Indiana Administrative Code
Title 407 - OFFICE OF THE CHILDREN'S HEALTH INSURANCE PROGRAM
Article 3 - BENEFITS AND MEDICAL POLICY
Rule 3 - CHIP; Coverage; Use of Medicaid Rules
Section 3-2 - Prior authorization; administrative review and appeals
Universal Citation: 407 IN Admin Code 3-2
Current through September 18, 2024
Authority: IC 12-17.6-2-11
Affected: IC 12-17.6
Sec. 2.
(a) The procedures and requirements set forth in 405 IAC 5-3 and 405 IAC 5-7 for Medicaid prior authorization, administrative review, and appeals shall apply to the following:
(1) Services rendered to CHIP
primary care case management members.
(2) Services rendered to CHIP risk-based
managed care members if the service is carved out of a CHIP risk-based MCO
contract.
(b) Except as provided in subsection (a) or as otherwise set forth in this article, the prior authorization procedures used by the Medicaid risk-based managed care program shall apply to services rendered to a CHIP risk-based managed care member.
(1) Services furnished by a CHIP MCO must be
sufficient in amount, duration, and scope to reasonably achieve the purpose for
which the services are furnished.
(2) CHIP MCOs shall publish their prior
authorization procedures. The initial publication of prior authorization
procedures and any updates to prior authorization procedures shall be made
effective not earlier than forty-five (45) days after the date of publication.
For purposes of this section, "publication" means, at minimum, making the prior
authorization procedures available by posting the prior authorization
procedures on the CHIP MCO's public website.
(3) A CHIP MCO's prior authorization
procedures shall include all information necessary for a provider to submit a
prior authorization request.
(4) A
provider that:
(A) has an agreement with the
office; and
(B) renders services to
a CHIP MCO member;
must follow the procedures published under this subsection whether that provider has a contract with the CHIP MCO or not.
(5) Decisions by CHIP
MCOs regarding prior authorization shall be made as expeditiously as possible
considering the circumstances of each request. If no decision is made within
seven (7) calendar days of receipt of all documentation required, authorization
is deemed to be granted.
Disclaimer: These regulations may not be the most recent version. Indiana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
