New Hampshire Code of Administrative Rules
He - Department of Health and Human Services
Subtitle He-W - Former Division of Human Services
Chapter He-W 500 - MEDICAL ASSISTANCE
Part He-W 530 - SERVICE LIMITS, CO-PAYMENTS, AND NON-COVERED SERVICES
Section He-W 530.07 - Prior Authorization of Services Which Exceed Service Limits

Universal Citation: NH Admin Rules He-W 530.07

Current through Register No. 40, October 3, 2024

(a) When the individual medical care plan of a recipient who is under 21 years of age indicates the need for services in excess of the service limits described in He-W 530.03, authorization to exceed the service limit shall be requested in accordance with He-W 546.

(b) When the individual medical care plan of a recipient who is 21 years of age or older indicates the need for services in excess of the service limits described in He-W 530.03, the provider shall request from the department additional visits or units of covered service(s) .

(c) All requests in (b) above shall be in advance of the service(s) being rendered, except that services provided during a retroactive eligibility period shall be exempt from this requirement.

(d) Requests for additional units of covered service(s) may be made by the following providers:

(1) Advanced practice registered nurses;

(2) Associate psychologists;

(3) Occupational therapists;

(4) Optometrists;

(5) Osteopathic physicians;

(6) Psychotherapy providers licensed by the board of mental health practice;

(7) Physicians;

(8) Physician's assistants;

(9) Podiatrists;

(10) Psychologists;

(11) Physical therapists; and

(12) Speech and language therapists.

(e) Providers shall direct requests for prior authorization of services in excess of the limits described in He-W 530.03 to the department.

(f) Prior to payment by the department, requests for prior authorization of covered services in excess of the limits described in He-W 530.03 shall:

(1) With the exception of services provided during a retroactive eligibility period, be submitted in advance of rendering additional services;

(2) Be submitted in writing to the department via mail, e-mail or fax;

(3) Be signed by a provider described in (d) above; and

(4) Be based on the provider's medical care plan developed for the recipient.

(g) Except as allowed by He-W 573.10, requests for prior authorization shall include, at a minimum:

(1) The recipient's name;

(2) The recipient's Title XIX program identification number;

(3) The recipient's diagnosis;

(4) A copy of the recipient's medical care plan;

(5) The number of additional visits or units of service being requested;

(6) The provider number of the individuals or agencies to whom the recipient is being referred for these additional services;

(7) Clinical documentation that addresses how the requested additional services meet the definition of medically necessary;

(8) Except as provided by (9) below, if the requested additional services do not meet the definition of medically necessary, clinical documentation that addresses:

a. Any extenuating circumstances unique to the recipient that would make denial of the additional services clinically contraindicative; or

b. Any new scientific evidence in the medical literature or by experts in the field about the efficacy or medical appropriateness of the services;

(9) If the requested additional services are for therapy services, as described in He-W 568, documentation demonstrating that the request meets the clinical criteria set forth in the Milliman Care Guidelines, 17th edition (February/March 2013), available as noted in Appendix A;

(10) A statement of the anticipated medical outcome if the requested additional services are provided; and

(11) A statement of the anticipated medical outcome, and either the estimated cost of such outcome or a description of medical services that might be required as the result of such outcome, if the requested additional services are not provided.

(h) Except as allowed by He-W 573.10, prior authorization requested in accordance with (b) through (g) above shall be approved by the department if the department determines that the requested additional services meet the definition of medically necessary or that coverage is supported by clinical documentation provided in accordance with (g) (8) above.

(i) If the department approves the prior authorization request in accordance with (h) above, the state's fiscal agent shall send written confirmation of the approval to the provider.

(j) The provider shall be responsible for determining that the recipient is Title XIX eligible on the date of service.

(k) Providers may monitor the number of services used by a recipient based on claims processed and paid by contacting the department's fiscal agent for this information.

(l) With the exception of requests for services provided during a retroactive eligibility period and wheelchair van services requested in accordance with He-W 573.10, requests for retroactive authorization for services rendered prior to the authorization request shall be denied by the department.

(m) Except as allowed by He-W 573.10, the department shall deny a prior authorization request when the department determines that the requested additional services do not meet the definition of medically necessary and that the coverage is not supported by clinical documentation provided in accordance with (g) (8) or (9) above.

(n) If the department denies the prior authorization request, the department shall forward a notice of denial to the recipient and the wheelchair van provider.

(o) The notice of denial shall contain the information required by 42 CFR 431.210, including:

(1) The reason for, and legal basis of, the denial; and

(2) Information that an appeal of the denial may be requested, in accordance with He-C 200, within 30 calendar days of the date on the notice of the denial.

(See Revision Note at chapter heading He-W 500); ss by #4863, eff 7-12-90, EXPIRED: 7-12-96

New. #6745, eff 5-1-98, EXPIRED: 12-31-98; ss by #6925, eff 1-1-99; ss by #8780, INTERIM, eff 1-1-07, EXPIRES:6-30-07; ss by #8929, eff 6-30-07; ss by #9366, eff 1-17-09; amd by #9622, eff 1-1-10; amd by #10017, eff 11-1-11; amd by #10031, eff 11-19-11; amd by #10342, eff 6-1-13; ss by #10605, eff 5-23-14

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