405 IAC 10-7-12
405 IAC 10-7-12 Prior authorization
Cite as Ind. Admin. Code tit. 405, r. 10-7-12
Sec. 12. (a) A managed care organization may implement utilization control procedures, including prior authorization or precertification
of services as provided under 42 CFR 438.210. The following services shall be exempt from prior authorization:
(1) Emergency services, subject to the requirements of section 9 of this rule.
(2) Family planning services.
(3) Urgent care.
(b) A provider that:
(1) has an agreement with the office; and
(2) renders services to a member;
shall follow the utilization control procedures implemented by the member's managed care organization under subsection (a) regardless of
whether that provider has a contract with the member's managed care organization.
(c) Managed care organizations shall make decisions regarding prior authorization and precertification in accordance with the requirements
of 405 IAC 5-3-14.