441—88.48 (249A) Services.
	 88.48(1) Managed services. Provision of the following services by any provider other than the patient manager requires authorization from the patient manager in order to be payable by Medicaid except that mental health and substance abuse services for all managed health care recipients are provided under the Iowa Plan program and do not require authorization (see rule 441—88.61(249A)):
	  a.   	 Inpatient hospital.
	  b.   	 Outpatient hospital.
	  c.   	 Home health.
	  d.   	 Physician (except services provided by an ophthalmologist).
	  e.   	 Clinic (rural health clinic, federally qualified health center, maternal health center, ambulatory surgical center, birthing center).
	  f.   	 Laboratory, X-ray.
	  g.   	 Medical supplies.
	  h.   	 Physical therapy, audiology, rehabilitation agency, advanced registered nurse practitioner.
	  i.   	 Rescinded IAB 11/5/97, effective 1/1/98.
	  j.   	 Podiatric.
These services require authorization even if the need for the service is considered urgent. However, in case of urgent medical conditions, the patient manager shall arrange for necessary care within 24 hours by either providing it or referring to and authorizing another appropriate provider to provide care.
	 88.48(2) Nonmanaged services. Provision of any services not listed in subrule 88.48(1) does not require authorization from the patient manager in order to be payable by Medicaid.
	 88.48(3) Authorizing managed services. The patient manager may make referrals to another provider for specialty care or for primary care during the patient manager’s absence or nonavailability.
	  a.   	 No special authorization or referral form is required, and referrals should occur in accordance with accepted practice in the medical community. To ensure that payment is made for properly authorized services, the patient manager shall provide the specialist or other provider with the patient manager’s Medicaid provider number (the national provider identifier number or Iowa-specific provider identifier number), which must be entered on the billing form to signify that the service has been authorized.
	  b.   	 After the patient manager’s initial referral of a patient to a specialist for ongoing treatment, the specialist shall not be required to receive further specific authorizations for the duration of the illness, or at the discretion of the patient manager, for a period of time specified by the patient manager.
	  c.   	 The referral shall include necessary services rendered by the specialist and referrals for related services made by the specialist. With the patient manager’s approval, the patient manager’s number may be relayed by the referred specialist to other providers considered necessary for proper treatment of the patient. All authorizations and referrals shall be documented by both the patient manager and the referred-to provider in the patient’s medical record.
	  d.   	 Emergency services are excluded from the authorization requirement, even though these services may be ones customarily requiring authorization under patient management. Urgent care requires authorization in order for Medicaid services to be paid. The unauthorized use of a patient manager’s authorization number shall be considered to be a false or fraudulent claim submission and may subject the provider to recoupment or to sanctions described at 441—subrule 79.2(3).
	 88.48(4) Special authorizations. Special authorization for the provision of managed services shall be given to providers by the department in situations such as, but not limited to, the death of the enrolled recipient’s patient manager, the patient manager has left medical practice, moved from the medical service area or has been removed as a Medicaid provider and the department has not yet been able to establish a new patient manager or other managed health care option for the recipient. The procedure for obtaining this special authorization shall be specified in the provider handbook. The special authorization procedures shall only be used until the department is able to enroll the recipient with another patient manager or managed health care option. Additionally, special authorizations may be given when contracting patient managers fail to comply with contract provisions such as, but not limited to, failure to maintain 24-hour access as specified in subrule 88.45(2), paragraph “b.”