405 IAC 5-3-9 - Prior authorization after services have begun
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-15-30-1
Sec. 9.
Prior authorization will be given after services have begun or supplies have been delivered only under the following circumstances:
(1) Pending or retroactive member
eligibility. The prior authorization request must be submitted within twelve
(12) months of the date of the issuance of the member's Medicaid
card.
(2) Mechanical or
administrative delays or errors by the office.
(3) Services rendered outside Indiana by a
provider who has not yet received a provider manual.
(4) Transportation services authorized under
405 IAC 5-30. The prior
authorization request must be submitted within twelve (12) months of the date
of service.
(5) The provider was
unaware that the member was eligible for services at the time services were
rendered. Prior authorization will be granted in this situation only if the
following conditions are met:
(A) The
provider's records document that the member refused or was physically unable to
provide the member identification (RID) number.
(B) The provider can substantiate that the
provider continually pursued reimbursement from the patient until Medicaid
eligibility was discovered.
(C) The
provider submitted the request for prior authorization within sixty (60) days
of the date Medicaid eligibility was discovered.
Notes
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No prior version found.