Current through Register No. 40, October 3, 2024
(a) Out-of-state hospitals shall obtain prior
authorization (PA) from the department before providing inpatient hospital
services to recipients, except that authorization for emergency hospital
services shall be obtained within 72 hours of admission.
(b) Inpatient hospital services at
out-of-state hospitals shall be limited as follows:
(1) For recipients who are absent from the
state, one of the following conditions shall be met:
a. Medical services are needed because of a
medical emergency;
b. Medical
services are needed and the recipient's health would be endangered if he or she
were required to travel to his or her state of residence; or
c. Needed medical services, or necessary
supplementary resources, are more readily available in the other state;
or
(2) For recipients
who are in state but request to receive services out of state, one of the
following conditions shall be met:
a. Medical
services are needed because of a medical emergency;
b. The recipient's attending physician has:
1. Proposed out-of-state
hospitalization;
2. Determined that
the proposed treatment plan is medically necessary; and
3. Determined that the proposed treatment is
not available from resources and facilities within the state;
c. The recipient's attending
physician has:
1. Proposed out-of-state
hospitalization;
2. Determined that
the proposed treatment plan is medically necessary; and
3. Determined that redirection to an in-state
facility would jeopardize either the treatment of an episode of care or a long
standing medical relationship between the recipient and a specific
physician;
d. The
recipient is age 18 or younger and the recipient's attending physician has:
1. Proposed out-of-state
hospitalization;
2. Determined that
the proposed treatment plan is medically necessary; and
3. Determined that referral to a pediatric
specialist is appropriate and there is no such pediatric specialist available
in New Hampshire;
e. The
out-of-state hospital is an enrolled provider and only the medicare deductible
and co-insurance are to be billed to NH medicaid;
f. The out-of-state hospital care is provided
prior to a recipient's eligibility determination and coverage is retroactive to
the time period in which the hospitalization occurred and the hospital is a
medicaid enrolled provider; or
g.
It is the general practice for recipients in a particular NH locality to use
medical resources in another state and the costs of obtaining care at the
out-of-state hospital will result in no higher costs than the costs of
obtaining in state hospital care.
(c) Prior authorization requests shall be
submitted as follows:
(1) On Form 272H,
"Request for Prior Authorization for Out of State Inpatient Admission" (10/2015
edition);
(2) The form shall be
signed and dated by a primary care physician, treating physician, or advanced
practice registered nurse requesting the service;
(3) The person in (2) above shall certify
that "...the requested treatments and/or procedures are medically necessary and
cost effective in obtaining measurable, realistic goals for the above-named
recipient"; and
(4) The form shall
be submitted with physician's notes and clinical notes supporting the medical
necessity for the requested services, including, but not limited to, the
medical care plan, relevant diagnostic tests, and progress notes.
(d) The department shall grant
prior authorization if the documentation on Form 272H supports the requirements
in (b) above.
(e) If the department
approves the PA request, the state's fiscal agent shall send written
confirmation of the approval to the provider.
(f) The provider shall be responsible for
determining that the recipient is medicaid eligible on the date of
service.
(g) If the department
denies the PA request, the department shall forward a notice of denial to the
recipient and the ordering provider on the department Form 272a, "Medical
Assistance Program Denial for Prior Authorized Services," which includes the
following information:
(1) The reason for,
and legal basis of, the denial; and
(2) Information that a fair hearing on the
denial may be requested within 30 calendar days of the date on the notice of
the denial, in accordance with He-C 200.
(See Revision Note at chapter heading He-W 500); ss by
#5897, eff 9-19-94, EXPIRED: 9-19-00
New. #7399, eff 11-2-00,
EXPIRED: 11-2-08
New. #9324, eff 11-21-08; amd by
#10031, eff 11-19-11
