405 IAC 14-5-5 Self-referral

Sec. 5. (a) An MCO shall include self-referral providers in their contracted networks. (b) Self-referral services are those that do not require a referral by an enrollee's PMP or other authorization by the MCO, and for which members may self-refer to any provider enrolled with the office qualified to provide the service. (c) HHW self-referral services and limitations are as follows: (1) Emergency services are covered without needing prior authorization or an existing MCO contract with the emergency care provider. (2) Urgent care services. (3) Family planning services may be provided by a provider contracted with the office qualified to provide the family planning service, including providers not in the MCO's network. (4) Immunizations are self-referral to a provider enrolled with the office. (5) Podiatric services may be provided by a provider licensed under IC 25-22.5 or IC 25-29 who has entered into a provider agreement with the office under IC 12-15-11. (6) Psychiatric services may be provided by a provider licensed under IC 25-22.5 who has entered into a provider agreement with the office under IC 12-15-11. (7) Eye care services, except surgical services, may be provided by a provider licensed under IC 25-22.5 or IC 25-24 who has entered into a provider agreement with the office under IC 12-15-11. (8) Diabetes self-management services are self-referral if given by a self-referral provider. (9) Chiropractic services may be provided by a licensed chiropractor when given within the scope of the practice of chiropractic as defined in IC 25-10-1-1 and 846 IAC 1-3 by a provider who has entered into a provider agreement with the office under IC 12-15-11. (10) Routine dental services may be provided by a licensed dental provider contracted with the MCO who has entered into a provider agreement with the office under IC 12-15-11. (11) Nonpsychiatric behavioral health services are self-referral when provided by a provider contracted with the MCO. This includes mental health, substance abuse, and chemical dependency services given by mental health specialty providers.