reglab/statecodes huggingface dataset:
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 2 - Definitions › Section 2-13 - "ICD-10-CM" defined

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 13.
"ICD-10-CM" means International Classification of Diseases -
				  10th Revision-Clinical Modification as set forth in
				  45 CFR
				  162.1002.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 2 - Definitions › Section 2-13.1 - "IEP" defined

Current through July 10, 2024
Authority: IC 12-15
Affected: IC
				  12-13-7-3; IC
				  20-18-2-9
Sec. 13.1.
"IEP" means individualized education program and has the
				  meaning set forth in IC
				  20-18-2-9.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 2 - Definitions › Section 2-13.2 - "IEP nursing services" defined

Current through July 10, 2024
Authority: IC 12-15
Affected: IC
				  12-13-7-3
Sec. 13.2.
"IEP nursing services" means medically necessary services
				  provided by a registered nurse who is employed by or under contract with a
				  Medicaid participating school corporation for a member pursuant to his or her
				  IEP.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 2 - Definitions › Section 2-13.3 - "IEP transportation services" defined

Current through July 10, 2024
Authority: IC 12-15
Affected: IC
				  12-13-7-3
Sec. 13.3.
"IEP transportation services" means:
(1) a trip from home to school and the return
				trip on a day when the student receives another Medicaid covered IEP service
				other than transportation; or
(2)
				from school or home to an off-site Medicaid service provider for an IEP covered
				service and the return trip.
The term also includes transportation of a student who
				  resides in an area that does not have school bus service when that student's
				  IEP stipulates a medical need for transportation.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 2 - Definitions › Section 2-15 - "Level of care" defined

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 15.
"Level of care", in an inpatient hospital setting, means the
				  reimbursement methodology used to pay providers for the services rendered,
				  including diagnosis related group, psychiatric, rehabilitation, and burn.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 2 - Definitions › Section 2-15.5 - "Medicaid" defined

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-7-2-128; IC 12-13-7-3; IC 12-15
Sec. 15.5.
"Medicaid" has the meaning set forth in
				  405 IAC
				  1-1-1(8).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 2 - Definitions › Section 2-16 - "Medical policy" defined

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 16.
"Medical policy" means those parameters for coverage of and
				  reimbursement for services and supplies furnished to members that are set out
				  in this article, the provider manual, and provider bulletins.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 2 - Definitions › Section 2-17 - "Medically necessary service" defined

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 17.
"Medically necessary service" as used in this title means a
				  covered service (as defined in section 6 of this rule) that is required for the
				  care or well-being of the patient and is provided in accordance with generally
				  accepted standards of medical or professional practice. For a service to be
				  reimbursable by the office, it must:
(1) be medically necessary, as determined by
				the office, which shall, in making that determination, utilize generally
				accepted standards of medical or professional practice; and
(2) not be listed in this title as a
				noncovered service, or otherwise excluded from coverage.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 2 - Definitions › Section 2-17.5 - "Member" defined

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-7-2-158; IC 12-13-7-3; IC 12-15
Sec. 17.5.
"Member" has the meaning set forth in
				  405 IAC
				  1-1-1(9).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 2 - Definitions › Section 2-18 - "Office" defined

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-7-2-134; IC 12-13-7-3; IC 12-15
Sec. 18.
"Office" has the meaning set forth in
				  405 IAC
				  1-1-1(12).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 2 - Definitions › Section 2-19 - "Outpatient services" defined

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 19.
"Outpatient services" means those services provided to a
				  member who is not registered as an inpatient in an acute care or psychiatric
				  hospital except as specifically referenced in a given section.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 2 - Definitions › Section 2-20 - "Prior authorization" defined

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 20.
"Prior authorization" means the procedure for the office's
				  prior review and authorization, modification, or denial of payment for covered
				  services within Medicaid allowable charges based upon criteria as described in
				  405 IAC 5-3 and throughout this
				  title.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 2 - Definitions › Section 2-21 - "Provider" defined

Current through July 10, 2024
Authority: IC 12-15
Affected: IC 12-13-7-3
Sec. 21.
"Provider" has the meaning set forth in
				  405 IAC
				  1-1-1(15).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 2 - Definitions › Section 2-22 - "Provider agreement" defined

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 22.
"Provider agreement" means a contract or certification
				  agreement between a provider and the office setting out the terms and
				  conditions of a provider's participation in Medicaid, which must be signed by
				  such provider prior to any reimbursement for providing covered services to
				  members.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 2 - Definitions › Section 2-24 - "Reimbursement" defined

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 24.
"Reimbursement" means such payment made to the provider by
				  the office pursuant to federal and state law, as compensation for providing
				  covered services to members.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 2 - Definitions › Section 2-26 - "School corporation" defined

Current through July 10, 2024
Authority: IC 12-15
Affected: IC
				  12-13-7-3; IC
				  20-18-2-16
Sec. 26.
"School corporation" has the meaning set forth in IC
				  20-18-2-16.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 2 - Definitions › Section 2-27 - "Telehealth services" defined

Current through July 10, 2024
Authority: IC 12-15
Affected: IC
				  12-13-7-3
Sec. 27.
"Telehealth services" means the use of telecommunications
				  and information technology to provide access to health assessment, diagnosis,
				  intervention, consultation, supervision, and information across a distance.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 2 - Definitions › Section 2-28 - "Telemedicine services" defined

Current through July 10, 2024
Authority: IC
				  12-15-5-11; IC
				  12-15-21
Affected: IC
				  12-13-7-3; IC
				  12-15-5-11; IC
				  25-1-9.5-6
Sec. 28.
"Telemedicine services" has the meaning set forth for
				  "telemedicine" in IC
				  25-1-9.5-6.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 2 - Definitions › Section 2-29 - "Usual and customary charge" defined

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 29.
"Usual and customary charge" has the meaning set forth in
				  405 IAC
				  1-1-1(18).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 3 - Prior Authorization › Section 3-1 - Prior authorization; generally

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-15-30-1
Sec. 1.
(a) Except as
				provided in section 2 of this rule, prior to providing any Medicaid service
				that requires prior authorization, the provider must submit a properly
				completed Medicaid prior authorization request and receive written notice
				indicating the approval for provision of such service.
(b) It is the responsibility of the provider
				to submit new requests for prior authorization for ongoing services in a timely
				manner before the current authorization period expires in order to ensure that
				services are not interrupted.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 3 - Prior Authorization › Section 3-2 - Prior authorization by telephone

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-15-30-1
Sec. 2.
(a) Prior
				authorization for selected services is available by telephone when the request
				is initiated by a provider authorized to request prior authorization as listed
				in section 10 of this rule. A prior authorization request form is not necessary
				for these selected services. Additional written substantiation and
				documentation may be required by the office. Notification of approval or denial
				will be given at the time the telephone call is made for the following:
(1) Inpatient hospital admission and
				concurrent review, when required under this rule.
(2) Continuation of emergency treatment for
				those conditions listed in section 13 of this rule on an inpatient basis
				originally without prior authorization subject to retrospective medical
				necessity review.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 3 - Prior Authorization › Section 3-3 - Prior authorization based on false information

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-15-30-1
Sec. 3.
Services authorized on the basis of false information
				  supplied by the provider or the provider's agent that the provider or the
				  provider's agent knew or should have reasonably known to be false are not
				  reimbursable.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 3 - Prior Authorization › Section 3-4 - Audit

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-15-30-1
Sec. 4.
Retrospective audit shall include postpayment review of the
				  medical record to determine whether the service was medically necessary as
				  defined in this article.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 3 - Prior Authorization › Section 3-5 - Written requests for prior authorization; contents

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-15-30-1
Sec. 5.
(a) Written
				evidence of physician involvement and personal patient evaluation will be
				required to document the acute medical needs. A current plan of treatment and
				progress notes, as to the necessity, effectiveness, and goals of therapy
				services, must be submitted with the Medicaid prior authorization request and
				available for audit purposes.
(b)
				For services requiring a written request for authorization, a properly
				completed Medicaid prior authorization request must be submitted and approved
				by the contractor prior to the service being rendered.
(c) The following information must be
				submitted with the written prior authorization request form:
(1) The name, address, age, and Medicaid
				number of the patient.
(2) The
				name, address, telephone number, provider number, and signature of the
				provider. The agency will accept any of the following:
(A) A prior authorization request form
				bearing the original signature of the provider.
(B) A scanned or faxed copy of an originally
				signed prior authorization request form described in clause (A).
(C) An original prior authorization request
				form bearing the provider's signature stamp.
(D) A scanned or faxed copy of a prior
				authorization request form described in clause (C).
(E) The electronic signature of the provider
				submitted through the prior authorization electronic management system
				according to agency policy.
(3) Diagnosis and related
				information.
(4) Services or
				supplies requested with appropriate CPT, HCPCS, or American Dental Association
				code.
(5) Name of suggested
				provider of services or supplies.
(6) Date of onset of medical
				problems.
(7) Plan of
				treatment.
(8) Treatment
				goals.
(9) Rehabilitation potential
				(where indicated), except as set forth in
				405 IAC
				5-19-7(5).
(10) Prognosis (where indicated).
(11) Description of previous services or
				supplies provided, length of such services, or when supply or modality was last
				provided.
(12) Statement whether
				durable medical equipment will be purchased, rented, or repaired and the
				duration of need.
(13) Statement of
				any other pertinent clinical information that the provider deems necessary to
				justify that the treatment was medically necessary.
(14) Additional information may be required
				as needed for clarification, including, but not limited to, the following:
(A) X-rays.
(B) Photographs.
(C) Other services being received.
(15) Diagnosis code.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 3 - Prior Authorization › Section 3-6 - Telephone requests for prior authorization; contents

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-15-30-1
Sec. 6.
A telephone review shall include the following:
(1) Initiation of phone request by a provider
				authorized to request prior authorization as listed in section 10 of this
				rule.
(2) The name, address, age,
				and Medicaid number of the member.
(3) The name, address, telephone number, and
				provider number of the provider.
(4) Diagnosis and related
				information.
(5) Services or
				supplies requested (CPT or HCPCS code).
(6) Name of suggested provider of services or
				supplies.
(7) Member specific
				clinical information required to establish that the service is medically
				necessary, including the following:
(A) Prior
				history, including results of diagnostic studies.
(B) Prior treatment.
(C) Rationale for treatment plan.
(D) Comorbid conditions.
(E) Treatment plan.
(F) Progress.
(G) Date of onset of medical
				conditions.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 3 - Prior Authorization › Section 3-7 - Determination of member eligibility

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-15-30-1
Sec. 7.
The provider assumes responsibility for verifying the
				  member's eligibility on the service date.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 3 - Prior Authorization › Section 3-8 - Limitations

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-15-30-1
Sec. 8.
(a) Any
				Medicaid service requiring prior authorization, which is provided without first
				receiving prior authorization, shall not be reimbursed by Medicaid. Prior
				authorization will be monitored by concurrent or postpayment review.
(b) Any authorization of a service by the
				office is limited to authorization for payment of Medicaid allowable charges
				and is not an authorization of the provider's estimated fees.
(c) Notwithstanding any prior authorization
				by the office, the provision of all services and supplies shall comply with the
				provider agreement, the appropriate provider manual applicable at the time such
				services or supplies were provided, all other Medicaid policy documents issued
				to providers, and any applicable state or federal statute or regulation.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 3 - Prior Authorization › Section 3-9 - Prior authorization after services have begun

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-15-30-1
Sec. 9.
Prior authorization will be given after services have begun
				  or supplies have been delivered only under the following circumstances:
(1) Pending or retroactive member
				eligibility. The prior authorization request must be submitted within twelve
				(12) months of the date of the issuance of the member's Medicaid
				card.
(2) Mechanical or
				administrative delays or errors by the office.
(3) Services rendered outside Indiana by a
				provider who has not yet received a provider manual.
(4) Transportation services authorized under
				405 IAC 5-30. The prior
				authorization request must be submitted within twelve (12) months of the date
				of service.
(5) The provider was
				unaware that the member was eligible for services at the time services were
				rendered. Prior authorization will be granted in this situation only if the
				following conditions are met:
(A) The
				provider's records document that the member refused or was physically unable to
				provide the member identification (RID) number.
(B) The provider can substantiate that the
				provider continually pursued reimbursement from the patient until Medicaid
				eligibility was discovered.
(C) The
				provider submitted the request for prior authorization within sixty (60) days
				of the date Medicaid eligibility was discovered.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 3 - Prior Authorization › Section 3-10 - Providers who may submit prior authorization requests

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-15-30-1
Sec. 10.
Except as otherwise provided in this title, prior
				  authorization requests may be submitted by any of the following:
(1) Doctor of medicine.
(2) Doctor of osteopathy.
(3) Dentist.
(4) Optometrist.
(5) Podiatrist.
(6) Chiropractor.
(7) Psychologist endorsed as a health service
				provider in psychology (HSPP).
(8)
				Home health agency.
(9)
				Hospitals.
(10) For drugs subject
				to prior authorization, any provider with prescriptive authority under Indiana
				law.
Requests from other provider types will not be accepted
				  except for transportation services.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 3 - Prior Authorization › Section 3-11 - Criteria for prior authorization

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-15-30-1
Sec. 11.
The office's decision to authorize, modify, or deny a given
				  request for prior authorization shall include consideration of the
				  following:
(1) Individual case-by-case
				review of the completed Medicaid prior authorization request form.
(2) The medical and social information
				provided on the request form or documentation accompanying the request
				form.
(3) Review of criteria set
				out in this section for the service requested.
(4) If the service is medically necessary as
				defined in this article.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 3 - Prior Authorization › Section 3-12 - Prior authorization; exceptions

Current through July 10, 2024
Authority: IC 12-15
Affected: IC 12-15-30-1
Sec. 12.
Notwithstanding any other provision of this rule, prior
				  authorization by the office is not required under the following
				  circumstances:
(1) When a service is
				provided to a member as an emergency service, "emergency service" means a
				service provided after the sudden onset of a medical condition manifesting
				itself by acute symptoms of sufficient severity that the absence of immediate
				medical attention could reasonably be expected to result in:
(A) placing the patient's health in serious
				jeopardy;
(B) serious impairment to
				bodily functions; or
(C) serious
				dysfunction of any bodily organ or part.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 3 - Prior Authorization › Section 3-13 - Services requiring prior authorization

Current through July 10, 2024
Authority: IC 12-15
Affected: IC 12-13-7-3
Sec. 13.
(a) Medicaid
				reimbursement is available for the following services with prior authorization:
(1) Reduction mammoplasties.
(2) Rhinoplasty or bridge repair of the nose
				when related to a significant obstructive breathing problem.
(3) Intersex surgery.
(4) Blepharoplasties for a significant
				obstructive vision problem.
(5)
				Sliding mandibular osteotomies for prognathism or micrognathism.
(6) Reconstructive or plastic
				surgery.
(7) Bone marrow or stem
				cell transplants.
(8) All organ
				transplants covered by Medicaid.
(9) Home health services.
(10) Maxillofacial surgeries related to
				diseases and conditions of the jaws and contiguous structures.
(11) Temporomandibular joint
				surgery.
(12) Submucous resection
				of nasal septum and septoplasty when associated with significant
				obstruction.
(13) Weight reduction
				surgery, including gastroplasty and related gastrointestinal surgery.
(14) Any procedure ordinarily rendered on an
				outpatient basis, when rendered on an inpatient basis.
(15) All dental admissions.
(16) Brand medically necessary
				drugs.
(17) Psychiatric inpatient
				admissions, including admissions for substance abuse.
(18) Rehabilitation inpatient
				admissions.
(19) Orthodontic
				procedures for members under twenty-one (21) years of age for cases of
				craniofacial deformity or cleft palate.
(20) Genetic testing for detection of cancer
				of the breast or breasts or ovaries.
(21) Medicaid rehabilitation option services,
				except for crisis intervention.
(22) Partial hospitalization, as provided
				under 405 IAC 5-20-8.
(23) Neuropsychological and psychological
				testing.
(24) As otherwise
				specified in this article.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 3 - Prior Authorization › Section 3-14 - Prior authorization decision; time limit

Current through July 10, 2024
Authority: IC 12-15
Affected: IC
				  12-15-30-1
Sec. 14.
Decisions by the office regarding prior authorization will
				  be made as expeditiously as possible considering the circumstances of each
				  request. If no decision is made by the office for a completed prior
				  authorization request within seven (7) calendar days of receipt of all
				  documentation specified in sections 5 and 9(1) of this rule, authorization is
				  deemed to be granted within the coverage and limitations specified in this
				  article.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 5 - Out-of-State Services › Section 5-1 - Out-of-state services; general

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2; IC
				  12-15-21-3
Affected: IC 12-15; IC 12-17.6
Sec. 1.
(a) Medicaid
				reimbursement is available for services provided outside Indiana as determined
				by the office and subject to the restrictions outlined in this rule.
(b) Areas may be designated by the office as
				in-state in relation to prior authorization requirements and for the purposes
				of reimbursement under any of the following circumstances:
(1) To increase access to medically necessary
				services in areas where the distance to an in-state facility would subject the
				member, or member's family, to significant financial hardship or create an
				unnecessary significant burden on the Medicaid member.
(2) To allow members to retain a primary
				medical provider or obtain specialty services from a facility, such as centers
				of excellence, when the care may not be available from an in-state provider or
				would require significant hardship due to geographic location.
(3) Transportation to an appropriate Indiana
				facility would cause significant undue expense or hardship to the member or the
				office.
(4) To address an emergency
				health crisis.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 5 - Out-of-State Services › Section 5-2 - Prior authorization requirements for out-of-state services

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC 12-15; IC 12-17.6
Sec. 2.
(a) Services
				provided out-of-state require prior authorization except as follows:
(1) Emergency services provided out-of-state
				are exempt from prior authorization; however, continuation of inpatient
				treatment and hospitalization is subject to the prior authorization
				requirements of the office.
(2)
				Members of the adoption assistance program placed outside of Indiana will
				receive approval for all routine medical and dental care provided
				out-of-state.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 5 - Out-of-State Services › Section 5-3 - Out-of-state suppliers of medical equipment

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 3.
In order to be treated as an in-state provider for purposes
				  of prior authorization any out-of-state supplier of medical equipment must
				  comply with the following:
(1)
				Maintain an Indiana business office, staffed during regular business hours,
				with telephone service.
(2) Provide
				service, maintenance, and replacements for Indiana members whose equipment has
				malfunctioned.
(3) Qualify with the
				Indiana secretary of state as a foreign corporation.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 6 - Restricted Utilization › Section 6-1 - Restricted utilization; generally

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 1.
Certain members will have restricted utilization information
				  linked to their Medicaid cards when it has been determined that services must
				  be controlled. Providers or services that the member may or may not use can be
				  identified through the automated voice response or eligibility verification
				  system.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 6 - Restricted Utilization › Section 6-2 - Exceptions; emergency situations and referrals

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 2.
(a) A
				provider other than the one to whom the member is restricted may provide
				treatment to the member without a referral from the authorized provider if the
				diagnosis is an emergency diagnosis.
(b) A provider other than the one to whom the
				member is restricted may provide services to the member if the authorized
				provider has referred the member.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 7 - Administrative Review and Appeals of Prior Authorization Determinations › Section 7-1 - Appeals of prior authorization determinations

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 1.
(a) Members
				may appeal the denial or modification of prior authorization of any Medicaid
				covered service under 405 IAC 1.1.
(b) Any provider submitting a request for
				prior authorization under
				405 IAC 5-3, which has been
				denied either in whole or in part, may appeal the decision under 405 IAC 1.1
				after exhausting the administrative remedies provided in this rule.
(c) When there is insufficient information
				submitted to render a decision, a prior authorization request will be suspended
				for up to thirty (30) days, and the office will request additional information
				from the provider. Suspension is not a final decision on the merits of the
				request and is not appealable. If the provider does not submit the additional
				information requested within thirty (30) days, the request shall be denied.
				Denial is a final decision and may be appealed pursuant to subsections (a) and
				(b).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 7 - Administrative Review and Appeals of Prior Authorization Determinations › Section 7-2 - Provider requests for administrative review

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 2.
(a) A
				provider authorized to submit prior authorization requests who wishes review of
				denial or modification of a prior authorization decision must request an
				administrative review before filing an appeal under 405 IAC 1.1.
(b) An administrative review request must be
				initiated within seven (7) working days of the receipt of modification or
				denial by the provider who submitted the prior authorization request. The
				request shall be submitted in writing to the office; telephonic requests will
				not be accepted.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 7 - Administrative Review and Appeals of Prior Authorization Determinations › Section 7-3 - Conduct of administrative review

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 3.
(a) The
				Medicaid contractor will perform the review.
(b) The review will assess medical
				information pertinent to the case in question.
(c) The review decision of the Medicaid
				contractor will be rendered within seven (7) working days of request. The time
				limit for issuance of a decision does not commence until the provider submits a
				complete request, including all necessary documentation required by the
				contractor to render a decision.
(d) The requesting provider and member will
				receive written notification of the decision containing the following:
(1) The determination reached by the Medicaid
				contractor, and the rationale for the decision.
(2) Provider and member appeal rights through
				the office.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 8 - Consultations and Second Opinions › Section 8-1 - Reimbursement

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 1.
Medicaid reimbursement is available for consultations
				  subject to the limitations contained in this rule.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 8 - Consultations and Second Opinions › Section 8-2 - "Consultation" defined

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 2.
As used in this rule, "consultation" means the rendering of
				  a medical opinion by a physician for a specific member, regarding evaluation or
				  management of a condition, requested by another physician. It requires the
				  consultant physician to examine the patient, unless the applicable standard of
				  care does not require a physical examination. A confirmatory consultation means
				  a second or third opinion. Reimbursement is available for consultative
				  pathology and radiology services under
				  405 IAC 5-18 and
				  405 IAC 5-27, where the
				  consultant physician does not examine the patient.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 8 - Consultations and Second Opinions › Section 8-3 - Restrictions

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 3.
(a) A
				consultation cannot be used for the evaluation of a nonphysician referred or
				self-referred member.
(b) An office
				or other outpatient consultation must address a specific condition not
				previously diagnosed or managed by the consulting physician. If an additional
				request for an opinion or advice regarding the same or a new problem is
				received from the attending physician and documented in the medical record, the
				office consultation codes may be used by the consulting physician
				again.
(c) Reimbursement for an
				initial consultation is limited to one (1) per consultant, per member, per
				inpatient hospital or nursing facility admission.
(d) Follow-up inpatient consultations may be
				billed if visits are needed to complete the initial consultation, or if
				subsequent consultative visits are requested by the attending physician. These
				consultative visits include monitoring progress, recommending management
				modifications, or advising on a new plan of care in response to changes in the
				patient's status.
(e) Reimbursement
				is not available if a member is referred for management of a condition or the
				consulting physician assumes patient management.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 8 - Consultations and Second Opinions › Section 8-4 - Confirmatory consultations

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 4.
(a) A
				confirmatory consultation is the rendering of a second or third medical
				opinion, completed by a physician for a specific member, regarding evaluation
				or management of a condition.
(b) A
				confirmatory consultation may be billed to Medicaid only when it is
				specifically requested by another physician or the office.
(c) A confirmatory consultation to
				substantiate that the service is medically necessary may be required as part of
				the prior authorization process.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 9 - Evaluation and Management Services › Section 9-1 - Limitations

Current through July 10, 2024
Authority: IC 12-15
Affected: IC
				  12-13-7-3
Sec. 1.
Medicaid reimbursement is available for office visits
				  limited to a maximum of thirty (30) per calendar year, per member, per provider
				  without prior authorization and subject to the restrictions in section 2 of
				  this rule.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 9 - Evaluation and Management Services › Section 9-2 - Restrictions

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 2.
(a) Office
				visits should be appropriate to the diagnosis and treatment given and properly
				coded.
(b) New patient office
				visits are limited to one (1) per member, per provider within the last three
				(3) years. For purposes of this subsection, "new patient" means one who has not
				received any professional services from the provider or another provider of the
				same specialty who belongs to the same group practice within the last three (3)
				years.
(c) If a physician uses an
				emergency room as a substitute for his or her office for nonemergency services,
				these visits should be billed as an office visit and will be reimbursed as
				such.
(d) If a surgical procedure
				is performed during the course of an office visit, it should be considered that
				the surgical fee includes the medical visit unless the member has never been
				seen by the provider prior to the surgical procedure, or the determination to
				perform surgery is made during the evaluation of the patient. If an evaluation
				of a separate clinical condition is performed on the same day as the surgery,
				both the evaluation and the surgery may be separately billed.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 9 - Evaluation and Management Services › Section 9-3 - Office visits exceeding established parameters

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2; IC
				  12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 3.
Medicaid reimbursement is available for office visits
				  exceeding the established parameters subject to prior authorization
				  requirements at
				  405 IAC 5-3.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 10 - Anesthesia Services › Section 10-1 - Providers eligible for reimbursement

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-15-2; IC
				  12-15-5; IC
				  12-15-30; IC
				  25-22.5-1-2
Sec. 1.
Anesthesia is a Medicaid covered service only when rendered
				  by the following providers:
(1) An
				Indiana Medicaid enrolled physician other than the operating surgeon or
				surgeon's assistant.
(2) An Indiana
				Medicaid enrolled practitioner who has a license that allows him or her to
				administer anesthesia under Indiana law.
(3) An Indiana Medicaid enrolled certified
				registered nurse anesthetist who practices within the scope of practice of his
				or her profession in accordance with IC
				25-22.5-1-2(a)(13)
				 and who holds a certificate from either the
				Council on Certification of Nurse Anesthetists or the Council on
				Recertification of Nurse Anesthetists.
(4) An Indiana Medicaid enrolled
				anesthesiologist assistant who is in compliance with all applicable
				requirements of state law, including any licensure requirements the state
				imposes on nonphysician anesthetists and who is a graduate of an educational
				program that meets all of the following criteria:
(A) Accredited by the Committee on Allied
				Health Education and Accreditation.
(B) Based at a medical school.
(C) Is of at least two (2) years in duration
				and included clinical and theory based anesthesia education.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 10 - Anesthesia Services › Section 10-2 - "Anesthetist" defined

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-15-2; IC
				  12-15-5; IC
				  12-15-30; IC
				  25-22.5-1-2
Sec. 2.
As used in this rule, "anesthetist" means an
				  anesthesiologist assistant (AA) or a certified registered nurse anesthetist
				  (CRNA).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 10 - Anesthesia Services › Section 10-3 - Reimbursement parameters

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-15-2; IC
				  12-15-5; IC
				  12-15-30; IC
				  25-22.5-1-2
Sec. 3.
(a) Services
				rendered by an anesthetist shall be reimbursed as follows:
(1) Directly to the CRNA, provided that the
				CRNA has a provider number based on current state registered nurse licensure
				and is certified or recertified by the Council on Certification of Nurse
				Anesthetists at the time services were rendered.
(2) Directly to the AA, provided that the AA
				has a provider number based upon a current state license.
(3) To an anesthesiologist or a professional
				corporation employing the anesthetist or anesthesiologist at the time services
				were rendered.
(4) To a hospital or
				other health care facility employing the anesthetist or anesthesiologist at the
				time services were rendered.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 10 - Anesthesia Services › Section 10-4 - Anesthesia administered during labor/delivery

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-15-2; IC 12-15-5; IC 12-15-30; IC
				  25-22.5-1-2
Sec. 4.
Anesthesia administered by the attending physician, during
				  labor or delivery (spinals, epidurals, pudendal, caudal, paracervical blocks,
				  etc.) are considered to be part of the delivery fee. If the anaesthesia is
				  administered by another licensed anesthesia provider, that is, physician,
				  anesthesiologist, or anesthetist, payment will be allowed for the procedures
				  listed in this section under
				  405 IAC 1-11.5.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 10 - Anesthesia Services › Section 10-5 - Noncovered services

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-15-2; IC
				  12-15-5; IC
				  12-15-30; IC
				  25-22.5-1-2
Sec. 5.
The following services are not reimbursed separately under
				  Medicaid when provided in conjunction with anesthesia services:
(1) Noninvasive electrocardiogram
				monitoring.
(2) Blood pressure
				monitoring.
(3) Monitoring of data
				scope.
(4) Intubation factor
				postoperative.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 12 - Chiropractic Services › Section 12-1 - Reimbursement

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2; IC
				  12-15-21-3
Affected: IC 12-13-7-3; IC 12-15; IC 25-10-1-1
Sec. 1.
(a) Medicaid
				reimbursement is available for covered services provided by a licensed
				chiropractor, enrolled as a provider, when rendered within the scope of the
				practice of chiropractic as defined in IC 25-10-1-1 and
				846 IAC 1-3, subject to the
				restrictions and limitations as described in the rule.
(b) Reimbursement is not available for any
				chiropractic services provided outside the scope of IC 25-10-1-1 and
				846 IAC 1-3, or for any
				chiropractic service for which federal financial participation is not
				available.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 12 - Chiropractic Services › Section 12-2 - Office visits

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15; IC
				  25-10-1-1
Sec. 2.
Medicaid reimbursement is available for chiropractic office
				  visits and spinal manipulation treatments or physical medicine treatments,
				  subject to the following restrictions:
(1) Reimbursement is limited to a total of
				fifty (50) office visits or treatments per member per year, which includes a
				maximum reimbursement of no more than five (5) office visits per member per
				year.
(2) Reimbursement is not
				available for the following types of extended or comprehensive office visits:
(A) New patient detailed.
(B) New patient comprehensive.
(C) Established patient detailed.
(D) Established patient comprehensive.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 12 - Chiropractic Services › Section 12-3 - Chiropractic x-ray services

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15; IC
				  25-10-1-1
Sec. 3.
Medicaid reimbursement is available for chiropractic x-ray
				  services, subject to the following restrictions:
(1) Reimbursement is limited to one (1)
				series of full spine x-rays per member per year. Component x-rays of the series
				are individually reimbursable; however, if components are billed separately,
				total reimbursement is limited to the allowable amount for the series. Prior
				authorization is not required.
(2)
				Reimbursement for localized spine series x-rays, and for x-rays of the joints
				or extremities, is allowable only when the x-rays are necessitated by a
				condition-related diagnosis. Prior authorization is not required.
(3) Diagnostic radiological exams of the head
				and vascular system, as defined by the applicable procedure code, are not
				reimbursable.
(4) Diagnostic
				ultrasound exams, as defined by the applicable procedure code, are not
				reimbursable.
(5) X-rays that may
				be necessitated by the failure of another practitioner to forward, upon
				request, x-rays or related documentation to a chiropractic provider, are not
				reimbursable. Chiropractors are entitled to receive x-rays from other providers
				at no charge to the member upon a member's written request to the other
				providers and upon reasonable notice.