Section 405IAC5-31-9. Prior authorization for services rendered outside the state nursing facility

   (a) Medical care rendered by practitioners outside the state nursing facility requires prior authorization.

  (b) Prior authorization will not be given for medical services included in the per diem rate.

  (c) Written evidence of physician involvement and personal patient evaluation in the progress notes and attached to the prior authorization form is required to document that the service is medically necessary.

  (d) Prior authorization will include consideration of the following:

(1) Review of the properly completed Medicaid prior authorization request form substantiating both of the following:

(A) The service is medically necessary.

(B) Explanation of why the service cannot be rendered at the facility.

(2) Review of criteria for the specific medical service requested as set forth in this article.

(Office of the Secretary of Family and Social Services; 405 IAC 5-31-9; filed May 30, 2007, 8:22 a.m.: 20070627-IR-405060158FRA; 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)