Section 405 IAC 5-22-2 - Nursing services; prior authorization requirementsAuthority: IC 12-15
Affected: IC 12-13-7-3
Sec. 2.
(a) Medicaid reimbursement is available for services rendered by registered nurses, licensed practical nurses, and home health agencies who are providers, subject to the following:(1) Prior authorization is required for all nursing services, except services ordered in writing by a physician prior to the recipient's discharge from an inpatient hospital, which may continue for a period not to exceed one hundred twenty (120) units within thirty (30) days of discharge without prior authorization and except as noted in subsection (c). Prior authorization requests may be submitted by an authorized representative of the home health agency. The prior authorization form must contain the information specified in 405 IAC 5-3-5. In addition, the following information must be submitted with the prior authorization request form:(A) A copy of the written plan of treatment, signed by the attending physician.(B) An estimate of the costs for the requested services as ordered by the physician and as set out in the written plan of treatment. The cost estimate must be provided on or with the plan of treatment and signed by the attending physician.(2) Prior authorization shall include consideration of the following:(A) Written order of a physician.(B) Services must be provided according to a plan of treatment developed in coordination with the attending physician.(C) The attending physician must review the plan of treatment every sixty (60) days and reorder the service if medically necessary.(D) Written evidence of physician involvement and personal patient evaluation will be required to document the acute medical needs. A current plan of treatment and progress notes, as to the necessity and effectiveness of nursing services, must be attached to the prior authorization request and available for postpayment audit purposes.(E) Additional hours of nursing service may be authorized for ventilator dependent patients who have a developed plan of home health care providing it is cost effective and prevents repeated or prolonged stays in an acute care facility.(b) Reimbursement is not available for care provided by family members or other individuals residing with the recipient.(c) Medicaid reimbursement is available for IEP nursing services when the services are medically necessary, consistent with the definition set forth in 405 IAC 5-2-13.2, and provided pursuant to a Medicaid enrolled student's IEP. The following apply to IEP nursing services:(1) The IEP is the prior authorization for IEP nursing services, when provided by a Medicaid participating school corporation.(2) The school corporation must bill for the appropriate start and stop time or times of IEP nursing services. Documentation of IEP nursing services must include: (A) The start and stop time or times for each IEP nursing service provided per date of service.(B) The place of service and a description of the beginning and ending date or dates and time or times if the IEP services provided off-site or during a school field trip.(3) The Medicaid enrolled student's IEP must: (A) specifically authorize the Medicaid covered IEP nursing service; and(B) demonstrate there is a medical need for the IEP nursing service.(4) The reimbursement rate will be set by the office.Office of the Secretary of Family and Social Services; 405 IAC 5-22-2; filed Jul 25, 1997, 4:00 p. m.: 20 IR 3338; filed Sep 27, 1999, 8:55 a.m.: 23 IR 317; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA; filed Apr 22, 2013, 9:47 a.m.: 20130522-IR-405120550FRA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFAFiled 8/1/2016, 3:44 p.m.: 20160831-IR-405150418FRAReadopted filed 7/28/2022, 2:21 p.m.: 20220824-IR-405220205RFAReadopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA