Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3

Affected: IC 12-15-30-1

Sec. 5. (a) Written evidence of physician involvement and personal patient evaluation will be required to document the acute medical needs. A current plan of treatment and progress notes, as to the necessity, effectiveness, and goals of therapy services, must be submitted with the Medicaid prior authorization request and available for audit purposes.

(b) For services requiring a written request for authorization, a properly completed Medicaid prior authorization request must be submitted and approved by the contractor prior to the service being rendered.

(c) The following information must be submitted with the written prior authorization request form:

1. (1) The name, address, age, and Medicaid number of the patient.

2. (2) The name, address, telephone number, provider number, and signature of the provider. The agency will accept any of the following:

   1. (A) A prior authorization request form bearing the original signature of the provider.
   2. (B) A scanned or faxed copy of an originally signed prior authorization request form described in clause (A).
   3. (C) An original prior authorization request form bearing the provider's signature stamp.
   4. (D) A scanned or faxed copy of a prior authorization request form described in clause (C).
   5. (E) The electronic signature of the provider submitted through the prior authorization electronic management system according to agency policy.
3. (3) Diagnosis and related information.
4. (4) Services or supplies requested with appropriate CPT, HCPCS, or American Dental Association code.
5. (5) Name of suggested provider of services or supplies.
6. (6) Date of onset of medical problems.
7. (7) Plan of treatment.
8. (8) Treatment goals.
9. (9) Rehabilitation potential (where indicated), except as set forth in 405 IAC 5-19-7(5).
10. (10) Prognosis (where indicated).
11. (11) Description of previous services or supplies provided, length of such services, or when supply or modality was last provided.
12. (12) Statement whether durable medical equipment will be purchased, rented, or repaired and the duration of need.
13. (13) Statement of any other pertinent clinical information that the provider deems necessary to justify that the treatment was medically necessary.

14. (14) Additional information may be required as needed for clarification, including, but not limited to, the following:

    1. (A) X-rays.
    2. (B) Photographs.
    3. (C) Other services being received.
15. (15) Diagnosis code.

(Office of the Secretary of Family and Social Services; 405 IAC 5-3-5; filed Jul 25, 1997, 4:00 p.m.: 20 IR 3304; filed Sep 27, 1999, 8:55 a.m.: 23 IR 308; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA; filed Oct 26, 2015, 9:10 a.m.: 20151125-IR-405150070FRA; filed Aug 1, 2016, 3:44 p.m.: 20160831-IR-405150418FRA; errata filed Nov 1, 2016, 9:36 a.m.: 20161109-IR-405160493ACA; filed Jul 23, 2018, 3:32 p.m.: 20180822-IR-405180125FRA; readopted filed May 30, 2023, 11:54 a.m.: 20230628-IR-405230292RFA)