Common use of Self-Referral Services Clause in Contracts

Self-Referral Services. In accordance with state and federal requirements, some covered benefits are available to members on a self-referral basis. These services shall not require a physician’s referral or other authorization from the Contractor. The Contractor must include self-referral providers in its contracted network. The Contractor may direct members to seek the services of the self-referral providers contracted in the Contractor’s network. However, with the exception of behavioral health and routine dental services, the Contractor cannot require that the members receive such services from network providers. Members may self-refer to any IHCP provider qualified to provide the service(s). When members choose to receive self-referral services from IHCP-enrolled self- referral providers who do not have contractual relationships with the Contractor, the Contractor is responsible for payment to these providers up to the applicable benefit limits and at 98% of Indiana Medicaid fee-for-service (FFS) rates.  Chiropractic services may be provided by a licensed chiropractor, enrolled as an IHCP provider, when rendered within the scope of the practice of chiropractic as defined in IC 25-10-1-1 and 846 IAC 1-1.  Eye care services, except surgical services may be provided by any provider licensed under IC 25-22.5 (doctor of medicine or doctor of osteopathy) or IC 25-24 (optometrist) who has entered into a provider agreement under IC 12-15-11.  Podiatric services may be provided by any provider licensed under IC 25-22.5 (doctor of medicine or doctor of osteopathy) or IC 25-29 (doctor of podiatric medicine) who has entered into a provider agreement under IC 12-15-11.  Psychiatric services may be provided by any provider licensed under IC 25-22.5 (doctor of medicine or doctor of osteopathy) who has entered into a provider agreement under IC 12-15-11.  Family planning services under federal regulation 42 CFR 431.51(b)(2) requires freedom of choice of providers and access to family planning services and supplies. Family planning services are those services provided to individuals of childbearing age to temporarily or permanently prevent or delay pregnancy. Family planning services also include sexually transmitted disease testing. Abortions and abortifacients are not covered family planning services, except as allowable under the federal Hyde Amendment. Members may self-refer to any IHCP provider qualified to provide the family planning service(s), including providers that are not in the Contractor’s network. Members may not be restricted in choice of a family planning service provider, so long as the provider is an IHCP provider. The IHCP Provider Manual provides a complete and current list of family planning services.  Emergency services are covered without the need for prior authorization or the existence of a Contractor contract with the emergency care provider. Emergency services must be available twenty four (24)-hours-a-day, seven (7)-days-a-week subject to the “prudent layperson” standard of an emergency medical condition, as defined in 42 CFR 438.114 and IC 12-15-12. See Section 3.3 for more information.  Immunizations are self-referral to any IHCP-enrolled provider. Immunizations are covered regardless of where they are received.  Diabetes self-management services are available on a self-referral basis to any IHCP provider when the member obtains the services from an IHCP self-referral provider.  Behavioral health services are self-referral if rendered by an in-network provider. Members may self-refer, within the Contractor’s network, for behavioral health services not provided by a psychiatrist, including mental health, substance abuse and chemical dependency services rendered by mental health specialty providers. Refer to Section

Self-Referral Services. In accordance with state and federal requirements, some covered benefits are available to members on a self-referral basis. These services shall not require a physician’s referral or other authorization from the Contractor. The Contractor must include self-referral providers in its contracted network. The Contractor may direct members to seek the services of the self-referral providers contracted in the Contractor’s network. However, with the exception of behavioral health and routine dental services, the Contractor cannot require that the members receive such services from network providers. Members may self-refer to any IHCP provider qualified to provide the service(s). When members choose to receive self-referral services from IHCP-enrolled self- referral providers who do not have contractual relationships with the Contractor, the Contractor is responsible for payment to these providers up to the applicable benefit limits and at 98% of Indiana Medicaid fee-for-service (FFS) rates.  • Chiropractic services may be provided by a licensed chiropractor, enrolled as an IHCP provider, when rendered within the scope of the practice of chiropractic as defined in IC 25-10-1-1 and 846 IAC 1-1.  Eye care services, except surgical services may be provided by any provider licensed under IC 25-22.5 (doctor of medicine or doctor of osteopathy) or IC 25-24 (optometrist) who has entered into a provider agreement under IC 12-15-11.  Podiatric services may be provided by any provider licensed under IC 25-22.5 (doctor of medicine or doctor of osteopathy) or IC 25-29 (doctor of podiatric medicine) who has entered into a provider agreement under IC 12-15-11.  Psychiatric services may be provided by any provider licensed under IC 25-22.5 (doctor of medicine or doctor of osteopathy) who has entered into a provider agreement under IC 12-15-11.  Family planning services under federal regulation 42 CFR 431.51(b)(2) requires freedom of choice of providers and access to family planning services and supplies. Family planning services are those services provided to individuals of childbearing age to temporarily or permanently prevent or delay pregnancy. Family planning services also include sexually transmitted disease testing. Abortions and abortifacients are not covered family planning services, except as allowable under the federal Hyde Amendment. Members may self-refer to any IHCP provider qualified to provide the family planning service(s), including providers that are not in the Contractor’s network. Members may not be restricted in choice of a family planning service provider, so long as the provider is an IHCP provider. The IHCP Provider Manual provides a complete and current list of family planning services.  Emergency services are covered without the need for prior authorization or the existence of a Contractor contract with the emergency care provider. Emergency services must be available twenty four (24)-hours-a-day, seven (7)-days-a-week subject to the “prudent layperson” standard of an emergency medical condition, as defined in EXHIBIT 1.M SCOPE OF WORK 42 CFR 438.114 and IC 12-15-12. See Section 3.3 for more information.  Immunizations are self-referral to any IHCP-enrolled provider. Immunizations are covered regardless of where they are received.  Diabetes self-management services are available on a self-referral basis to any IHCP provider when the member obtains the services from an IHCP self-referral provider.  Behavioral health services are self-referral if rendered by an in-network provider. Members may self-refer, within the Contractor’s network, for behavioral health services not provided by a psychiatrist, including mental health, substance abuse and chemical dependency services rendered by mental health specialty providers. Refer to Section

Self-Referral Services. In accordance with state and federal requirements, some covered benefits are available to members on a self-referral basis. These services shall not require a physician’s referral or other authorization from the Contractor. The Contractor must include self-referral providers in its contracted network. The Contractor may direct members to seek the services of the self-referral providers contracted in the Contractor’s network. However, with the exception of behavioral health and routine dental services, the Contractor cannot require that the members receive such services from network providers. Members may self-refer to any IHCP provider qualified to provide the service(s). When members choose to receive self-referral services from IHCP-enrolled self- referral providers who do not have contractual relationships with the Contractor, the Contractor is responsible for payment to these providers up to the applicable benefit limits and at 98% of Indiana Medicaid fee-for-service (FFS) rates.  • Chiropractic services may be provided by a licensed chiropractor, enrolled as an IHCP provider, when rendered within the scope of the practice of chiropractic as defined in IC 25-10-1-1 and 846 IAC 1-1.  Eye care services, except surgical services may be provided by any provider licensed under IC 25-22.5 (doctor of medicine or doctor of osteopathy) or IC 25-24 (optometrist) who has entered into a provider agreement under IC 12-15-11.  Podiatric services may be provided by any provider licensed under IC 25-22.5 (doctor of medicine or doctor of osteopathy) or IC 25-29 (doctor of podiatric medicine) who has entered into a provider agreement under IC 12-15-11.  Psychiatric services may be provided by any provider licensed under IC 25-22.5 (doctor of medicine or doctor of osteopathy) who has entered into a provider agreement under IC 12-15-11.  Family planning services under federal regulation 42 CFR 431.51(b)(2) requires freedom of choice of providers and access to family planning services and supplies. Family planning services are those services provided to individuals of childbearing age to temporarily or permanently prevent or delay pregnancy. Family planning services also include sexually transmitted disease testing. Abortions and abortifacients are not covered family planning services, except as allowable under the federal Hyde Amendment. Members may self-refer to any IHCP provider qualified to provide the family planning service(s), including providers that are not in the Contractor’s network. Members may not be restricted in choice of a family planning service provider, so long as the provider is an IHCP provider. The IHCP Provider Manual provides a complete and current list of family planning services.  Emergency services are covered without the need for prior authorization or the existence of a Contractor contract with the emergency care provider. Emergency services must be available twenty four (24)-hours-a-day, seven (7)-days-a-week subject to the “prudent layperson” standard of an emergency medical condition, as defined in 42 CFR 438.114 and IC 12-15-12. See Section 3.3 for more information.  Immunizations are self-referral to any IHCP-enrolled provider. Immunizations are covered regardless of where they are received.  Diabetes self-management services are available on a self-referral basis to any IHCP provider when the member obtains the services from an IHCP self-referral provider.  Behavioral health services are self-referral if rendered by an in-network provider. Members may self-refer, within the Contractor’s network, for behavioral health services not provided by a psychiatrist, including mental health, substance abuse and chemical dependency services rendered by mental health specialty providers. Refer to SectionEmergency

Self-Referral Services. In accordance with state and federal requirements, some covered benefits are available to members on a self-referral basis. These services shall not require a physician’s referral or other authorization from the Contractor. The Contractor must include self-referral providers in its contracted network. The Contractor may direct members to seek the services of the self-referral providers contracted in the Contractor’s network. However, with the exception of behavioral health and routine dental services, the Contractor cannot require that the members receive such services from network providers. Members may self-refer to any IHCP provider qualified to provide the service(s). When members choose to receive self-referral services from IHCP-enrolled self- referral providers who do not have contractual relationships with the Contractor, the Contractor is responsible for payment to these providers up to the applicable benefit limits and at 98% of Indiana Medicaid fee-for-service (FFS) rates.  • Chiropractic services may be provided by a licensed chiropractor, enrolled as an IHCP provider, when rendered within the scope of the practice of chiropractic as defined in IC 25-10-1-1 and 846 IAC 1-1.  • Eye care services, except surgical services may be provided by any provider licensed under IC 25-22.5 (doctor of medicine or doctor of osteopathy) or IC 25-24 (optometrist) who has entered into a provider agreement under IC 12-15-11.  • Podiatric services may be provided by any provider licensed under IC 25-22.5 (doctor of medicine or doctor of osteopathy) or IC 25-29 (doctor of podiatric medicine) who has entered into a provider agreement under IC 12-15-11.  • Psychiatric services may be provided by any provider licensed under IC 25-22.5 (doctor of medicine or doctor of osteopathy) who has entered into a provider agreement under IC 12-15-11.  • Family planning services under federal regulation 42 CFR 431.51(b)(2) requires freedom of choice of providers and access to family planning services and supplies. Family planning services are those services provided to individuals of childbearing age to temporarily or permanently prevent or delay pregnancy. Family planning services also include sexually transmitted disease testing. Abortions and abortifacients are not covered family planning services, except as allowable under the federal Hyde Amendment. Members may self-refer to any IHCP provider qualified to provide the family planning service(s), including providers that are not in the Contractor’s network. Members may not be restricted in choice of a family planning service provider, so long as the provider is an IHCP provider. The IHCP Provider Manual provides a complete and current list of family planning services.  • Emergency services are covered without the need for prior authorization or the existence of a Contractor contract with the emergency care provider. Emergency services must be available twenty four (24)-hours-a-day, seven (7)-days-a-week subject to the “prudent layperson” standard of an emergency medical condition, as defined in 42 CFR 438.114 and IC 12-15-12. See Section 3.3 for more information.  • Immunizations are self-referral to any IHCP-enrolled provider. Immunizations are covered regardless of where they are received.  • Diabetes self-management services are available on a self-referral basis to any IHCP provider when the member obtains the services from an IHCP self-referral provider.  • Behavioral health services are self-referral if rendered by an in-network provider. Members may self-refer, within the Contractor’s network, for behavioral health services not provided by a psychiatrist, including mental health, substance abuse and chemical dependency services rendered by mental health specialty providers. Refer to Section