reglab/statecodes huggingface dataset:
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 17 - Hospital Services › Section 17-2 - Prior authorization; generally

Current through July 10, 2024
Authority: IC 12-15
Affected: IC 12-13-7-3
Sec. 2.
(a) Prior
				authorization is required for all nonemergent inpatient hospital admissions of
				Medicaid eligible members.
Nonemergent inpatient hospital admissions include all
				  elective or planned inpatient hospital admissions and inpatient hospital
				  admissions for which the patient's condition permitted adequate time to
				  schedule the availability of a suitable accommodation. The following are exempt
				  from this requirement:
(1) Inpatient
				hospital admissions when covered by Medicare.
(2) Routine vaginal and cesarean section
				deliveries.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 17 - Hospital Services › Section 17-3 - Emergency; weekend inpatient admissions

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.
Emergency inpatient admissions for diagnoses reimbursed
				  under the level of care payment methodology and emergency substance abuse
				  inpatient admissions must be reported to the office within forty-eight (48)
				  hours of admission, not including Saturdays, Sundays, or legal holidays, in
				  order to receive Medicaid reimbursement. At that time, the same standards for
				  prior authorization will be applied as would have been applied if the
				  authorization had been requested before the admission.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 17 - Hospital Services › Section 17-4 - Physical rehabilitation services

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) Medicaid
				reimbursement is available for physical rehabilitation services when such
				services are prior authorized subject to this section.
(b) Prior to admission to a physical
				rehabilitation unit, an assessment of the patient's total rehabilitative
				potential must be completed and documented in the medical record.
(c) Medicaid reimbursement is available for
				physical rehabilitation admission based on the following conditions:
(1) The patient is medically
				stable.
(2) The patient is
				responsive to verbal or visual stimuli.
(3) The patient has sufficient mental
				alertness to participate in the program.
(4) The patient's premorbid condition
				indicates a potential for rehabilitation.
(5) The expectation for improvement is
				reasonable.
(6) The criteria listed
				in 405 IAC 5-32 are
				met.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 17 - Hospital Services › Section 17-5 - Inpatient detoxification, rehabilitation, and aftercare for chemical dependency

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.
(a) Medicaid
				reimbursement is available for inpatient detoxification, rehabilitation, and
				aftercare for chemical dependency when such services are prior authorized
				subject to this section.
(b)
				Admission to a general hospital floor is not indicated unless the medical
				services are required for life support and cannot be rendered in a substance
				abuse treatment unit or facility.
(c) Prior authorization for inpatient
				detoxification, rehabilitation, and aftercare for chemical dependency shall
				include consideration of the following:
(1)
				All requests for prior authorization will be reviewed on a case-by-case
				basis.
(2) The treatment,
				evaluation, and detoxification are based on the stated medical
				condition.
(3) The need for safe
				withdrawal from alcohol or other drugs.
(4) A history of recent convulsions or poorly
				controlled convulsive disorder.
(5)
				Reasonable evidence that detoxification and aftercare cannot be accomplished in
				an outpatient setting.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 18 - Laboratory Services › Section 18-1 - Clinical diagnostic laboratory services; 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. 1.
Most clinical diagnostic laboratory procedures, performed in
				  a physician's office, by an independent laboratory, or by a hospital laboratory
				  for its outpatients, will be reimbursed on the basis of fee schedules
				  established by Medicare. For purposes of this fee schedule, clinical diagnostic
				  services include all laboratory tests. Laboratory procedures are subject to the
				  Clinical Laboratories Improvement Act (CLIA) rules and regulations.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 18 - Laboratory Services › Section 18-2 - Reimbursement 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) A fee
				will be reimbursed by Medicaid for separate charges made by physicians,
				independent laboratories, or hospital laboratories for the drawing of or
				collection of specimens. These services are covered only in circumstances when
				a blood sample is drawn through venipuncture or where a urine sample is
				collected by catheterization.
(b)
				Billings on the claim form for specimen collection fees must be itemized. Only
				one (1) charge per day for each patient shall be allowed for venipuncture. A
				charge for catheterization will be allowed for each patient encounter, that is,
				there is no per day or per claim limitation.
(c) Handling or conveyance of a specimen will
				be reimbursed by Medicaid if these services are billed by a physician,
				chiropractor, or podiatrist.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 18 - Laboratory Services › Section 18-3 - Inpatient and outpatient laboratory facilities; limitations

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.
(a) To be
				eligible for reimbursement, a laboratory service must be ordered in writing by
				a physician or other practitioner authorized to do so under state
				law.
(b) Laboratories performing
				the services must bill Medicaid directly unless otherwise approved by the
				Centers for Medicare and Medicaid Services.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 18 - Laboratory Services › Section 18-4 - Nonanatomical laboratory 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. 4.
(a) The
				interpretation of laboratory procedures that do not require the services of a
				physician are not reimbursable. Medicaid reimbursement is available for the
				interpretation of laboratory results that require the expertise of a physician
				as indicated by current medical practice standards and in accordance with
				appropriate CPT codes.
(b)
				Consultative pathology services are reimbursable if they:
(1) are requested by the member's attending
				physician in writing;
(2) relate to
				a test result that lies outside the clinically significant normal or expected
				range in view of the condition of the member;
(3) result in a written narrative report
				included in the member's medical record; and
(4) require the exercise of medical judgment
				by the consultant physician.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 19 - Medical Supplies and Equipment › Section 19-1 - Medical supplies

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC
				  12-15-13-6
Sec. 1.
(a) Medical
				and surgical supplies (medical supplies) are:
(1) disposable items that are not reusable
				and must be replaced on a frequent basis;
(2) used primarily and customarily to serve a
				medical purpose;
(3) generally not
				useful to a person in the absence of a disability, illness, or injury;
				and
(4) covered only for the
				treatment of a medical condition.
Reimbursement is available for medical supplies subject to
				  the restrictions listed in this section.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 19 - Medical Supplies and Equipment › Section 19-2 - "Durable medical equipment" or "DME"

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 2.
As used in this rule, "durable medical equipment" or "DME"
				  means equipment that can withstand repeated use, is primarily and customarily
				  used to serve a medical purpose, and generally is not useful to a member in the
				  absence of a disability, illness, or injury.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 19 - Medical Supplies and Equipment › Section 19-2.5 - "Durable medical equipment" or "DME" requiring a face-to-face encounter

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 2.5.
Documentation of a face-to-face encounter for home health
				  services in accordance with 42 CFR 440.70(f)
				  is required for the following specified items:
(1) Specified items may include, but are not
				limited to, the following:
(A) Decubitus care
				equipment.
(B) Hospital beds and
				accessories.
(C) Oxygen and related
				respiratory equipment.
(D)
				Humidifiers, compressors, and nebulizers.
(E) Monitoring devices.
(F) Patient lifts.
(G) Compression devices.
(H) Ultraviolet light.
(I) Nerve stimulators and devices.
(J) Infusion supplies.
(K) Traction equipment.
(L) Wheelchairs and wheelchair
				accessories.
(M) Whirlpool
				equipment.
(N) Speech generating
				devices.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 19 - Medical Supplies and Equipment › Section 19-3 - Reimbursement parameters for durable medical equipment

Current through July 10, 2024
Authority: IC 12-15
Affected: IC
				  12-13-7-3; IC
				  12-15-13-6
Sec. 3.
(a) Medicaid
				reimbursement is available for the rental or purchase of DME subject to the
				restrictions listed in this rule.
(b) DME and associated repair costs,
				including, but not limited to:
(1) ice
				bags;
(2) bed rails;
(3) canes;
(4) walkers;
(5) crutches;
(6) standard wheelchairs;
(7) traction equipment; or
(8) oxygen and equipment and supplies for its
				delivery; for the usual care and treatment of members in long-term care
				facilities are reimbursed in the facility's per diem rate and may not be billed
				to Medicaid by the facility, pharmacy, or other provider. Nonstandard or
				custom/special equipment and associated repair costs require prior
				authorization by the office and may be billed separately to Medicaid, when
				authorized. Facilities cannot require members to purchase or rent such
				equipment with their personal funds.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 19 - Medical Supplies and Equipment › Section 19-4 - Repair of purchased durable medical equipment

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 4.
Medicaid reimbursement is available for the repair of
				  purchased DME, subject to this rule. All repairs of purchased DME require prior
				  authorization by the office. Medicaid will not make payment for repair of
				  equipment that is still under warranty. No payment shall be authorized for
				  repair necessitated by member misuse or abuse. Repair of rental equipment is
				  the responsibility of the rental provider. Payment for maintenance charges for
				  properly functioning equipment is not covered by Medicaid. Repair costs for DME
				  included in a long term care facility's per diem rate is also included in the
				  per diem rate.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 19 - Medical Supplies and Equipment › Section 19-5 - Reimbursement for replacement durable medical equipment

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 5.
Subject to the criteria set forth in section 7 of this rule,
				  Medicaid will pay for replacement of DME items. Notwithstanding such criteria,
				  authorization for large DME, such as nonstandard or custom/special wheelchairs,
				  hospital beds, and lifts, will not be given more than once every five (5) years
				  per member unless there is a change in the member's medical needs, documented
				  in writing by the requesting provider, significant enough to warrant a
				  different type of equipment.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 19 - Medical Supplies and Equipment › Section 19-6 - Durable medical equipment subject to 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
				  12-13-7-3; IC 12-15
Sec. 6.
(a) Prior
				authorization by the office is required for all DME rented or purchased with
				Medicaid funds, except for the following:
(1)
				Cervical collars.
(2) Back
				supportive devices such as corsets.
(3) Hernia trusses.
(4) Oxygen and supplies and equipment for its
				delivery for nursing facility residents.
(5) Parenteral infusion pumps when used in
				conjunction with parenteral hyperalimentation, including central venous
				catheters.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 19 - Medical Supplies and Equipment › Section 19-7 - Prior authorization criteria

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 7.
Prior authorization requests for DME shall be reviewed on a
				  case-by-case basis by the office, using all of the following criteria:
(1) The item must be medically necessary for
				the treatment of an illness or injury or to improve the functioning of a body
				member.
(2) The item must be
				adequate for the medical need; however, items with unnecessary convenience or
				luxury features will not be authorized.
(3) The anticipated period of need, plus the
				cost of the item will be considered in determining whether the item shall be
				rented or purchased. This decision shall be made by the office based on the
				least expensive option available to meet the member's needs.
(4) Documentation of a face-to-face encounter
				for home health services in accordance with
				42 CFR
				440.70(f) is required for
				specified items in accordance with section 2.5 of this rule.
(5) Rehabilitation potential is not required
				for prior authorization requests for specialized wheelchairs if the member is a
				resident of a nursing facility designated by the office as a children's nursing
				facility as defined at
				405 IAC
				1-14.6-2(k).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 19 - Medical Supplies and Equipment › Section 19-8 - Ownership of durable medical equipment

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 8.
DME purchased with Medicaid funds becomes the property of
				  the office.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 19 - Medical Supplies and Equipment › Section 19-9 - Wheelchairs and similar motorized vehicles

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 9.
(a) Medicaid
				reimbursement is available for wheelchairs or similar motorized vehicles,
				subject to the restrictions listed in this section, and requires prior
				authorization.
(b) Motorized
				vehicles are covered only when the member is enrolled in a school, sheltered
				workshop, or work setting, or if the member is left alone for significant
				periods of time. It must be documented that the member can safely operate the
				vehicle and that the member does not have the upper extremity function
				necessary to operate a manual wheelchair.
(c) Requests for wheelchairs or similar
				motorized vehicles require a completed medical clearance form submitted with
				the prior authorization request before the requests shall be reviewed.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 19 - Medical Supplies and Equipment › Section 19-10 - Braces and orthopedic shoes

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 10.
Medicaid reimbursement is available for the
				  following:
(1) Braces for the leg,
				arm, back, and neck.
(2) Orthopedic
				shoes and corrective shoe features.
(3) Corrective features built into shoes,
				such as heels, lifts, and wedges.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 19 - Medical Supplies and Equipment › Section 19-11 - Prosthetic devices

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 11.
Medicaid reimbursement is available for prosthetic devices
				  under the following conditions:
(1)
				All prosthetic devices must be ordered in writing by a physician, optometrist,
				or dentist.
(2) Prior authorization
				by the office is required for all basic prosthetic components and repairs. Once
				the basic prosthesis is approved, all customizing features will be exempt from
				prior authorization.
(3) Prosthetic
				devices dispensed for solely cosmetic reasons, for example, hairpieces or
				makeup, are not covered by Medicaid.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 19 - Medical Supplies and Equipment › Section 19-12 - Home hemodialysis equipment

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 12.
(a) Medicaid
				reimbursement is available for home hemodialysis equipment, including plumbing
				and water conditioner installation.
(b) Payment for removal and reinstallation of
				equipment due to member relocation is limited to moves made necessary by
				circumstances beyond the member's control.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 19 - Medical Supplies and Equipment › Section 19-13 - Hearing aids; purchase

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3
Sec. 13.
Medicaid reimbursement is available for the purchase,
				  repair, or replacement of hearing aids under the following conditions:
(1) Prior authorization is required for the
				purchase of hearing aids.
(2) When
				a member is to be fitted with a hearing amplification device by either a
				licensed audiologist or a registered hearing aid specialist, a medical
				clearance and audiometric test form must be completed and submitted with the
				prior authorization request form. Professional services associated with the
				dispensing of a hearing aid must be performed in accordance with the
				appropriate provisions of
				405 IAC 5-22.
(3) Hearing aids purchased by Medicaid become
				the property of the office.
(4)
				Hearing aids are not covered for members with a unilateral pure tone average
				(500, 1,000, 2,000, or 3,000 hertz) equal to or less than thirty (30)
				decibels.
(5) Binaural aids and
				CROS-type aids will be authorized only when significant, objective benefit to
				the member can be documented.
(6)
				Medicaid does not reimburse for canal hearing aids.
(7) Medicaid reimbursement of hearing aids is
				based on the most recently published fee schedule in effect. If this amount is
				not available, then use clause (A) as follows:
(A) The average acquisition cost of the item
				adjusted by a multiplier of one and two-tenths (1.2), if available. If this
				amount is not available, then use clause (B).
(B) The manufacturer's suggested retail price
				adjusted by a multiplier of seventy-five hundredths (0.75).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 19 - Medical Supplies and Equipment › Section 19-14 - Hearing aids; maintenance and repair

Current through July 10, 2024
Authority: IC 12-15
Affected: IC
				  12-13-7-3
Sec. 14.
Medicaid reimbursement is available for the maintenance or
				  repair of hearing aids under the following conditions:
(1) Repairs for hearing aids and ear molds do
				not require prior authorization; however, reimbursement for such repairs shall
				not be made more often than once every twelve (12) months. Repairs may be prior
				authorized more frequently for members under twenty-one (21) years of age if
				circumstances are documented justifying need.
(2) Batteries, sound hooks, tubing, and cords
				do not require prior authorization.
(3) Medicaid payment is not available for
				repair of hearing aids still under warranty.
(4) Routine servicing of functioning hearing
				aids is not covered by Medicaid.
(5) No payment shall be made for repair or
				replacement of hearing aids necessitated by member misuse or abuse whether
				intentional or unintentional.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 19 - Medical Supplies and Equipment › Section 19-15 - Hearing aids; replacement

Current through July 10, 2024
Authority: IC 12-15
Affected: IC
				  12-13-7-3
Sec. 15.
Medicaid reimbursement is available for the replacement of
				  hearing aids under the following conditions:
(1) Medicaid reimbursement is available for
				the replacement of hearing aids subject to section 14 of this rule.
(2) Requests for replacement of hearing aids
				must:
(A) document a change in the member's
				hearing status; and
(B) state the
				purchase date and condition of the current hearing aid.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 19 - Medical Supplies and Equipment › Section 19-16 - Augmentative communication devices

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 16.
(a) As used
				in this section, "augmentative communication device" means a device or system
				that compensates for the loss or impairment of a speech function due to a
				congenital condition, an acquired disability, or a progressive neurological
				disease. The term includes only that equipment used for the purpose of
				communication, including both electronic and nonelectronic devices.
(b) As used in this section, "communication
				device" refers to an augmentative communication device.
(c) Medicaid reimbursement is available for a
				communication device subject to the following:
(1) The device must be ordered in writing by
				a medical doctor or doctor of osteopathy.
(2) Prior authorization is required for a
				communication device. Documentation supporting that the device is medically
				necessary must be provided on, or attached to, the prior authorization request
				form submitted by the requesting practitioner. A clinical evaluation by a
				speech pathologist, substantiating the communication device is medically
				necessary, must be submitted as part of the prior authorization
				request.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 19 - Medical Supplies and Equipment › Section 19-17 - Pneumatic artificial voicing systems

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 17.
(a) Medicaid
				reimbursement is available for a pneumatic artificial voicing system or an
				artificial larynx, subject to prior authorization. Prior authorization will be
				granted only upon satisfaction of the following:
(1) Documentation must be presented that
				substantiates the member has demonstrated sufficient mental and physical
				capabilities to benefit from the use of the system.
(2) Documentation must be presented that
				substantiates the member has demonstrated sufficient articulation and language
				skills to benefit from the use of the system.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 19 - Medical Supplies and Equipment › Section 19-18 - Noncovered durable medical equipment

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 18.
The following equipment is not covered by Medicaid:
(1) Equipment that basically serves comfort
				or convenience functions, for example, the following:
(A) Elevators.
(B) Stairway elevators.
(C) Posture chairs, for example, cardiac
				chair or geri chair.
(D) Portable
				whirlpool pumps.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 20 - Mental Health Services › Section 20-1 - Reimbursement limitations

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 1.
(a) Medicaid
				reimbursement is available for mental health services provided by licensed
				physicians, psychiatric hospitals, general hospitals, psychiatric residential
				treatment facilities for children under twenty-one (21) years of age,
				outpatient mental health facilities, and psychologists endorsed as health
				service providers in psychology subject to the limitations set out in this
				rule. For purposes of this rule, "psychiatric residential treatment facility"
				or "PRTF" means a facility that meets the requirements set forth in section 3.1
				of this rule.
(b) Reimbursement for
				inpatient psychiatric services is not available in institutions for mental
				diseases for a member under sixty-five (65) years of age unless the member is
				under twenty-one (21) years of age, or under twenty-two (22) years of age and
				had begun receiving inpatient psychiatric services immediately before his or
				her twenty-first birthday.
(c)
				Medicaid reimbursement is available for inpatient psychiatric services provided
				to an individual between twenty-two (22) and sixty-five (65) years of age in a
				certified psychiatric hospital of sixteen (16) beds or less.
(d) Prior authorization is required for all
				inpatient psychiatric admissions including admissions for substance abuse.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 20 - Mental Health Services › Section 20-2 - Reserving beds in psychiatric hospitals and psychiatric residential treatment facilities

Current through July 10, 2024
Authority: IC
				  12-15-1-10; 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 reserving beds in a psychiatric hospital (and
				not in a general acute care hospital) for hospitalization of members at
				one-half (1/2) the regular per diem rate when all of the following conditions
				are present:
(1) Hospitalization is ordered
				by the physician for treatment of an acute condition that cannot be treated in
				the facility.
(2) The total length
				of time allowed for payment of a reserved bed for a single hospital stay is
				fifteen (15) days. If the member requires hospitalization longer than the
				fifteen (15) consecutive days, the member must be discharged from the
				facility.
(3) A physician's order
				for the hospitalization 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 20 - Mental Health Services › Section 20-3 - Requirements for psychiatric hospitals

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 3.
Psychiatric hospitals must meet the following conditions in
				  order to be reimbursed for inpatient services:
(1) The facility must be certified and a
				provider.
(2) The facility must
				maintain special medical records for psychiatric hospitals as required by
				42 CFR
				482.61, effective October 1, 1995, (not
				including secondary Code of Federal Regulations citations therein).
(3) The facility must provide services under
				the direction of a licensed physician.
(4) The facility must meet federal
				certification standards for psychiatric hospitals.
(5) The facility must meet utilization review
				requirements. The overall operation of a utilization review plan of a facility
				is monitored by the survey personnel of the Indiana state department of health
				as contracted by the office. The hospital will be visited by the inspection of
				care team annually to review medical and treatment records.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 20 - Mental Health Services › Section 20-3.1 - PRTF; requirements

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 3.1.
PRTFs must meet the following conditions in order to be
				  reimbursed for inpatient services:
(1)
				The facility must be licensed as a private secure facility under
				465 IAC 2-11.
(2) The facility must be accredited by one
				(1) of the following:
(A) The Joint Commission
				on Accreditation of Healthcare Organizations.
(B) The American Osteopathic
				Association.
(C) The Council on
				Accreditation of Services for Families and Children.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 20 - Mental Health Services › Section 20-4 - Individually developed plan of care

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 4.
(a) Each
				Medicaid eligible member admitted to a psychiatric hospital or PRTF must have
				an individually developed plan of care. In the case of a person between
				twenty-two (22) and sixty-five (65) years of age in a psychiatric hospital of
				sixteen (16) beds or less or a person sixty-five (65) years of age and over,
				the plan of care must be developed by the attending or staff physician. For a
				person under twenty-one (21) years of age, the plan of care must be developed
				by the physician and interdisciplinary team. In all cases, the plans of care
				must be developed not later than fourteen (14) days after admission. For a
				member who becomes eligible for Medicaid after admission to a facility, the
				plan of care must be prepared to cover all periods for which Medicaid coverage
				is claimed and as follows:
(1) The individual
				plan of care for a member between twenty-two (22) and sixty-five (65) years of
				age in a psychiatric hospital of sixteen (16) beds or less and for a member
				sixty-five (65) years of age and over shall set forth treatment objectives and
				prescribe an integrated program of appropriate therapies, activities, and
				experiences designed to meet these objectives. The plan shall be based upon a
				diagnostic evaluation that includes examination of the medical, psychological,
				social, and behavioral aspects of the member's situation. It shall include, at
				an appropriate time, a postdischarge plan and plan for coordination of
				inpatient services with partial discharge plans and appropriate related
				services in the member's community to ensure continuity of care when returned
				to the member's family and community upon discharge. The plan of care shall be
				reviewed and updated at least every ninety (90) days by the member's attending
				or staff physician for determinations that the services provided were and are
				required on an inpatient basis and for recommendations as to necessary
				adjustments in the plan as indicated by the member's overall adjustment as an
				inpatient. The quarterly plan of care must be in writing and made a part of the
				member's record.
(2) The individual
				plan of care for a member under twenty-one (21) years of age shall comply with
				the requirements as set forth in
				42 CFR
				441.155. Additionally, the periodic update of
				the plan of care must be in writing and made a part of the member's record.
				Recertification is required at least every sixty (60) days. Initial evaluative
				examinations are exempt from prior authorization.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 20 - Mental Health Services › Section 20-5 - Certification of need for admission

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15; IC 26-2-8-106
Sec. 5.
Medicaid reimbursement is available for services in an
				  inpatient psychiatric facility only when the member's need for admission has
				  been certified. The certification of need must be completed as follows:
(1) By the attending physician or staff
				physician for a member between twenty-two (22) and sixty-five (65) years of age
				in a psychiatric hospital of sixteen (16) beds or less and for a member
				sixty-five (65) years of age and over.
(2) In accordance with
				42 CFR
				441.152(a), effective
				October 1, 1995 (not including secondary Code of Federal Regulations citations
				therein), and 42 CFR
				441.153, effective October 1, 1995 (not
				including tertiary Code of Federal Regulations citations resulting therefrom),
				for an individual twenty-one (21) years of age and under.
(3) By telephone precertification review
				prior to admission for an individual who is a member of Medicaid when admitted
				to the facility as a nonemergency admission, to be followed by a written
				certification of need within ten (10) working days of admission.
(4) By telephone precertification review
				within forty-eight (48) hours of an emergency admission, not including
				Saturdays, Sundays, and legal holidays, to be followed by a written
				certification of need within fourteen (14) working days of admission. If the
				provider fails to call within forty-eight (48) hours of an emergency admission,
				not including Saturdays, Sundays, and legal holidays, Medicaid reimbursement
				shall be denied for the period from admission to the actual date of
				notification.
(5) In handwriting or
				electronically, consistent with IC
				26-2-8-106, within ten (10)
				working days after receiving notification of an eligibility determination for
				an individual applying for Medicaid while in the facility and covering the
				entire period for which Medicaid reimbursement is being sought.
(6) In handwriting or electronically,
				consistent with IC
				26-2-8-106, at least every sixty
				(60) days after admission, or as requested by the office to recertify that the
				member continues to require inpatient psychiatric hospital services.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 20 - Mental Health Services › Section 20-6 - Emergency admissions

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 6.
Medicaid reimbursement is available for emergency admissions
				  only in cases of a sudden onset of a psychiatric condition manifesting itself
				  by acute symptoms of such severity that the absence of immediate medical
				  attention could reasonably be expected to result in one (1) of the
				  following:
(1) Danger to the
				individual.
(2) Danger to
				others.
(3) Death of the
				individual.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 20 - Mental Health Services › Section 20-7 - Unnecessary services

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 7.
Medicaid reimbursement will be denied for any days during
				  which the inpatient psychiatric hospitalization or stay in a PRTF is found not
				  to have been medically necessary. Telephone precertifications substantiating
				  that the service is medically necessary will provide a basis for Medicaid
				  reimbursement only if adequately supported by the written certification of need
				  submitted in accordance with section 5 of this rule. If the required written
				  documentation is not submitted within the specified time frame, Medicaid
				  reimbursement will be denied.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 20 - Mental Health Services › Section 20-8 - Outpatient mental health services

Current through July 10, 2024
Authority: IC 12-15
Affected: IC 12-13-7-3
Sec. 8.
Medicaid reimbursement is available for outpatient mental
				  health services provided by licensed physicians, psychiatric hospitals,
				  psychiatric wings of acute care hospitals, outpatient mental health facilities,
				  and psychologists endorsed as a health service provider in psychology (HSPP).
				  Outpatient mental health services rendered by a medical doctor, doctor of
				  osteopathy, or HSPP are subject to the following limitations:
(1) Outpatient mental health services
				rendered by a medical doctor or doctor of osteopathy are subject to the
				limitations set out in
				405 IAC 5-25.
(2) Subject to prior authorization by the
				office Medicaid will reimburse physician or HSPP directed outpatient mental
				health services for group, family, and individual outpatient psychotherapy when
				the services are provided by one (1) of the following practitioners:
(A) A licensed psychologist.
(B) A licensed independent practice school
				psychologist.
(C) A licensed
				clinical social worker.
(D) A
				licensed marital and family therapist.
(E) A licensed mental health
				counselor.
(F) A person holding a
				master's degree in social work, marital and family therapy, or mental health
				counseling, except that partial hospitalization services provided by such
				person shall not be reimbursed by Medicaid.
(G) An advanced practice nurse who is a
				licensed, registered nurse with a master's degree in nursing with a major in
				psychiatric or mental health nursing from an accredited school of
				nursing.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.5 - Medicaid Rehabilitation Option Services › Section 21.5-1 - Definitions

Current through July 10, 2024
Authority: IC 12-15
Affected: IC 12-13-7-3; IC 12-29; IC 25-23-1; IC
				  25-23.6-10.5; IC 25-27.5-5
Sec. 1.
(a) As used
				in this rule, "Medicaid rehabilitation option" or "MRO" refers to medical or
				remedial services recommended by a physician or other licensed professional,
				within the scope of his or her practice, for the maximum reduction of a mental
				disability and the restoration of a member's best possible functional
				level.
(b) As used in this rule,
				"licensed professional" means any of the following persons:
(1) A licensed psychiatrist.
(2) A licensed physician.
(3) A licensed psychologist or a psychologist
				endorsed as a health service provider in psychology (HSPP).
(4) A licensed clinical social worker
				(LCSW).
(5) A licensed mental
				health counselor (LMHC).
(6) A
				licensed marriage and family therapist (LMFT).
(7) A licensed clinical addiction counselor
				(LCAC), as defined under IC 25-23.6-10.5.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.5 - Medicaid Rehabilitation Option Services › Section 21.5-2 - Reimbursement

Current through July 10, 2024
Authority: IC 12-15
Affected: IC
				  12-7-2-40.6; IC
				  12-13-7-3; IC 12-29
Sec. 2.
(a) The
				office will reimburse MRO services for members who meet specific diagnosis and
				level of need criteria under the approved DMHA assessment tool. The listing of
				diagnostic and level of need criteria approved for reimbursement shall be as
				follows:
(1) Will be listed and published in
				a provider manual by the office.
(2) May be updated by the office as
				needed.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.5 - Medicaid Rehabilitation Option Services › Section 21.5-3 - Behavioral health rehabilitation services

Current through July 10, 2024
Authority: IC 12-15
Affected: IC
				  12-13-7-3
Sec. 3.
(a) The
				services reimbursable as behavioral health rehabilitation services are clinical
				behavioral health services that are provided for members, families, or groups
				of persons who are living in the community and who need aid on an intermittent
				basis for emotional disturbances, mental illness, or addiction. Behavioral
				health rehabilitation services are as follows:
(1) Behavioral health counseling and
				therapy.
(2) Medication training
				and support.
(3) Skills training
				and development.
(4) Behavioral
				health level of need redetermination.
(5) Crisis intervention.
(6) Child and adolescent intensive resiliency
				services.
(7) Adult intensive
				rehabilitative services.
(8)
				Intensive outpatient alcohol or drug treatment.
(9) Alcohol or drug (substance-related
				disorder) counseling.
(10) Peer
				recovery services.
(11) Case
				management.
(12) Psychiatric
				assessment and intervention.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.5 - Medicaid Rehabilitation Option Services › Section 21.5-4 - Behavioral health counseling and therapy

Current through July 10, 2024
Authority: IC 12-15
Affected: IC
				  12-13-7-3; IC
				  25-23.6-10.5
Sec. 4.
(a) The
				services reimbursable as individual or group behavioral health counseling and
				therapy consist of a series of time-limited, structured, face-to-face sessions
				that work toward the goals identified in the individualized integrated care
				plan. The service must be provided at the member's home or at other locations
				outside the clinic setting as follows:
(1)
				Requirements for individual or group behavioral health counseling and therapy
				services shall be as follows:
(A) Services may
				be provided for members of all ages.
(B) Providers must meet the either of the
				following qualifications:
(i) A licensed
				professional, except for a licensed clinical addiction counselor, as defined
				under IC 25-23.6-10.5.
(ii) A QBHP.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.5 - Medicaid Rehabilitation Option Services › Section 21.5-6 - Skills training and development

Current through July 10, 2024
Authority: IC 12-15
Affected: IC
				  12-13-7-3
Sec. 6.
(a) The
				services reimbursable as individual or group skills training and development
				involve face-to-face contact that results in the development of skills directed
				toward eliminating psychosocial barriers. The development of skills is provided
				through structured interventions for attaining goals identified in the
				individualized integrated care plan and the monitoring of the member's progress
				in achieving those skills. Requirements for individual or group skills training
				and development shall be as follows:
(1)
				Services may be provided for members of all ages.
(2) Services may be provided in an individual
				setting or group setting.
(3)
				Providers must meet any of the following qualifications:
(A) A licensed professional.
(B) A QBHP.
(C) An OBHP.
(4) Programming standards shall be as
				follows:
(A) The service requires
				face-to-face contact with the member.
(B) Members are expected to show a benefit
				from services, with the understanding that improvement may be
				incremental.
(C) Services must
				result in demonstrated movement towards, or achievement of, the member's
				treatment goals identified in the individualized integrated care
				plan.
(D) Services are
				rehabilitative in nature and time limited.
(E) The member is the focus of the
				service.
(F) Documentation must
				support how the service benefits the member, including when the service is
				provided in a group setting.
(G)
				When provided in a group setting, services must be provided in an age
				appropriate setting for a member less than eighteen (18) years of
				age.
(5) Exclusions shall
				be as follows:
(A) Services that are
				habilitative in nature, except for the achievement of developmental milestones
				for members less than eighteen (18) years of age that would have occurred
				absent an emotional disturbance.
(B) Skill building activities not identified
				in the individualized integrated care plan.
(C) Job coaching.
(D) Activities purely for recreation or
				diversion.
(E) Academic
				tutoring.
(6) Individual
				and group skills training and development services are not reimbursable if
				delivered on the same day as child and adolescent intensive rehabilitative
				services or adult intensive rehabilitative services.