Guides and Manuals
Linked documents are PDFs, unless otherwise listed.
Provider Manuals and Quick Reference Guides
- MHS Provider Manual (PDF), updated June 1, 2017
- Indiana Medicaid Provider Manual (PDF)
- MHS Provider Quick Reference Guide (PDF), effective June 1, 2018
- MHS Dental Provider Manual (PDF)
- MHS Plan Overview (PDF)
- MHS Provider Orientation (PDF)
- 2018 HEDIS Quick Reference Guide (PDF)
Clinical & Payment Policies
Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information.
All policies found in the MHS Clinical Policy Manual apply to MHS members. Policies in the MHS Clinical Policy Manual may have either a MHS or a “Centene” heading. MHS utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a MHS clinical policy does not exist. InterQual is a nationally recognized evidence-based decision support tool. You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling MHS. In addition, MHS may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or InterQual® criteria is payable by MHS.
The Clinical Policy Manuals may be accessed through the link below. This site allows you to:
Search all folders by keyword by entering a search term in the keyword prompt and then pressing enter. Or you may browse by catalog subject by selecting the manual drop-downs on the left hand side.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
MHS Clinical Policies - Coming Soon
Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. They are used to help identify whether health care services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.
All policies found in the MHS Payment Policy Manual apply with respect to MHS members. Policies in the MHS Payment Policy Manual may have either a MHS or a “Centene” heading. In addition, MHS may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by MHS.
The Payment Policy Manuals may be accessed through the link below. This site allows you to:
Search all folders by keyword by entering a search term in the keyword prompt and then pressing enter. Or you may browse by catalog subject by selecting the manual drop-downs on the left hand side. If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
Ambetter from MHS
Pay for Performance and Scorecards
- New! Top 10 Rejection Codes Help Aid (PDF)
- 5010 837P/I Companion Guide and Addendum B (PDF)
- 276-277-Companion-Guide (PDF)
- 270-271 Companion Guide (PDF)
- MHS Denial Codes (PDF) updated November 2017
- EDI COB Mapping Guide (PDF)
- Reject Reason Codes and Descriptions (PDF), updated January 2017
- Edifecs Ramp Manager Tutorial – EDI X12 Testing Center (PDF)
Member Management, Member Benefits and Services
Pregnancy Member Management
- IHCP Bulletin – Pregnancy Related Services (PDF)
- Presumptive Eligibility information and FAQ on indianamedicaid.com
- Notification of Pregnancy information and FAQ on indianamedicaid.com
- 40 Weeks Provider Toolkit (PDF)
- Enhanced Services for Pregnant Members (PDF)
Program Descriptions, Tools, and other Reference Guides
- HIP Plus Tip Sheet (PDF)
- HIP Provider Newsletter (PDF), January 28th, 2015
- QI Program Description (PDF)
- Medical Record Documentation Audit Tool (PDF)
- School-Based Health Partnership Survey Report (PDF)
- Provider Relations and Contracting Territories Map and Contact Information (PDF)
- MemberConnections Territory Map and Contact Information (PDF)
- CAHPS Provider Tip Sheet (PDF)
- Well-Child Documentation Tips (PDF)
Posters & Brochures
Indiana Medicaid Bulletins and FAQs
- Review all IHCP News, Banners and Bulletins
Having trouble finding what you need in a PDF? Hit Ctrl+F or go to Edit > Find, type in the term you are looking for, and press enter. Find will take you to the first use of that term. Each time you press enter, find will take you to the next occurrence of the term until you reach the end of the document.
If you would like any of these guides in print, please contact Provider Services at 1-877-647-4848.