Minnesota Administrative Rules
Agency 196 - Human Services Department
Chapter 9505 - HEALTH CARE PROGRAMS
CONDITIONS FOR MEDICAL ASSISTANCE AND GENERAL ASSISTANCE MEDICAL CARE PAYMENT
Part 9505.5010 - PRIOR AUTHORIZATION REQUIREMENT

Subpart 1. Provider requirements.

A provider shall obtain prior authorization as a condition of payment under the medical assistance, general assistance medical care, and MinnesotaCare programs for health services designated under parts 9505.0170 to 9505.0475 and 9505.5025; and Minnesota Statutes, section 256B.0625, subdivision 25. The provider of the health service shall submit the request on form DHS-3065 or DHS-3066, or the American Dental Association (ADA) form as required in subpart 3, and shall submit materials, reports, progress notes, admission histories, and other information that substantiates that the service is medically necessary to treat the recipient. If the provider obtains prior authorization before the health service is provided but before payment, the provider shall be assured payment at the authorized level after the recipient has received the service. If a provider requests prior authorization after the service has been provided but before payment, the provider shall be assured of payment only if prior authorization is given. Additionally, prior authorization shall assure the provider payment for the approved health service only if the service is given during a time the person is a recipient and the provider meets all requirements of the medical assistance, general assistance medical care, or MinnesotaCare programs.

Subp. 2. [Repealed, 19 SR 2433]

Subp. 3. Submission of forms.

The provider shall submit to the department a request for prior authorization on form DHS-3065 or DHS-3066, or the American Dental Association (ADA) form, which has been completed according to instructions in the Minnesota Health Care Programs Provider Manual, and other information necessary to address the criteria in part 9505.5030. The provider shall bear the burden of establishing compliance with the criteria in part 9505.5030 and shall submit information which demonstrates that the criteria in part 9505.5030 are met. The provider who administers or supervises the recipient's care shall personally review and sign the form and any attached documentation.

Subp. 4. Consequences for failure to obtain prior authorization.

A provider who furnishes health services without obtaining prior authorization under parts 9505.5010 to 9505.5030 shall be denied payment. A physician, hospital, or other provider who is denied payment because of failure to comply with parts 9505.5010 to 9505.5030 shall not seek payment from the recipient and the recipient shall not be liable for payment of the service for which the provider is denied payment due to lack of prior authorization.