405 IAC 5-17-2 - Prior authorization; generally
Authority: IC 12-15
Affected: IC 12-13-7-3
Sec. 2.
(a) Prior
authorization is required for all nonemergent inpatient hospital admissions of
Medicaid eligible members.
Nonemergent inpatient hospital admissions include all elective or planned inpatient hospital admissions and inpatient hospital admissions for which the patient's condition permitted adequate time to schedule the availability of a suitable accommodation. The following are exempt from this requirement:
(1) Inpatient
hospital admissions when covered by Medicare.
(2) Routine vaginal and cesarean section
deliveries.
(b) Prior
authorization is required for all Medicaid covered rehabilitation, burn, and
psychiatric inpatient stays that are reimbursed under the level of care
methodology described in
405 IAC 1-10.5 as well as
substance abuse stays that are reimbursed under the DRG methodology described
at 405 IAC 1-10.5.
(c) Any surgical procedure usually performed
on an outpatient basis, when scheduled as an inpatient procedure, must be prior
authorized. The length of stay for the inpatient admission is determined by the
appropriate diagnosis related group, but will be subject to retrospective
review to determine if the services were medically necessary.
(d) Criteria for determining that the
inpatient admission is medically necessary shall include the following:
(1) Technical or medical difficulties during
the outpatient procedure as documented in the medical record.
(2) Presence of physical or mental conditions
that make prolonged preoperative or postoperative observations by a nurse or
skilled medical personnel a necessity.
(3) Performance of another procedure
simultaneously, which itself requires hospitalization.
(4) Likelihood of another procedure following
the initial procedure, which would require hospitalization.
(e) Days that are not prior
authorized under the level of care methodology as required by this rule will
not be covered by Medicaid.
(f) In
addition to the prior authorization requirements set forth in this section,
prior authorization is also required for the procedures listed in
405 IAC 5-3-13.
Notes
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No prior version found.