405 IAC 5-1-1 Intent and purpose

Sec. 1. (a) Under IC 12-7-1-1, Title XIX of the federal Social Security Act, and federal regulations adopted thereunder (as adopted by IC 12-13-7-3), the office with the advice of its medical staff, hereby adopts and promulgates this article to: (1) interpret and implement the provisions of IC 12-15-5-1 and IC 12-15-21-3; (2) ensure the efficient, economical, and medically reasonable operation of a medical assistance program (hereinafter referred to as Medicaid) in Indiana; and (3) safeguard against overutilization, fraud, abuse, and utilization and provision of services and supplies that are not medically necessary. (b) The purposes for this article are accomplished in this article by means of the following: (1) A rule describing the prior authorization process mandated by IC 12-15-21-3(1). (2) A rule interpreting the definition of provider as set out in IC 12-7-2-149 [NOTE: IC 12-7-2 is repealed by P.L. 145-2026, SECTION 62, effective July 1, 2026.]. (3) Rules describing the services that require prior authorization by the office under IC 12-15-21-3(1). (4) Rules describing the criteria to be applied by the office in the prior authorization or denial of services under IC 12-15-21-3(1). (5) Rules describing the limitations consistent with medically necessary services on the duration of services to be provided under IC 12-15-21-3(3). (6) Rules interpreting IC 12-15-5-2 by listing specific services that are not covered by Medicaid because federal financial participation is not available for such services or such services are not medically necessary in view of alternative services available under this rule.