. If they select a plan before the first day of their birth month, their enrollment will be effective in that plan on the first of their birth month. If they do not select a plan, they will be assigned a plan with an enrollment effective date of the first day of their birth month. This is true for all Medicaid eligible individuals including those receiving waiver services and client case management from a AAA.

MCEs claim processing systems have logic to match members using other data elements such as address and date of birth when there are different names on file with Medicare and Medicaid.

The MCE contracts are in process of being fully executed and FSSA is awaiting final CMS approval. Once these two items are complete, IHCP we will post the contracts to the transparency portal.

Providers will use the PathWays MCEs’ Provider Portals to view patient liability and waiver liability information.

Providers will use the PathWays MCEs’ Provider Portals to view patient liability and waiver liability information.

The IHCP Portal continues to be the source of truth for Medicaid eligibility, and providers can see their patients’ MCE enrollment there. Other functions, such as claims submission and claims status check, will be conducted in the MCEs’ Provider Portals.

Modifiers can be in any order on claims.

FSSA has redesigned the nursing facility rate setting process. Rates will now be issued on prospective basis twice a year. In the rare instance of a retroactive rate change that could have claim impact, providers will need to replace the impacted claims with the new billed charges. Alternatively, if providers are aware that there will be a new rate published retroactively for the date of service, the provider can submit the original claim with the anticipated rate to ensure their claim is reprocessed and paid when there is a claims sweep following the loading of retroactive rates.

Yes. This requirement is detailed in BT202449, https://www.in.gov/medicaid/providers/files/bulletins/BT202449.pdf. MCEs will continue to require this information.

Providers may bill multiple months on the same claim, however, all claim lines within a claim must be limited to a single calendar month. Failure to adhere to this creates a risk of a matching issue with authorizations and EVV records.

No. Providers and facilities can be involved in the assessment with the consent of the member but need not be the authorized representative.

The MCEs will work with members to identify in-network providers in their area and coordinate with those providers.

Yes, each MCE is required to participate in readiness review. Readiness review is a systematic large-scale review, where FSSA reviews the MCEs’ processes, polices, procedures, etc.  As part of readiness review, each MCE must demonstrate to FSSA that they are able to process claims. Additionally, each MCE offered a claim testing opportunity with providers in May of 2024.

No. There will be no change to the current admission requirements to Nursing Facilities for Medicaid recipients. Medicaid recipients who are seeking admission to a Medicaid-certified Nursing Facility and are using Medicaid as their payor source, regardless of the length of stay, require a Level of Care (LOC) assessment and eligibility determination.  A nursing facility LOC determination serves as the prior authorization for nursing facility admissions and for continued stays.

Providers should contact each of the MCEs to inquire about their contract amendments. MCEs sent contract amendments in late 2023 and early 2024. All providers currently contracted with the MCEs should have received their contract amendment by now. You can contact the MCEs at the contact info below:

• Anthem: Email: INMLTSSProviderRelations@anthem.com; Phone: 833-310-3775
• Humana: Email: InMedicaidProviderRelations@humana.com; Phone: 866-274-5888
• UnitedHealthcare: Email: in_providerservices@uhc.com; Phone 877-610-9785

This is not a new population to Medicaid. Hospitals who take traditional Medicaid, HCC Medicaid, HIP, traditional Medicare, and Medicare Advantage beneficiaries today, are currently serving the prospective PathWays population.