405 IAC 5-22-2 - Nursing services; prior authorization requirements
Authority: 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.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
Authority: 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.