405 Ind. Admin. Code 5-1-1

Current through May 29, 2024

Section 405 IAC 5-1-1 - Intent and purpose

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

Affected: IC 12-7-1-1; IC 12-13-7-3; IC 12-15-5-1; IC 12-15-5-2

Sec. 1.

(a) Under IC 12-7-1-1, Title XIX of the federal Social Security Act, and federal regulations adopted thereunder (as adopted by IC 12-13-7-3), the office with the advice of its medical staff, hereby adopts and promulgates this article to:

(1) interpret and implement the provisions of IC 12-15-5-1 and IC 12-15-21-3;

(2) ensure the efficient, economical, and medically reasonable operation of a medical assistance program (hereinafter referred to as Medicaid) in Indiana; and

(3) safeguard against overutilization, fraud, abuse, and utilization and provision of services and supplies that are not medically necessary.

(b) The purposes for this article are accomplished in this article by means of the following:

(1) A rule describing the prior authorization process mandated by IC 12-15-21-3(1).

(2) A rule interpreting the definition of provider as set out in IC 12-7-2-149.

(3) Rules describing the services that require prior authorization by the office under IC 12-15-21-3(1).

(4) Rules describing the criteria to be applied by the office in the prior authorization or denial of services under IC 12-15-21-3(1).

(5) Rules describing the limitations consistent with medically necessary services on the duration of services to be provided under IC 12-15-21-3(3).

(6) Rules interpreting IC 12-15-5-2 by listing specific services that are not covered by Medicaid because federal financial participation is not available for such services or such services are not medically necessary in view of alternative services available under this rule.

405 IAC 5-1-1

Office ofthe Secretary of Family and Social Services; 405 IAC 5-1-1; filed Jul 25, 1997, 4:00 p.m.: 20IR 3299; filed Sep 27, 1999, 8:55 a.m.: 23 IR 307; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; readopted filed Sep 19, 2007, 12:16p.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

Readopted filed 7/28/2022, 2:21 p.m.: 20220824-IR-405220205RFA

Readopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA