Section 405 IAC 14-6-7 - Self-referralAuthority: IC 12-15-1-10
Affected: IC 12-15-5; IC 12-15-11; IC 12-15-12; IC 25-10-1-1; IC 25-22.5; IC 25-23-1-1; IC 25-24; IC 25-29
Sec. 7.
(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) PathWays 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 1-1 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 rendered by the following mental health specialty providers to which the member may self-refer within network: (A) Outpatient mental health clinics.(B) Community mental health centers.(D) Licensed psychologists.(E) Health services providers in psychology.(F) Licensed social workers.(G) Licensed clinical social workers.(I) Independent practice school psychologists.(J) Advanced practice nurses under IC 25-23-1-1 (b)(3), credentialed in psychiatric or mental health nursing by the American Nurses Credentialing Center.(K) Persons holding a master's degree in social work, marital and family therapy, or mental health counseling.Office of the Secretary of Family and Social Services; 405 IAC 14-6-7; filed 8/30/2024, 11:42 a.m.: 20240925-IR-405240180FRA