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TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES

Final Rule
LSA Document #08-192(F)

DIGEST

Amends 405 IAC 5-3-13 to apply prior authorization to community mental health rehabilitation services. Repeals 405 IAC 5-21-7. Effective 30 days after filing with the Publisher.



SECTION 1. 405 IAC 5-3-13 IS AMENDED TO READ AS FOLLOWS:

405 IAC 5-3-13 Services requiring prior authorization

Authority: IC 12-8-6-3; IC 12-8-6-5; IC 12-15


Sec. 13. (a) Medicaid reimbursement is available for the following services with prior authorization:
(1) Reduction mammoplasties.
(2) Rhinoplasty or bridge repair of the nose when related to a significant obstructive breathing problem.
(3) Intersex surgery.
(4) Blepharoplasties for a significant obstructive vision problem.
(5) Sliding mandibular osteotomies for prognathism or micrognathism.
(6) Reconstructive or plastic surgery.
(7) Bone marrow or stem cell transplants.
(8) All organ transplants covered by the Medicaid program.
(9) Home health services.
(10) Maxillofacial surgeries related to diseases and conditions of the jaws and contiguous structures.
(11) Temporomandibular joint surgery.
(12) Submucous resection of nasal septum and septoplasty when associated with significant obstruction.
(13) Weight reduction surgery, including gastroplasty and related gastrointestinal surgery.
(14) Any procedure ordinarily rendered on an outpatient basis, when rendered on an inpatient basis.
(15) All dental admissions.
(16) Brand medically necessary drugs.
(17) Other drugs as specified in accordance with 405 IAC 5-24-8.5.
(18) Psychiatric inpatient admissions, including admissions for substance abuse.
(19) Rehabilitation inpatient admissions.
(20) Assertive community treatment intensive case management as provided under 405 IAC 5-21-1.
(21) Orthodontic procedures for members under twenty-one (21) years of age for cases of craniofacial deformity or cleft palate.
(22) Genetic testing for detection of cancer of the breast or breasts or ovaries.
(23) Community mental health rehabilitation services.
(23) (24) As otherwise specified in this article.
If any of the surgeries listed in this section are performed during a hospital stay for another condition, prior authorization is required for the surgical procedure.

(b) Requests for prior authorization for the surgical procedures in this section will be reviewed for medical necessity on a case-by-case basis in accordance with this rule.
(Office of the Secretary of Family and Social Services; 405 IAC 5-3-13; filed Jul 25, 1997, 4:00 p.m.: 20 IR 3306; filed Sep 1, 2000, 2:16 p.m.: 24 IR 14; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; filed Jan 7, 2002, 10:11 a.m.: 25 IR 1613; filed Feb 26, 2004, 3:45 p.m.: 27 IR 2244; filed Feb 14, 2005, 10:25 a.m.: 28 IR 2132; filed Feb 3, 2006, 2:00 p.m.: 29 IR 1903; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA; filed Aug 18, 2009, 11:32 a.m.: 20090916-IR-405080192FRA)


SECTION 2. 405 IAC 5-21-7 IS REPEALED.

LSA Document #08-192(F)
Notice of Intent: 20080319-IR-405080192NIA
Proposed Rule: 20090603-IR-405080192PRA
Hearing Held: June 25, 2009
Approved by Attorney General: August 7, 2009
Approved by Governor: August 17, 2009
Filed with Publisher: August 18, 2009, 11:32 a.m.
Documents Incorporated by Reference: None Received by Publisher
Small Business Regulatory Coordinator: Glenna Asmus, Office of Medicaid Policy and Planning, Indiana Family and Social Services Administration, 402 W. Washington Street, Room W374, Indianapolis, IN 46204, (317) 234-4753, glenna.asmus@fssa.in.gov

Posted: 09/16/2009 by Legislative Services Agency

DIN: 20090916-IR-405080192FRA
Composed: Apr 25,2024 5:44:46AM EDT
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