Section 405 IAC 5-31-9 - Prior authorization for services rendered outside the state nursing facilityAuthority: 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) Medical care rendered by practitioners outside the state nursing facility 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 that the service is medically necessary.(d) Prior authorization will include consideration of the following: (1) Review of the properly completed Medicaid prior authorization request form substantiating both of the following: (A) The service is medically necessary.(B) Explanation of why the service cannot be rendered at the facility.(2) Review of criteria for the specific medical service requested as set forth in this article.Office ofthe Secretary of Family and Social Services; 405 IAC 5-31-9; filed May 30, 2007, 8:22 a.m.: 20070627-IR-405060158FRA; readopted filed Sep 19, 2007,12:16p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFAFiled 8/1/2016, 3:44 p.m.: 20160831-IR-405150418FRAErrata filed 11/1/2016, 9:36 a.m.: 20161109-IR-405160493ACAReadopted filed 7/28/2022, 2:21 p.m.: 20220824-IR-405220205RFAReadopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA