Court Opinion

ID: 9715426
Source: CourtListenerOpinion
Date Created: 2023-08-26 06:05:34.200805+00
Date Added: 2024-06-11T18:23:34.955794
License: Public Domain

*191SULLIVAN, Judge,
dissenting.
I respectfully disagree with a portion of the majority's discussion of standing. To be sure, Methodist had standing to seek an administrative hearing. This is a far ery from conferring standing to obtain judicial review of an administrative proceeding to which the petitioner was not a party. The important question is whether Methodist, certainly a real party in interest as the medical service provider, may obtain judicial review although it was not the requester for prior authorization. Here, the request clearly indicated that Methodist was the medical provider. That request was denied and the majority correctly observes that to require Methodist to resubmit a request for prior authorization would be futile. Methodist was a party-in-fact to the administrative proceeding. For this reason I agree that Methodist was an appropriate petitioner for judicial review.
I am unable to agree with affirmance of the review court's decision, however. The court of review and the majority opinion here concludes that at the time in question, a request for prior authorization could only be denied for medical reasons and that such denial could not be based upon considerations of timeliness. In my view, the majority is incorrect in holding that because the rule in effect in August 1991 did not expressly place any time limitations upon submission of a prior authorization request, there were no such limitations.
At the time this cause arose, the rule concerning the matter of prior authorization was 470 Ind. Admin. Code 5-8-3 (Supp.1991). It is now found in the same form as 405 Ind. Admin. Code 1-6-8. It stated then as now, that services provided without prior authorization "shall not be reimbursed by Medicaid." It also provides and provided that a prior authorization request must be submitted and authorization received prior to submission of a claim for reimbursement. 405 Ind. Admin. Code 1-6-3-(b)(1), formerly 470 Ind. Admin. Code 5-8-3-(b)(1) (Supp.1987).4
It cannot be seriously questioned that the underlying purpose of the various rule requirements is for medical providers to obtain reimbursement for services provided to Medicare eligible patients. A prior authorization request has no significance outside the context of reimbursement. It is therefore absolutely necessary in my estimation, to read the prior authorization requirements in the context of the basic regulation dealing with reimbursement. That rule is 405 Ind. Admin. Code 1-1-3 and was in identical form in 1991 as 470 Ind. Admin. Code 5-1-3. It states and stated that absent a waiver payment for services requires a claim to be filed with the Medicaid contractor within twelve months of the date of the provision of the service. A waiver of the twelve-month requirement is appropriate when the services were rendered to a patient thereafter determined to be retroactively eligible for Medicaid. But in no event would such a waiver be indicated if authorization is not sought within twelve months of the eligibility notification. To do so would be to render meaningless the underlying time constraints for filing a claim for reimbursement. In any event, the outside limit for filing a request for prior authorization should necessarily coincide with the outside limit for filing a claim for reimbursement. Here, the request was not filed until fourteen months after the patient's Medicaid eligibility was known, and some seventeen months after the services were provided. Because prior authorization is a condition precedent to reimbursement for medical services, and because there could not be a timely claim for reimbursement under 470 Ind. Admin. Code 5-1-3, there was no reason to grant a meaningless authorization.
The Administrative Law Judge correctly affirmed the administrative denial of the pri- or authorization request. The review court was, therefore, in error in reversing that determination. I would reverse the judgment of the review court and remand with instructions to affirm the administrative decision.

. Provision of transportation services for medical purposes was formerly covered by 470 Ind. Admin. Code 5-8-3-(b)(4), now 405 Ind. Admin. Code 1-6-3-(b)(4). There was no express time limitation for submission of prior authorization. Presently, however, the rule requires such request be submitted within twelve months of the service.