Section 405 IAC 14-5-9 - Utilization managementAuthority: IC 12-15-1-10; IC 12-17.6-2-11
Affected: IC 12-15-5; IC 12-15-12; IC 12-17.6-2; IC 27-1-37.5-17
Sec. 9.
(a) An MCO shall operate and maintain its own utilization management (UM) program based the requirements and limitations in this section.(b) Through the MCO's UM program, the MCO may place appropriate limits on covering services based on medical necessity or utilization control criteria, if the services furnished can reasonably be expected to achieve their intended purpose.(c) Under 42 CFR 438.210(a)(3)(ii), an MCO shall not arbitrarily deny or reduce the amount, duration, or scope of required services solely because of a member's diagnosis, type of illness, or condition.(d) The MCO shall follow the office's UM hierarchy, which includes the following: (1) Compliance with applicable federal requirements.(2) Compliance with applicable Indiana law.(3) Compliance with the Indiana Medicaid state plan.(4) Compliance with applicable Indiana Administrative Code requirements.(5) Using Medicaid FFS policies for the following services:(A) Applied behavioral analysis therapy.(C) EndoPredict breast cancer prognostic test.(F) Speech-generating devices.(I) Bariatric procedures.(6) Noncustomized national clinical guidelines, of which the MCO may choose InterQual or Milliman Care Guidelines (MCG), but must use the full suite of review criteria in these platforms, including using the applicable MCG or InterQual guideline instead of an MCO derived UM policy or criteria if an item or a service is covered by MCG or InterQual.(7) MCO developed criteria, which must be preapproved by the office before carrying out of the criteria.(8) Professional society guidelines.(9) Professional references or guidance by subject matter expert published peer reviewed literature.(10) Best standards of care, guided by published peer reviewed literature.(e) The MCO requires providers to submit the Indiana health coverage program prior authorization request form developed by the office for services requiring prior authorization.(f) The MCO's program must allow a provider the right for a peer to peer utilization review under IC 27-1-37.5-17.(g) The MCO shall give written notice to a member and provider of any decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The notice must meet the requirements of 42 CFR 438.404.(h) The MCO shall notify a member of standard authorization decisions as quickly as needed by the member's health condition, not to exceed five (5) calendar days after a request for services, unless otherwise provided in 405 IAC 5-3-14. An extension of up to fourteen (14) calendar days is permitted if the: (1) member or provider requests an extension; or(2) MCO provides justification to the office of a need for more information, and explains how the extension is in the member's best interest.(i) Whenever a provider indicates, or the MCO determines, that following the standard time frame may seriously jeopardize a member's life, health, or ability to attain, maintain, or regain maximum function, the MCO shall make an expedited authorization decision and give notice as quickly as needed by the member's health condition not later than forty-eight (48) hours after receiving the service request. The MCO may extend the forty-eight (48) hours by up to fourteen (14) calendar days if the: (1) member or provider requests an extension; or(2) MCO provides justification to the office of a need for more information, and explains how the extension is in the member's best interest.(j) An extension granted under to subsections (h) and (i) requires written notice to the member, which must include the reason for the extension and the member's right to file a grievance.(k) Unless otherwise provided in 405 IAC 5-3-14, if an MCO fails to respond to a member's prior authorization request within five (5) calendar days after receiving the necessary documentation, the authorization is considered to be granted.Office of the Secretary of Family and Social Services; 405 IAC 14-5-9; filed 8/30/2024, 11:42 a.m.: 20240925-IR-405240180FRA