405 IAC 5-3-11 - Criteria for prior authorization

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3

Affected: IC 12-15-30-1

Sec. 11.

The office's decision to authorize, modify, or deny a given request for prior authorization shall include consideration of the following:

(1) Individual case-by-case review of the completed Medicaid prior authorization request form.

(2) The medical and social information provided on the request form or documentation accompanying the request form.

(3) Review of criteria set out in this section for the service requested.

(4) If the service is medically necessary as defined in this article.

Notes

405 IAC 5-3-11

Office ofthe Secretary of Family and Social Services; 405 IAC 5-3-11; filed Jul 25, 1997, 4:00p.m.: 20 IR 3305; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822;filed Oct 3, 2001, 9:47 a.m.: 25 IR 378; readopted filed Sep 19, 2007, 12:16p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA Filed 8/1/2016, 3:44 p.m.: 20160831-IR-405150418FRA Errata filed 11/1/2016, 9:36 a.m.: 20161109-IR-405160493ACA Readopted filed 7/28/2022, 2:21 p.m.: 20220824-IR-405220205RFA Readopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA