Indiana Administrative Code
Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES
Article 10 - HEALTHY INDIANA PLAN
Rule 7 - Benefits and Medical Policy
Section 7-12 - Prior authorization

Universal Citation: 405 IN Admin Code 7-12

Current through September 18, 2024

Authority: IC 12-15-44.5-9

Affected: IC 12-15-44.5

Sec. 12.

(a) A managed care organization may implement utilization control procedures, including prior authorization or precertification of services as provided under 42 CFR 438.210. The following services shall be exempt from prior authorization:

(1) Emergency services, subject to the requirements of section 9 of this rule.

(2) Family planning services.

(3) Urgent care.

(b) A provider that:

(1) has an agreement with the office; and

(2) renders services to a member;

shall follow the utilization control procedures implemented by the member's managed care organization under subsection (a) regardless of whether that provider has a contract with the member's managed care organization.

(c) Managed care organizations shall make decisions regarding prior authorization and precertification in accordance with the requirements of 405 IAC 5-3-14.

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