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    v1.0.28
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyIndiana DOI Psychiatric Care Prior Auth | OpenPaye…
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    CurrentIndiana Department of InsurancePolicy 2422.10.10

    Certification of Need/Inpatient Psychiatric Care

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    This policy governs prior authorization and Form 1261A certification-of-need requirements for Medicaid reimbursement of inpatient psychiatric hospital and psychiatric residential treatment facility services for individuals under age 21 or age 65 and older.

    Policy Summary
    PayerIndiana Department of Insurance
    PolicyCertification of Need/Inpatient Psychiatric Care
    Policy CodePolicy 2422.10.10
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionFacilities must complete and submit Form 1261A to the appropriate reviewing authority for prior authorization.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Under 21 or 65+Age groups requiring approved Form 1261A
    Form 1261ARequired certification and prior authorization form
    Before admissionSubmission timing for individuals under age 21
    Within 10 daysApplicant submission deadline

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Suspend Medicaid
    Action when disapproved and recipient remains in facility

    Psychiatric Facility Reimbursement Requirements

    Requirements for psychiatric facility reimbursement

    Medicaid reimbursement requires ALL of the following:

    ALL of the following

    • ONE of

      • ALL of the following

        • Individual is under age 21

      • ALL of the following

        • Individual is age 65 or older
    • Services are inpatient psychiatric hospital or psychiatric residential treatment facility services provided in a Medicaid-certified psychiatric facility
    • Form 1261A, Certification-Plan of Care for Inpatient Psychiatric Hospital Services, is approved as the prior authorization certification of need

    Submission Timing and Age Thresholds

    Coverage threshold
    Age thresholdUnder age 21 or aged 65 and older
    Covered servicesInpatient psychiatric hospital and psychiatric residential treatment facility services
    Required authorizationAn approved prior authorization certification of need documented on Form 1261A
    Applicant submission timing
    Submission deadlineWithin 10 days after the applicant has been determined eligible for Medicaid
    Applies toMedicaid applicants
    Application processing

    Form 1261A Submission and Review Actions

    Prior Authorization

    Complete and submit Form 1261A

    The facility is responsible for completing and submitting Form 1261A, Certification-Plan of Care for Inpatient Psychiatric Hospital Services, as the prior authorization request.

    Prior Authorization

    Submit to the correct reviewing authority

    Submit the Form 1261A request to the reviewing authority assigned to the facility and member’s program. State facilities submit it to the IHCP Office Medical Review Team, Office of Medicaid Policy and Planning; privately owned facilities submit it to the appropriate prior authorization unit of the Medicaid fiscal contractor based on the member’s program assignment.

    • State facilities: IHCP Office Medical Review Team, Office of Medicaid Policy and Planning.
    • Privately owned facilities: appropriate prior authorization unit of the Medicaid fiscal contractor based on the member’s program assignment.

    Key Terms

    Form 1261A
    Form nameCertification-Plan of Care for Inpatient Psychiatric Hospital Services
    PurposeRequired prior authorization certification of need for inpatient psychiatric hospital and psychiatric residential treatment facility services
    Approval requirementAn approved Form 1261A is required for Medicaid reimbursement for the covered individuals and services addressed by the policy
    PA contractor
    RolePrior authorization review authority
    Decision responsibilityDetermines whether a prior authorization request is approved
    Review basis
    Policy Summary
    PayerIndiana Department of Insurance
    PolicyCertification of Need/Inpatient Psychiatric Care
    Policy CodePolicy 2422.10.10
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionFacilities must complete and submit Form 1261A to the appropriate reviewing authority for prior authorization.
    SourceLink
    On This Page
    Psychiatric Facility Reimbursement RequirementsSubmission Timing and Age ThresholdsForm 1261A Submission and Review ActionsKey Terms
    Caseworkers complete the application process in the usual manner using post-eligibility budgeting procedures
    Prior Authorization

    Submit before admission for individuals under 21

    For individuals under age 21, submit Form 1261A prior to the admission of a Medicaid recipient.

    Prior Authorization

    Submit within 10 days for applicants

    For Medicaid applicants, submit Form 1261A within 10 days after the applicant has been determined eligible for Medicaid.

    Documentation Required

    Retain and route Form 1261A copies

    Following approval or disapproval of the plan of care, the original Form 1261A is returned to the facility, and a copy is forwarded to the Local Office for retention in the case file. The Local Office must not forward copies of the signed Form 1261A to the Medical Review Team.

    • Original: returned to the facility.
    • Copy: forwarded to the Local Office for case-file retention.
    • Do not forward signed-form copies from the Local Office to the Medical Review Team.
    Prior Authorization

    PA review criteria

    The prior authorization contractor determines whether the request is approved based on medical necessity and administrative criteria.

    Medical necessity and administrative criteria
    Psychiatric facility
    DefinitionA Medicaid-certified psychiatric hospital or psychiatric residential treatment facility
    Services providedInpatient psychiatric hospital and psychiatric residential treatment facility services
    Policy relevanceThe facility setting in which the covered services and Form 1261A certification-of-need requirements apply