Section 405IAC5-5-2. Prior authorization requirements for out-of-state services

   (a) The services listed in section 1 of this rule require prior authorization except as follows:

(1) Emergency services provided out-of-state are exempt from prior authorization; however, continuation of inpatient treatment and hospitalization is subject to the prior authorization requirements of Indiana.

(2) Members of the adoption assistance program placed outside of Indiana will receive approval for all routine medical and dental care provided out-of-state.

(3) Recipients may obtain services listed in section 1 of this rule in the following designated out-of-state cities subject to the prior authorization requirements for in-state services set out in this article:

(A) Louisville, Kentucky.

(B) Cincinnati, Ohio.

(C) Harrison, Ohio.

(D) Hamilton, Ohio.

(E) Oxford, Ohio.

(F) Sturgis, Michigan.

(G) Watseka, Illinois.

(H) Danville, Illinois.

(I) Owensboro, Kentucky.

(4) Recipients may obtain services in Chicago, Illinois, subject to all of the following conditions:

(A) The recipient's physician determines the service is medically necessary.

(B) Transportation to an appropriate Indiana facility would cause undue hardship to the patient or the patient's family.

(C) The service is not available in the immediate area.

(D) The recipient's physician complies with all of the criteria set forth in this article, in accordance with the state plan and 42 CFR 456.3.

  (b) Prior authorization will not be approved for the following services outside of Indiana and are not covered outside of Indiana for designated cities listed in subsection (a)(3) through (a)(4):

(1) Nursing facilities, ICFs/IID, or home health agency services.

(2) Any other type of long term care facility, including facilities directly associated with or part of an acute general hospital.

  (c) Prior authorization may be granted for any time period from one (1) day to one (1) year for out-of-state medical services listed in section 1 of this rule if the service is medically necessary and any one (1) of the following criteria is also met:

(1) The service is not available in Indiana. However, care provided by out-of-state Veterans Administration and Shrine hospitals is an exception to this requirement.

(2) The member has received services from the provider previously.

(3) Transportation to an appropriate Indiana facility would cause undue expense or hardship to the member or Medicaid.

(4) The out-of-state provider is a regional treatment center or distributor.

(5) The out-of-state provider is significantly less expensive than the Indiana providers, for example, large laboratories versus an individual pathologist.

(Office of the Secretary of Family and Social Services; 405 IAC 5-5-2; filed Jul 25, 1997, 4:00 p.m.: 20 IR 3308; filed Sep 27, 1999, 8:55 a.m.: 23 IR 309; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA; filed Aug 1, 2016, 3:44 p.m.: 20160831-IR-405150418FRA; errata filed Nov 1, 2016, 9:36 a.m.: 20161109-IR-405160493ACA)