Indiana Administrative Code › Title 470 - DIVISION OF FAMILY RESOURCES › Article 12 - PRIOR REVIEW OF OFF-SITE MEDICAL SERVICES; DEPARTMENT OF CORRECTION, STATE BOARD OF HEALTH, AND DEPARTMENT OF MENTAL HEALTH › Rule 1 - Prior Review and Authorization of Requests for Off-Site Medical Services › Section 1-1 - Definitions

Current through July 10, 2024
Authority: IC 12-13-2-3; IC 12-13-5-3; IC 12-16-1-3
Affected: IC 12-15-30; IC 12-16-1
Sec. 1.
(a) "Affected agency" means the department of correction, the state board of health or the department of mental health.
(b) "Eligible individual" means any person, other than a Medicaid recipient, who requires medical or dental services while in the custody or care of an affected agency.
(c) "Health facility" means hospital, dispensary, out-patient department, practitioner's office, dental clinic, or other appropriate treatment facility.
(d) "Medical services" means services requested by a physician (M.D. or D.O.) or dentist, including the provision of supplies and use of appropriate health facilities. The term includes medical services or supplies provided by such other licensed practitioners, institutions or suppliers as a physician may specifically prescribe. Transportation services are specifically exempted from this rule
[470 IAC 12]
.
(e) "Covered medical services" means medical services subject to review by the department, hereinabove defined, which are provided to an eligible individual in a health facility or place other than an institution, at a total cost of more than $150.00. Such services include any medical or dental procedure, or series of such procedures related to a specific diagnosis, illness, injury, condition or syndrome.
(f) "Department" means the state department of public welfare (SDPW).
(g) "Request" means written or telephonic request for approval of medical services in the form and manner specified by the department.
(h) "Institution" means a facility housing, or responsible for, eligible individuals and operating under the jurisdiction of an affected agency.
(i) "SDPW 590 element" means the licensed medical professional staff of the department charged with the responsibility to prior review requests for medical services.
(j) "Emergency services" means those covered medical services which, by their medical nature, do not allow time for formal prior review by SDPW (see section 6
[ 470 IAC 12-1-6 ]
).
(k) "Off-site services" means medical services delivered by a provider who is outside the administrative jurisdiction of any of the institutions of the affected agencies.
(l) "Prior review" means the professional review by the licensed medical professional staff of the SDPW 590 element, in advance of delivery, of a request for specific covered medical services for eligible individuals.
(m) "590 contractor" means the same fiscal agent with which it contracts under IC  12-1-7-17
[Repealed by Acts 1984, P.L. 80, SECTION 10. See IC  12-1-7-17.1 ]
, as it provides administrative and fiscal services in support of this rule
[470 IAC 12]
.
(n) "Provider" means a licensed or certified practitioner or institution which provides any medical or dental service, and which is properly enrolled in this program.