reglab/statecodes huggingface dataset:
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 12 - Chiropractic Services › Section 12-4 - Laboratory 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. 4.
Laboratory services are reimbursable only when such services
				  are necessitated by a condition-related diagnosis.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 12 - Chiropractic Services › Section 12-5 - Muscle testing 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. 5.
Muscle testing services, either manual or electrical, are
				  reimbursable only if prior authorization has been obtained.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 12 - Chiropractic Services › Section 12-7 - Durable 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; IC
				  25-10-1-1
Sec. 7.
Medicaid reimbursement is not available for durable medical
				  equipment (DME) provided by chiropractors.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 13 - Intermediate Care Facilities for the Mentally Retarded › Section 13-1 - Policy; definitions

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 12-15-32
Sec. 1.
(a) Medicaid
				reimbursement is available for services provided by a certified intermediate
				care facility for individuals with intellectual disabilities (ICF/IID) when
				such services have been rendered to a member whose reimbursement has been
				approved by the office. Such services must be provided in accordance with IC
				12-15-32, 42 CFR
				483.400-480, and this rule.
(b) As used in this rule, "small ICF/IID"
				means a certified intermediate care facility for individuals with intellectual
				disabilities that:
(1) provides ICF/IID
				services for not less than four (4) and not more than eight (8) developmentally
				disabled persons in a residential setting; and
(2) meets the federal requirements for an
				ICF/IID group home.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 13 - Intermediate Care Facilities for the Mentally Retarded › Section 13-2 - 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
Sec. 2.
(a) Medicaid
				reimbursement is available for services provided by a state owned ICF/IID in
				accordance with
				405 IAC 1-4.
(b) Medicaid reimbursement is available for
				services provided by a large private or small ICF/IID in accordance with
				405 IAC 1-12.
(c) The ICF/IID per diem rate covers those
				services and products furnished by the facility for the usual care and
				treatment of such patients.
(d)
				Requests for reimbursement of ICF/IID services shall be expressed in units of
				full days. A day begins at midnight and ends twenty-four (24) hours later. The
				midnight-to-midnight method is to be used when reporting days of service, even
				if the health facility uses a different definition for statistical or other
				purposes. The day of discharge is not covered.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 13 - Intermediate Care Facilities for the Mentally Retarded › Section 13-3 - Services included in the per diem rate for large private and small ICFs/IID

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.
The per diem rate for large private and small ICFs/IID shall
				  include the following services:
(1)
				Room and board, which includes the following:
(A) Routine and special dietary
				services.
(B) Personal laundry
				services.
(C) Room
				accommodations.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 13 - Intermediate Care Facilities for the Mentally Retarded › Section 13-4 - Services included in the per diem rate for large state ICFs/MR; exceptions

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. 4.
(a) The per
				diem rate for a large state ICF/MR shall include the following services:
(1) Room and board (room accommodations,
				dietary services, and laundry services).
(2) Medical services.
(3) Mental health services.
(4) Dental services.
(5) Therapy and habilitation
				services.
(6) Durable medical
				equipment (DME).
(7) Medical and
				nonmedical supplies.
(8)
				Pharmaceutical products.
(9)
				Transportation.
(10) Optometric
				services.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 13 - Intermediate Care Facilities for the Mentally Retarded › Section 13-5 - Prior authorization for services rendered outside the large state ICF/MR

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. 5.
(a) Medical
				care rendered by practitioners outside the large state ICF/MR requires prior
				authorization.
(b) Prior
				authorization will not be given for medical services included in the per diem
				rate.
(c) Written evidence of
				physician involvement and personal patient evaluation in the progress notes and
				attached to the prior authorization form is required to document the medical
				necessity of the service.
(d) Prior
				authorization will include consideration of the following:
(1) Review of the properly completed Medicaid
				prior review and authorization request form substantiating both of the
				following:
(A) Medical necessity of the
				service.
(B) Explanation of why the
				service cannot be rendered at the facility.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 13 - Intermediate Care Facilities for the Mentally Retarded › Section 13-6 - Reserving beds

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. 6.
(a) Medicaid
				reimbursement is available for reserving beds in an ICF/IID for members, at
				one-half (1/2) the regular per diem rate, when one (1) of the following
				conditions is present:
(1) Hospitalization
				must be ordered by the physician for treatment of an acute condition that
				cannot be treated in the facility. The total length of time allowed for payment
				of a reserved bed for a single hospital stay shall be fifteen (15) days. If the
				member requires hospitalization longer than the fifteen (15) consecutive days,
				the member must be discharged from the facility. If the member is discharged
				from the ICF/IID following a hospitalization in excess of fifteen (15)
				consecutive days, the ICF/IID is still responsible for appropriate discharge
				planning if the ICF/IID does not intend to provide ongoing services following
				the hospitalization for those individuals who continue to require ICF/IID level
				of services. A physician's order for hospitalization must be maintained in the
				member's file at the facility.
(2)
				A leave of absence must be for therapeutic reasons, as prescribed by the
				attending provider and as indicated in the member's habilitation plan. The
				total length of time allotted for therapeutic leaves in any calendar year shall
				be sixty (60) days per member residing in an ICF/IID. The leave days need not
				be consecutive. If the member is absent for more than sixty (60) days per year,
				no further Medicaid reimbursement shall be available for reserving a bed for
				that member in that year. A physician's order for the therapeutic leave must be
				maintained in the member's file at the facility.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 13 - Intermediate Care Facilities for the Mentally Retarded › Section 13-8 - Admission to large state ICFs/IID

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
				  12-15-5; IC
				  12-15-30
Sec. 8.
Admissions to large state ICFs/IID shall be based upon a
				  determination of the need for such care by the division of disability, aging,
				  and rehabilitative services/bureau of developmental disabilities services. The
				  interdisciplinary professional team from the proposed placement facility, as
				  required by federal law, shall review the comprehensive evaluation covering
				  physical, emotional, social, and cognitive factors to ensure the member's needs
				  are met. The office must authorize the reimbursement of each member prior to
				  the first Medicaid payment.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 13 - Intermediate Care Facilities for the Mentally Retarded › Section 13-10 - Transfer to another ICF/IID

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. 10.
(a) A form
				as prescribed by
				405 IAC 5-13-7(d)(3)
[section 7(d)(3) of this rule]
must be submitted to the office for any transfer to another ICF/IID
				facility. If a diagnosis and evaluation was completed within the last twelve
				(12) months prior to the date of transfer, it must be submitted.
(b) Each facility is a separate provider and
				is issued an individual provider number. Each facility must use its assigned
				provider number. Therefore, transfers between facilities must be done in
				accordance with procedures outlined in this section.
(c) For large state ICFs/IID, if the
				recipient is transferred to a noncertified unit, the admission procedure as
				described in section 8 of this rule must be followed for any readmission to the
				large state ICF/IID in order to determine reimbursement.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 14 - Dental Services › Section 14-1 - Policy

Current through July 10, 2024
Authority: IC 12-15
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 1.
(a) Medicaid
				reimbursement is available only for those dental services listed in section 2
				of this rule subject to the limitations set out in this rule.
(b) For those members twenty-one (21) years
				of age and over, all covered services will require prior authorization except
				the following:
(1) Diagnostic and preventative
				services.
(2) Direct
				restorations.
(3) Treatment of
				lesions.
(4) Periodontal services
				for the following immuno-compromised individuals:
(A) Transplant patients.
(B) Pregnant women.
(C) Diabetic patients.
(5) Extractions.
(6) Emergency and trauma care.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 14 - Dental Services › Section 14-2 - Covered 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
Sec. 2.
The following are covered dental services under
				  Medicaid:
(1) Evaluations.
(2) Radiographs.
(3) Prophylaxis.
(4) Topical fluoride for members twenty (20)
				years of age and younger.
(5)
				Sealant for permanent molars and premolars for members twenty (20) years of age
				and younger.
(6) Amalgam.
(7) Unilateral and bilateral space
				maintainers for members twenty (20) years of age and younger.
(8) Resin anteriors and posteriors.
(9) Recement crowns.
(10) Steel crown primary.
(11) Stainless steel crown
				permanent.
(12) Therapeutic
				pulpotomy.
(13)
				Extractions.
(14) Oral
				biopsies.
(15)
				Alveoplasty.
(16) Excision of
				lesions.
(17) Excision of benign
				tumor.
(18) Odontogenic cyst
				removal.
(19) Nonodontogenic cyst
				removal.
(20) Incise and drain
				abscess.
(21) Fracture simple
				stabilize.
(22) Compound fracture
				of the mandible.
(23) Compound
				fracture of the maxilla.
(24)
				Repair of wounds.
(25)
				Suturing.
(26) Emergency treatment
				dental pain.
(27) Analgesia for
				members twenty (20) years of age and younger.
(28) Drugs and medicaments.
(29) Periodontic procedures.
(30) Other dental services as medically
				necessary to treat members eligible for the EPSDT program.
(31) General anesthesia.
(32) Intravenous (IV) sedation covered only
				for oral surgical services.
(33)
				Dentures and partials.
(34)
				Orthodontic services for members twenty (20) years of age and under
				only.
(35) Physician fluoride
				varnish services for members younger than four (4) years of age.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 14 - Dental Services › Section 14-3 - Diagnostic 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
Sec. 3.
Medicaid reimbursement is available for diagnostic services,
				  including initial and periodic evaluations, prophylaxis, radiographs, and
				  emergency treatments, with the following limitations:
(1) Either a full mouth series or panorex is
				limited to one (1) set per member every three (3) years.
(2) Bitewing radiographs are limited to one
				(1) set per member every twelve (12) months. One (1) set of bitewings is
				defined as either:
(A) four (4) horizontal
				films; or
(B) seven (7) to eight
				(8) vertical films.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 14 - Dental Services › Section 14-4 - Topical fluoride

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. 4.
Reimbursement is available for one (1) topical application
				  of fluoride every six (6) months per member from the time of first tooth
				  eruption. Topical applications of fluoride are not covered for members
				  twenty-one (21) years of age or older. Brush-in fluoride (topical application
				  of fluoride phosphate) is not a covered service.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 14 - Dental Services › Section 14-5 - Treatment of dental caries

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. 5.
Treatment of dental caries with amalgam, composites, or
				  resin restorations or stainless steel crowns is covered. The use of pit
				  sealants on permanent molars and premolars only is a covered service for
				  members under twenty-one (21) years of age. There is a limit of one (1)
				  treatment per tooth, per lifetime. Margination of restorations and occlusal
				  adjustments are not covered.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 14 - Dental Services › Section 14-6 - Prophylaxis

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. 6.
Prophylaxis is a covered service in accordance with the
				  following limitations:
(1) One (1)
				unit every six (6) months for noninstitutionalized members twelve (12) months
				of age up to their twenty-first birthday.
(2) One (1) unit every twelve (12) months for
				noninstitutionalized members twenty-one (21) years of age and older.
(3) Institutionalized members may receive up
				to one (1) unit every six (6) months.
(4) Prophylaxis is not covered for members
				under twelve (12) months of age.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 14 - Dental Services › Section 14-7 - Periodontal root planing and scaling

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. 7.
Periodontal root planing and scaling for members over three
				  (3) years of age and under twenty-one (21) years of age, or for
				  institutionalized members, is limited to four (4) units every two (2) years.
				  For noninstitutionalized members twenty-one (21) years of age and older,
				  periodontal root planing and scaling is limited to four (4) units per lifetime.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 14 - Dental Services › Section 14-8 - Extractions

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. 8.
Medicaid reimbursement is available for extraction of teeth.
				  Extraction of teeth must be medically necessary, and the diagnosis must support
				  extraction. If multiple extractions are performed on the same date of service,
				  the maximum allowable payment for additional teeth will be reduced by ten
				  percent (10%) of the maximum allowable for the first tooth. Payment for
				  preoperative and postoperative care is included in the allowance for the
				  operative procedure and may not be billed separately to Medicaid. Payment for
				  placement of sutures or tissue trim, or both, in simple extractions is included
				  in the reimbursement fee for the extractions and may not be billed separately
				  to Medicaid.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 14 - Dental Services › Section 14-9 - Space maintenance

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. 9.
Medicaid reimbursement is available for space maintenance in
				  children with deciduous molar teeth subject to the following
				  restrictions:
(1) Space maintenance
				for children under three (3) years of age requires prior authorization by the
				office. Space maintenance for missing permanent teeth requires prior
				authorization by the office.
(2)
				Adjustment to space maintainers, bands, and all other appliances is included in
				the reimbursement for the service and may not be billed separately to
				Medicaid.
(3) All requests for
				prior authorization will be reviewed on a case-by-case basis by the
				contractor.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 14 - Dental Services › Section 14-11 - Analgesia

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. 11.
Nitrous oxide analgesia is covered only for those twenty
				  (20) years of age and younger. Preanesthetic medication is a covered service
				  for all ages.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 14 - Dental Services › Section 14-12 - Infection control

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. 12.
Infection control is not a covered service. All routine
				  supplies and services should be included in the reimbursement amount for the
				  procedure.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 14 - Dental Services › Section 14-13 - Emergency treatment of dental pain

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. 13.
Palliative treatment of facial pain, such as abscess,
				  incision, and drainage, is limited to emergency treatment only.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 14 - Dental Services › Section 14-14 - 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
Sec. 14.
Payment for office visits is not covered. Reimbursement is
				  available only for covered services actually performed. Covered services
				  provided outside the office will be reimbursed at the fee allowed for the same
				  service provided in the office.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 14 - Dental Services › Section 14-15 - General anesthesia and intravenous sedation

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. 15.
(a) Medicaid
				reimbursement is available for general anesthesia. General anesthesia for
				members twenty-one (21) years of age and older may only be provided in a
				hospital (inpatient or outpatient) or ambulatory surgical center and must
				include documentation of the following in the patient's record to be eligible
				for reimbursement:
(1) Specific reasons why
				such services are needed, including specific justification if such services are
				to be provided on an outpatient basis.
(2) Documentation that the member cannot
				receive necessary dental services unless general anesthesia is administered.
				For example, a member may be unable to cooperate with the dentist due to
				physical or mental disability.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 14 - Dental Services › Section 14-16 - Periodontics; surgical

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. 16.
Periodontic surgery is a covered service only for cases of
				  drug-induced periodontal hyperplasia. Documentation in the patient's record
				  must substantiate that the service was provided for drug-induced periodontal
				  hyperplasia.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 14 - Dental Services › Section 14-17 - Oral surgery

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. 17.
No oral surgical procedures shall be reimbursed other than
				  those listed in this rule and as defined by provider bulletin. Placement of
				  sutures or tissue trim, or both, in a simple extraction does not constitute a
				  surgical extraction. Multiple simple extractions with placement of sutures or
				  tissue trim, or both, performed in either office or hospital shall not be
				  reimbursed as surgical extractions. Payment of preoperative and postoperative
				  care is included in the reimbursement for the operative procedure and may not
				  be billed separately to Medicaid.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 14 - Dental Services › Section 14-18 - Hospital admissions for covered dental services or procedures

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. 18.
The patient's record must document that admission of a
				  member to a hospital for the purpose of performing any elective dental service,
				  or any elective dental service performed on an inpatient basis, is a medically
				  necessary service.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 14 - Dental Services › Section 14-19 - Prior authorization for early and periodic screening, diagnostic, and treatment covered 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
Sec. 19.
Prior authorization must be obtained for services not listed
				  in section 2 of this rule but which are medically necessary to treat members
				  eligible for the EPSDT.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 14 - Dental Services › Section 14-20 - Dental services provided in a state owned ICF/IID

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. 20.
Dental services that can be provided in a state owned
				  ICF/IID shall be included in the per diem rate and do not require prior
				  authorization. Necessary dental services that cannot be provided on-site by the
				  dental staff require prior authorization according to the following:
(1) Dental services prior authorized by the
				contractor must be billed to Medicaid directly by the outside dental
				provider.
(2) Prior authorization
				shall not be given for dental services provided off-site that are included
				within the per diem rate.
(3)
				Documentation on the Medicaid dental prior authorization request must
				substantiate:
(A) the dental service is
				medically necessary; and
(B) an
				explanation of why the service cannot be rendered at the facility.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 14 - Dental Services › Section 14-21 - Maxillofacial surgery

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. 21.
Providers shall be required, based upon the facts of the
				  case, to obtain a second or third opinion substantiating the medically
				  necessary service or approach for maxillofacial surgery related to diseases and
				  conditions of the jaws and contiguous structures. The second opinion is
				  required regardless of the surgical setting in which the surgery is to be
				  performed, such as an ambulatory surgical treatment center, a hospital, or a
				  clinic.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 15 - Early and Periodic Screening, Diagnostic, and Treatment Services › Section 15-1 - Policy

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.
EPSDT is a federally mandated preventive health care program
				  covered by Medicaid. The purpose of EPSDT is to facilitate the introduction of
				  young members into a continuing health care system that will detect
				  abnormalities before such abnormalities become chronic or debilitating. EPSDT
				  program services are covered by Medicaid subject to the limitations set forth
				  in this rule.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 15 - Early and Periodic Screening, Diagnostic, and Treatment Services › Section 15-2 - Initial screening

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.
An initial screening shall be performed by the EPSDT
				  screening provider when referred by the office or upon the initial request of
				  the member for EPSDT services in accordance with the Indiana EPSDT program
				  recommended screening procedures schedule (hereafter referred to as periodicity
				  schedule). A screening or any portion of a screening is not required where
				  medical contraindications are documented.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 15 - Early and Periodic Screening, Diagnostic, and Treatment Services › Section 15-3 - Periodic screening

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) Periodic
				screenings shall be provided by the EPSDT screening provider in accordance with
				the office's EPSDT periodicity schedule as long as the member chooses to
				participate in the EPSDT program, or until the member reaches his or her
				twenty-first birthday.
(b) A
				periodic screening shall include the following:
(1) A comprehensive health and developmental
				history, including assessment of both physical and mental health
				development.
(2) A comprehensive
				unclothed physical exam.
(3) A
				nutritional assessment.
(4) A
				developmental assessment.
(5)
				Appropriate vision and hearing testing.
(6) Dental screening.
(7) Health education, including anticipatory
				guidance.
(8) In addition to the
				required procedures listed in this subsection, the periodic screening shall
				include administration of or referral for any other test, procedure, or
				immunization that is medically necessary or clinically indicated.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 15 - Early and Periodic Screening, Diagnostic, and Treatment Services › Section 15-4 - Treatment

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.
Any treatment found medically necessary as a result of a
				  diagnosis pursuant to an initial or periodic screening may be provided subject
				  to any prior authorization requirements for the services set out in this
				  article. However, if a service is not covered under the state plan, it is still
				  available to EPSDT eligible members subject to prior authorization requirements
				  if it is medically necessary to correct or ameliorate defects and physical and
				  mental illnesses and conditions discovered by the screening services.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 15 - Early and Periodic Screening, Diagnostic, and Treatment Services › Section 15-5 - Prior authorization

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. 5.
Prior authorization is not required for screening services.
				  Treatment services are subject to the same prior authorization requirements for
				  the services as set out in this article.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 15 - Early and Periodic Screening, Diagnostic, and Treatment Services › Section 15-6 - Member and provider participation

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. 6.
(a) Any
				member under twenty-one (21) years of age may participate in the EPSDT program.
				Each member will be informed about the program by the office in accordance with
				federal regulations. Participation in EPSDT by members is voluntary.
(b) Individual physicians, physician group
				practices, hospitals, or physician-directed clinics who are enrolled as
				providers may provide a complete EPSDT screen.
(c) Any enrolled provider may provide EPSDT
				diagnostic and/or treatment services within the scope of his or her practice
				upon referral from the screening provider.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 15 - Early and Periodic Screening, Diagnostic, and Treatment Services › Section 15-7 - Screening 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. 7.
Providers of services who perform screening or treatment
				  services as a result of an EPSDT screening referral shall be subject to the
				  same limitations for such services as set out in this article.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 15 - Early and Periodic Screening, Diagnostic, and Treatment Services › Section 15-8 - EPSDT periodicity and screening schedule

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. 8.
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Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 16 - Home Health Agency and Clinic Services › Section 16-1 - Providers eligible for 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.
Services provided to a member by:
(1) home health agencies;
(2) clinics;
(3) federally qualified health
				centers;
(4) free-standing surgical
				centers;
(5) therapy
				centers;
(6) rehabilitation
				centers; or
(7) other such
				facilities;
are covered subject to the limitations set out in this rule
				  and 405 IAC 5-22.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 16 - Home Health Agency and Clinic Services › Section 16-2 - Home health agency services

Current through July 10, 2024
Authority: IC 12-15
Affected: IC 12-13-7-3
Sec. 2.
(a) Medicaid
				reimbursement is available to home health agencies for:
(1) skilled nursing services provided by a
				registered nurse or licensed practical nurse;
(2) home health aide services;
(3) physical, occupational, and respiratory
				therapy services;
(4) speech
				pathology services;
(5) renal
				dialysis; and
(6) telehealth
				services;
when such services are provided within the limitations listed
				  in sections 3 and 3.1 of this rule.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 16 - Home Health Agency and Clinic Services › Section 16-3 - Prior authorization for home health agency services; 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. 3.
(a) All home
				health services require prior authorization by the office, except the
				following:
(1) Services provided by a
				registered nurse, licensed practical nurse, or home health aide, which have
				been ordered in writing by a physician prior to the patient's discharge from a
				hospital, and that do not exceed one hundred twenty (120) units within thirty
				(30) calendar days of discharge from a hospital. These services may not
				continue beyond thirty (30) calendar days unless prior authorization is
				received.
(2) Any combination of
				therapy services ordered in writing by a provider in accordance with
				405 IAC 5-22-6(b)(1)
				 prior to the patient's discharge from a
				hospital and that do not exceed thirty (30) units within thirty (30) calendar
				days of discharge from a hospital. These services may not continue beyond
				thirty (30) calendar days unless prior authorization is
				received.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 16 - Home Health Agency and Clinic Services › Section 16-3.1 - Home health agency services; limitations

Current through July 10, 2024
Authority: IC 12-15
Affected: IC 12-13-7-3; IC 12-15-13-6
Sec. 3.1.
(a) In
				addition to the prior authorization requirements as outlined in section 3 of
				this rule, services provided by a registered nurse, licensed practical nurse,
				home health aide, or renal dialysis aide employed by a home health agency must
				be as follows:
(1) Prescribed or ordered in
				writing by a physician.
(2)
				Provided in accordance with a written plan of treatment developed by the
				attending physician.
(3)
				Intermittent or part time, except for ventilator-dependent patients who have a
				developed plan of home health care.
(4) Health-related nursing care. Homemaker,
				chore services, and sitter/companion service are not covered, except as
				specified under applicable Medicaid waiver programs.
(5) Medically necessary.
(6) Less expensive than any alternate modes
				of care.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 16 - Home Health Agency and Clinic Services › Section 16-4 - Rehabilitation center services; limitations

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.
Medicaid reimbursement is available for rehabilitation
				  center services provided by appropriately licensed, certified, or registered
				  staff members subject to the following limitations:
(1) All rehabilitation center services
				require prior authorization by the department, except those services ordered in
				writing by a physician prior to the patient's discharge from a hospital. Any
				combination of therapy services ordered in writing may not exceed thirty (30)
				hours, sessions, or visits in thirty (30) calendar days unless prior
				authorization is obtained from the department.
(2) All services must be ordered in writing
				by a physician.
(3) All services
				must be provided in accordance with a written plan of care developed
				cooperatively between the therapist or psychologist and the attending
				physician.
(4) All services must be
				medically necessary. Educational services, including, but not limited to, the
				remediation of learning disabilities are not covered by Medicaid.
(5) All therapies provided in a
				rehabilitation center must be provided in accordance with
				405 IAC 5-22.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 16 - Home Health Agency and Clinic Services › Section 16-5 - Rural health clinics and federally qualified health clinics; 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. 5.
Medicaid reimbursement is available to rural health clinics
				  (RHCs) and federally qualified health clinics (FQHCs) for services provided by
				  the following providers:
(1) A
				physician.
(2) A physician
				assistant.
(3) A nurse
				practitioner.
(4) A clinical
				psychologist.
(5) A clinical social
				worker. Reimbursement is also available for services and supplies incident to
				such services as would otherwise be covered if furnished by a physician or as
				an incident to a physician's services. Services to a homebound individual are
				only available in the case of those FQHCs that are located in an area that has
				a shortage of home health agencies as determined by the office. Any other
				ambulatory service included in the Medicaid state plan is considered a covered
				FQHC service if the FQHC offers such a service. FQHC services are defined the
				same as the services provided by RHCs.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 16 - Home Health Agency and Clinic Services › Section 16-6 - Freestanding clinics and surgical centers; limitations

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. 6.
Medicaid reimbursement is available to freestanding clinics
				  and surgical centers for services provided to members subject to the following
				  limitations:
(1) Prior authorization
				is required for all services and supplies the charges for which exceed the cost
				limits or utilization parameters set out in this article.
(2) Medicaid reimbursement is not available
				for facility charges if the services provided are such that they ordinarily
				could have been provided in a physician's office. Such services provided
				outside a physician's office will be reimbursed at the fee allowed for the same
				service provided in the office.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 16.5 - Freestanding Birthing Center Services › Section 16.5-1 - Definitions

Current through July 10, 2024
Authority: IC 12-8-6.5-5; IC 12-15
Affected: IC 12-13-7-2; IC 16-18-2-36.5; IC 16-21-2; IC
				  25-23-1-13.1
Sec. 1.
(a) The
				definitions in this section apply throughout this rule.
(b) "Certified nurse midwife" means a person
				licensed to practice as a nurse midwife under IC 25-23-1-13.1.
(c) "Freestanding birthing center" means a
				health facility that is:
(1) not a hospital
				licensed under IC 16-21-2;
(2)
				where childbirth is planned to occur away from a pregnant woman's
				residence;
(3) licensed or
				otherwise approved by the state to provide prenatal labor and delivery or
				postpartum care and other ambulatory services; and
(4) intended for the sole purpose of
				delivering a normal, uncomplicated, or low-risk pregnancy.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 16.5 - Freestanding Birthing Center Services › Section 16.5-2 - Policy; scope

Current through July 10, 2024
Authority: IC
				  12-8-6.5-5; IC 12-15
Affected: IC
				  12-13-7-2
Sec. 2.
(a) The
				purpose of this rule is to establish a reimbursement methodology for services
				provided by freestanding birthing centers covered by Medicaid.
(b) A provider's continued participation in
				Medicaid and the receipt of payment for services are contingent on the
				provider's:
(1) maintaining state licensure of
				the birthing center; and
(2)
				conforming with:
(A) the provider agreement
				entered into by the provider and the office; and
(B) this rule.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 16.5 - Freestanding Birthing Center Services › Section 16.5-3 - Reimbursement

Current through July 10, 2024
Authority: IC 12-8-6.5-5; IC 12-15
Affected: IC 12-13-7-2
Sec. 3.
(a) Covered
				freestanding birthing center services shall be reimbursed in accordance with
				this section.
(1) Services, including prenatal
				labor and delivery, that would otherwise be performed in a hospital setting
				shall be reimbursed to a freestanding birthing center at a flat rate determined
				by the office.
(2) A labor
				management fee when the patient is transferred to a hospital before the
				delivery is completed shall be paid to a freestanding birthing center at a flat
				rate determined by the office.
(3)
				The services of physicians and certified nurse midwives shall be reimbursed in
				accordance with
				405 IAC
				1-11.5.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 16.5 - Freestanding Birthing Center Services › Section 16.5-4 - Limitations

Current through July 10, 2024
Authority: IC
				  12-8-6.5-5; IC 12-15
Affected: IC
				  12-13-7-2
Sec. 4.
(a) Services
				provided in a birthing center shall be limited in the following manner:
(1) A member must be considered as having a
				normal, uncomplicated, or low-risk pregnancy.
(2) A delivery shall be performed by a:
(A) certified nurse midwife; or
(B) physician.
(3) Surgical services are limited to
				episiotomy and episiotomy repair and shall not include operative obstetrics or
				cesarean sections.
(4) Labor shall
				not be inhibited, stimulated, or augmented with chemical agents during the
				first or second stage of labor.
(5)
				Systemic analgesia may be administered. Local anesthesia may be administered
				for pudendal block and episiotomy repair.
(6) General and conductive anesthesia shall
				not be administered at a freestanding birthing center.
(7) A birthing center shall not routinely
				keep a member in the facility for in excess of twenty-four (24)
				hours.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 16.5 - Freestanding Birthing Center Services › Section 16.5-5 - Rural health clinics and federally qualified health centers; reimbursement

Current through July 10, 2024
The
				  readopted version of this section by 6/26/2023, 8:51 a.m.:
				  20230726-IR-405220392FRA
				  is not yet available.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 17 - Hospital Services › Section 17-1 - Reimbursement; limitations

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) Inpatient
				and outpatient hospital services are covered when such services are provided or
				prescribed and documented by a physician and when the services are medically
				necessary for the diagnosis or treatment of the member's condition, subject to
				the limitations set out in this article.
(b) Reimbursement shall be made only for
				covered services. In addition, if an inpatient procedure requires prior
				authorization and prior authorization is either not obtained or denied,
				reimbursement for the inpatient procedure and any associated services,
				including inpatient days, shall be denied.
(c) Reimbursement is not available for
				reserving a bed during a therapeutic leave of absence from an acute care
				hospital.
(d) Reimbursement for
				inpatient hospital services is available only when it is determined to be
				medically necessary for the services to be performed only in an inpatient
				hospital setting.
(e) Reimbursement
				will be denied for any days of the hospital stay during which the inpatient
				hospitalization is found not to have been medically necessary.
(f) Reimbursement under the level of care
				methodology described in
				405 IAC 1-10.5 will be made for
				the lesser of:
(1) the number of days
				actually used; or
(2) the number of
				days prior authorized by the office.