405 IAC 5-17-1 Reimbursement; limitations

Sec. 1. (a) Inpatient and outpatient hospital services are covered when such services are provided or prescribed and documented by a physician and when the services are medically necessary for the diagnosis or treatment of the member's condition, subject to the limitations set out in this article. (b) Reimbursement shall be made only for covered services. In addition, if an inpatient procedure requires prior authorization and prior authorization is either not obtained or denied, reimbursement for the inpatient procedure and any associated services, including inpatient days, shall be denied. (c) Reimbursement is not available for reserving a bed during a therapeutic leave of absence from an acute care hospital. (d) Reimbursement for inpatient hospital services is available only when it is determined to be medically necessary for the services to be performed only in an inpatient hospital setting. (e) Reimbursement will be denied for any days of the hospital stay during which the inpatient hospitalization is found not to have been medically necessary. (f) Reimbursement under the level of care methodology described in 405 IAC 1-10.5 will be made for the lesser of: (1) the number of days actually used; or (2) the number of days prior authorized by the office. (g) The member's medical condition, as described and documented in the medical record by the primary or attending physician must justify the intensity of service provided. (h) All transfers, including interfacility transfers where the transferring or receiving facility or unit is paid according to the level of care methodology as described in 405 IAC 1-10.5 will be subject to retrospective review.