Statutes, codes, and regulations
Indiana Administrative Code
Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICESArticle 5 - MEDICAID SERVICES
Rule 405 IAC 5-5 - Out-of-State Services
Section 405 IAC 5-5-2 - Prior authorization requirements for out-of-state services

405 Ind. Admin. Code 5-5-2

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Current through January 8, 2025
Section 405 IAC 5-5-2 - Prior authorization requirements for out-of-state services

Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2; IC 12-15-21-3

Affected: IC 12-15; IC 12-17.6

Sec. 2.

(a) Services provided out-of-state require prior authorization except as follows:
(1) Emergency services provided out-of-state are exempt from prior authorization; however, continuation of inpatient treatment and hospitalization is subject to the prior authorization requirements of the office.
(2) Members of the adoption assistance program placed outside of Indiana will receive approval for all routine medical and dental care provided out-of-state.
(b) Prior authorization will not be approved for the following services outside of Indiana:
(1) Nursing facilities, ICFs/IID, or home health agency services.
(2) Any other type of long term care facility, including facilities directly associated with or part of an acute general hospital.
(c) Prior authorization may be granted for any time period from one (1) day to one (1) year for out-of-state medical services if the service is medically necessary and any one (1) of the following criteria is also met:
(1) The service is not available in Indiana. However, care provided by out-of-state Veterans Administration facilities is an exception to this requirement.
(2) The member has received services from the provider previously.
(3) Transportation to an appropriate Indiana facility would cause undue expense or hardship to the member or Medicaid.
(4) The out-of-state provider is a regional treatment center or distributor.
(5) The out-of-state provider is significantly less expensive than the Indiana providers.

405 IAC 5-5-2

Office of the Secretary of Family and Social Services; 405 IAC 5-5-2; filed Jul 25, 1997, 4:00 p.m.: 20 IR 3308; filed Sep 27, 1999, 8:55 a.m.: 23 IR 309; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA
Filed 8/1/2016, 3:44 p.m.: 20160831-IR-405150418FRA
Errata filed 11/1/2016, 9:36 a.m.: 20161109-IR-405160493ACA
Filed 4/19/2018, 11:29 a.m.: 20180516-IR-405170306FRA
Readopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA