Authority: IC 12-15-44.5-9

Affected: IC 12-15-44.5

Sec. 12. (a) A managed care organization may implement utilization control procedures, including prior authorization or precertification of services as provided under 42 CFR 438.210. The following services shall be exempt from prior authorization:

1. (1) Emergency services, subject to the requirements of section 9 of this rule.
2. (2) Family planning services.
3. (3) Urgent care.

(b) A provider that:

1. (1) has an agreement with the office; and
2. (2) renders services to a member;

shall follow the utilization control procedures implemented by the member's managed care organization under subsection (a) regardless of whether that provider has a contract with the member's managed care organization.

(c) Managed care organizations shall make decisions regarding prior authorization and precertification in accordance with the requirements of 405 IAC 5-3-14.

(Office of the Secretary of Family and Social Services; 405 IAC 10-7-12; filed May 18, 2015, 12:34 p.m.: 20150617-IR-405140339FRA; filed Jan 19, 2018, 8:42 a.m.: 20180214-IR-405170484FRA; readopted filed Oct 16, 2024, 11:20 a.m.: 20241113-IR-405230817RFA)