405 Ind. Admin. Code 5-21.5-17

Current through December 4, 2024

Section 405 IAC 5-21.5-17 - Prior authorization

Authority: IC 12-15

Affected: IC 12-13-7-3

Sec. 17.

(a) MRO services are packaged according to diagnosis and level of need. Diagnosis and level of need qualifications for service packages, and services included within each service package:

(1) will be listed and published in a provider manual by the OMPP; and

(2) may be updated by the OMPP as needed.

(b) Prior authorization is required as follows:

(1) A member uses all units of one (1) or more of the services authorized in the service package within the defined service package term, and additional units of that service are needed.

(2) A member needs a service that is not authorized within a service package.

(3) A service package provided through a certified DMHA ACT team.

(4) A member who is denied an MRO service package may submit prior authorization for a specific MRO service.

(5) Services may be prior authorized for retroactive Medicaid eligibility periods.

(c) Providers who may submit prior authorization, as referenced in 405 IAC 5-3-13, include any of the following:

(1) A doctor of medicine.

(2) A doctor of osteopathy.

(3) An HSPP.

405 IAC 5-21.5-17

Office ofthe Secretary of Family and Social Services; 405 IAC 5-21.5-17; filed May 27, 2010, 9:15 a.m.: 20100623-IR-405100045FRA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA

Filed 8/1/2016, 3:44 p.m.: 20160831-IR-405150418FRA

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

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