405 IAC 13-2-2 Prior authorization; administrative review and appeals

Sec. 2. (a) The procedures and requirements set forth in 405 IAC 5-3 and 405 IAC 5-7 for Medicaid prior authorization, administrative review, and appeals shall apply to the following: (1) Services rendered to CHIP primary care case management members. (2) Services rendered to CHIP risk-based managed care members if the service is carved out of a CHIP risk-based MCO contract. (b) Except as provided in subsection (a) or as otherwise set forth in this article, the prior authorization procedures used by the Medicaid risk-based managed care program shall apply to services rendered to a CHIP risk-based managed care member. (1) Services furnished by a CHIP MCO must be sufficient in amount, duration, and scope to reasonably achieve the purpose for which the services are furnished. (2) CHIP MCOs shall publish their prior authorization procedures. The initial publication of prior authorization procedures and any updates to prior authorization procedures shall be made effective not earlier than forty-five (45) days after the date of publication. For purposes of this section, "publication" means, at minimum, making the prior authorization procedures available by posting the prior authorization procedures on the CHIP MCO's public website. (3) A CHIP MCO's prior authorization procedures shall include all information necessary for a provider to submit a prior authorization request. (4) A provider that: (A) has an agreement with the office; and (B) renders services to a CHIP MCO member; must follow the procedures published under this subsection whether that provider has a contract with the CHIP MCO or not. (5) Decisions by CHIP MCOs regarding prior authorization shall be made as expeditiously as possible considering the circumstances of each request. If no decision is made within seven (7) calendar days of receipt of all documentation required, authorization is deemed to be granted.