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Prior Authorization - Indiana Medicaid Provider …

Indiana HEALTH COVERAGE PROGRAMS PR O V I D E R RE F E R E N C E MO D U L E Prior Authorization L I B R A R Y R E F E R E N C E N UM B E R : P R O M O D 0 0 0 1 2 P U B L I S H E D : S E P T E M B E R 1 4 , 2 0 1 7 P O L I C I E S A N D P R O C E D U R ES A S O F M A Y 1 , 2 0 17 V E R S I O N : 2 . 0 Copyright 2017 DXC Technology Company. All rights reserved. Library Reference Number: PROMOD00012 iii Published: September 14, 2017 Policies and procedures as of May 1, 2017 Version: Revision History Version Date Reason for Revisions Completed By Policies and procedures as of October 1, 2015 Published: February 25, 2016 New document FSSA and HPE Policies and procedures as of July 1, 2016 Published: October 13, 2016 Scheduled update FSSA and HPE Policies and procedures as of July 1, 2016 (CoreMMIS updates as of February 13, 2017) Published: March 14, 2017 CoreMMIS update FSSA and HPE Policies a

Prior Authorization Revision History iv Library Reference Number: PROMOD00012 Published: April 26, 2018 Policies and procedures as of February 1, 2018

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Transcription of Prior Authorization - Indiana Medicaid Provider …

1 Indiana HEALTH COVERAGE PROGRAMS PR O V I D E R RE F E R E N C E MO D U L E Prior Authorization L I B R A R Y R E F E R E N C E N UM B E R : P R O M O D 0 0 0 1 2 P U B L I S H E D : S E P T E M B E R 1 4 , 2 0 1 7 P O L I C I E S A N D P R O C E D U R ES A S O F M A Y 1 , 2 0 17 V E R S I O N : 2 . 0 Copyright 2017 DXC Technology Company. All rights reserved. Library Reference Number: PROMOD00012 iii Published: September 14, 2017 Policies and procedures as of May 1, 2017 Version: Revision History Version Date Reason for Revisions Completed By Policies and procedures as of October 1, 2015 Published: February 25, 2016 New document FSSA and HPE Policies and procedures as of July 1, 2016 Published: October 13, 2016 Scheduled update FSSA and HPE Policies and procedures as of July 1, 2016 (CoreMMIS updates as of February 13, 2017) Published: March 14, 2017 CoreMMIS update FSSA and HPE Policies and procedures as of May 1, 2017 Published.

2 September 14, 2017 Scheduled update: Reorganized and edited text as needed for clarity Updated the Fee-for-Service Prior Authorization section Updated the Managed Care Prior Authorization section Added dental admissions to the list of services that require PA in the Prior Authorization Policies for Specific Medical Services section In the Time Parameters for Prior Authorization Requests section: Added Portal as an option for receiving Authorization status Added note box regarding MCE information Updated the Prior Authorization Request Forms section Updated instructions for the universal and dental PA request forms Updated the Prior Authorization Request Status and Decision Letter section, including adding a table that shows PA status responses in the IVR, Portal, and 278 transaction and associated statuses in the decision letter FSSA and DXC Prior Authorization Revision History iv Library Reference Number: PROMOD00012 Published.

3 September 14, 2017 Policies and procedures as of May 1, 2017 Version: Version Date Reason for Revisions Completed By Updated the Prior Authorization Update Decision Letter section Updated the 278 Transactions and HIPAA Compliance section Updated references to 278 companion and implementation guide in several sections Added a reference for place-of-service codes in the Facility Type Codes section Updated the Paper Attachments and Electronic PA Requests section Updated the introductory section of the Prior Authorization Administrative Review and Appeal Procedures section Library Reference Number: PROMOD00012 v Published: September 14, 2017 Policies and procedures as of May 1, 2017 Version: Table of Contents Section 1: Introduction to Prior Authorization .

4 1 Prior Authorization Overview .. 1 Fee-for-Service Prior Authorization .. 1 Managed Care Prior Authorization .. 2 Transferring Outstanding Prior Authorizations .. 2 Prior Authorization Policy Requirements .. 3 Prior Authorization Policies for Out-of-State Providers .. 3 Prior Authorization Policies for Specific Types of Providers or Services .. 3 Prior Authorization Policies for Specific Medical Services .. 4 Prior Authorization Limitations .. 5 Section 2: Prior Authorization Procedures .. 7 Prior Authorization and Eligibility Verification .. 7 Provider Requests for Prior Authorization .. 7 Methods for Submitting PA Requests.

5 8 Provider Types Allowed to Submit PA Requests .. 8 Signature Stamp and Electronic Signature Policies for PA Requests, Attached Forms, and Supporting Documents .. 9 Time Parameters for Prior Authorization Requests .. 9 Suspension for Requests of Additional Information .. 10 New PA Requests for Ongoing Services .. 10 Telephone Prior Authorization Requests .. 10 Telephone PA Exclusions .. 11 Telephone PA Procedures .. 11 Prior Authorization Request Forms .. 12 Indiana Health Coverage Programs Prior Authorization Request Form .. 12 IHCP Prior Review and Authorization Dental Request Form .. 15 Medicaid Second Opinion Form.

6 17 Medical Clearance Forms for DME or Medical Supplies .. 17 Prior Authorization Request Status and Decision Letter .. 18 Prior Authorization Update Requests .. 19 Procedures for Submitting PA Update 20 Prior Authorization Update Decision Letter .. 20 Prior Authorization Procedures for Special Programs .. 20 590 Program Authorizations .. 20 Home and Community-Based Services Waiver Authorizations .. 21 1915(i) Home and Community-Based Services Authorizations .. 21 Retroactive Prior Authorization .. 21 Prior Authorization and Third Party Liability .. 22 Section 3: 278 Electronic Transaction .. 23 278 Transactions and HIPAA Compliance.

7 23 Data Elements .. 24 Certification Type Codes .. 24 Service Type Codes .. 24 Facility Type Codes .. 25 Level-of-Service Codes .. 25 Release of Information Codes .. 25 UMO Information .. 26 Segments .. 26 Diagnosis Segment .. 26 Previous Certification Identification Segment .. 26 Prior Authorization Table of Contents vi Library Reference Number: PROMOD00012 Published: September 14, 2017 Policies and procedures as of May 1, 2017 Version: Procedures Segment .. 26 Message Segment .. 27 Reasons for Rejection of the 278 Request .. 27 Duplicate Requests or Approval of Nonspecific Codes .. 27 Paper Attachments and Electronic PA Requests.

8 28 Retroactive Prior Authorization with 278 Transactions .. 29 Request for Transportation Services .. 29 278 Response .. 29 Action 30 Reject Reason 30 Section 4: Prior Authorization Administrative Review and Appeal Procedures .. 31 Administrative Review of PA Decisions .. 31 Administrative Hearing Appeal Process for PA Decisions .. 32 Provider Appeals of Prior Authorization Decisions .. 32 Member Appeals of Prior Authorization Decisions .. 32 Library Reference Number: PROMOD00012 1 Published: September 14, 2017 Policies and procedures as of May 1, 2017 Version: Section 1: Introduction to Prior Authorization Note: The information in this document applies to Prior Authorization for nonpharmacy services.

9 For information about pharmacy-related Prior Authorization , see the Pharmacy Services module. The Indiana Health Coverage Programs (IHCP) requires Prior Authorization (PA) based on medical necessity for certain services. Certain services also require submitting PA requests for additional units when normal limits are exhausted. The Indiana Administrative Code (IAC) serves as a comprehensive reference for IHCP covered services and PA procedures and parameters. IHCP providers are responsible for reading the portions of the IAC that apply to their areas of service. Specific PA criteria are found in 405 IAC 5-3 and 407 IAC.

10 In addition to the IAC, the Code of Federal Regulations (CFR), Indiana Code (IC), Family and Social Services Administration (FSSA) Medical Policy Manual, and IHCP Provider Reference Modules, along with bulletins and banner pages published on , provide a complete resource for PA policy and procedures. Prior Authorization Overview Multiple entities provide PA for IHCP services. Determining which entity to contact for PA depends on whether the service is reimbursed through the fee-for-service (FFS) or managed care delivery system. This section provides an overview of FFS PA and managed care PA. It also provides information about transferring existing PAs when a member changes from a managed care program to Traditional Medicaid or other FFS plan.


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