Section 405 IAC 14-5-5 - Self-referralAuthority: IC 12-15-1-10; IC 12-17.6-2-11
Affected: IC 12-15-5; IC 12-15-11; IC 12-15-12; IC 12-17.6-2; IC 25-10-1-1; IC 25-22.5; IC 25-24; IC 25-29
Sec. 5.
(a) An MCO shall include self-referral providers in their contracted networks.(b) Self-referral services are those that do not require a referral by an enrollee's PMP or other authorization by the MCO, and for which members may self-refer to any provider enrolled with the office qualified to provide the service.(c) HHW self-referral services and limitations are as follows:(1) Emergency services are covered without needing prior authorization or an existing MCO contract with the emergency care provider.(2) Urgent care services.(3) Family planning services may be provided by a provider contracted with the office qualified to provide the family planning service, including providers not in the MCO's network.(4) Immunizations are self-referral to a provider enrolled with the office.(5) Podiatric services may be provided by a provider licensed under IC 25-22.5 or IC 25-29 who has entered into a provider agreement with the office under IC 12-15-11.(6) Psychiatric services may be provided by a provider licensed under IC 25-22.5 who has entered into a provider agreement with the office under IC 12-15-11.(7) Eye care services, except surgical services, may be provided by a provider licensed under IC 25-22.5 or IC 25-24 who has entered into a provider agreement with the office under IC 12-15-11.(8) Diabetes self-management services are self-referral if given by a self-referral provider.(9) Chiropractic services may be provided by a licensed chiropractor when given within the scope of the practice of chiropractic as defined in IC 25-10-1-1 and 846 IAC 1-3 by a provider who has entered into a provider agreement with the office under IC 12-15-11.(10) Routine dental services may be provided by a licensed dental provider contracted with the MCO who has entered into a provider agreement with the office under IC 12-15-11.(11) Nonpsychiatric behavioral health services are self-referral when provided by a provider contracted with the MCO. This includes mental health, substance abuse, and chemical dependency services given by mental health specialty providers.Office of the Secretary of Family and Social Services; 405 IAC 14-5-5; filed 8/30/2024, 11:42 a.m.: 20240925-IR-405240180FRA