Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-15-30-1
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, effectiveness, and goals of therapy
services, must be submitted with the Medicaid prior authorization request and
available for audit purposes.
For services requiring a written request for authorization, a properly
completed Medicaid prior authorization request must be submitted and approved
by the contractor prior to the service being rendered.
The following information must be
submitted with the written prior authorization request form:
(1) The name, address, age, and Medicaid
number of the patient.
name, address, telephone number, provider number, and signature of the
provider. The agency will accept any of the following:
(A) A prior authorization request form
bearing the original signature of the provider.
(B) A scanned or faxed copy of an originally
signed prior authorization request form described in clause (A).
(C) An original prior authorization request
form bearing the provider's signature stamp.
(D) A scanned or faxed copy of a prior
authorization request form described in clause (C).
(E) The electronic signature of the provider
submitted through the prior authorization electronic management system
according to agency policy.
(3) Diagnosis and related
(4) Services or
supplies requested with appropriate CPT, HCPCS, or American Dental Association
(5) Name of suggested
provider of services or supplies.
(6) Date of onset of medical
(7) Plan of
(where indicated), except as set forth in
(10) Prognosis (where indicated).
(11) Description of previous services or
supplies provided, length of such services, or when supply or modality was last
(12) Statement whether
durable medical equipment will be purchased, rented, or repaired and the
duration of need.
(13) Statement of
any other pertinent clinical information that the provider deems necessary to
justify that the treatment was medically necessary.
Additional information may be required
as needed for clarification, including, but not limited to, the following:
(C) Other services being received.
(15) Diagnosis code.