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 566 - DENTAL SERVICES
Section He-W 566.07 - Prior Authorization

Universal Citation: NH Admin Rules He-W 566.07

Current through Register No. 40, October 3, 2024

(a) The following dental services and procedures, as described in He-W 566.04, shall require prior authorization from the department:

(1) Comprehensive and interceptive orthodontic treatment;

(2) Dental orthotic device;

(3) Surgical periodontal treatment;

(4) Extraction of asymptomatic teeth and third molars; and

(5) Removable prosthesis.

(b) Procedures for prior authorization shall be as follows:

(1) The prior authorization shall be for the item or treatment requested and be obtained prior to providing the item or treatment;

(2) Notwithstanding (1) above, for extractions that warrant immediate action, both the prior authorization request and the claim for payment shall be submitted to the address in (4) below after the extraction is performed;

(3) The recipient shall have the primary responsibility for obtaining prior authorization and may do this with the assistance of the provider, who requests authorization on behalf of the recipient; and

(4) Requests for dental prior authorizations shall be addressed to:

New Hampshire Department of Health and Human Services

Office of Medicaid Business and Policy

Dental Director's Office

Attn: Dental Consultant

129 Pleasant Street

Concord, NH 03301

(c) Requests for prior authorization shall include sufficient, current medical information to enable the department to evaluate the request.

(d) Prior authorization requests for services in (a) above, shall include:

(1) An explanation describing the illness, special care, or specific condition, to enable the department to understand the physical and/or emotional problem of the recipient and the specified goal for which the item or treatment is being requested;

(2) Assurance that the required treatment is the least restrictive, most cost-effective alternative;

(3) Cost of the treatment, if known;

(4) Diagnosis;

(5) Expected outcome and recommended timetable of the prescribed item or treatment;

(6) Name and address of the intended provider;

(7) Name and address of person or agency making the request;

(8) Radiographs;

(9) Periodontal charting when surgical periodontal treatment is requested; and

(10) Recipient name, address, date of birth, and medicaid identification number (MID).

(e) In addition to (d) above, prior authorization requests for the extraction of third molars and asymptomatic teeth shall also include an explanation describing the specific conditions or illness that requires tooth removal and a radiograph supporting the rationale for removal, and shall include the diagnosed pathology, if present, for each tooth requested.

(f) Prior authorization requests for comprehensive and interceptive orthodontic treatment shall include, in addition to the information specified in (c) and (d) above, information specified in He-W 566.05(g).

(g) Prior authorizations shall be approved by the department upon determination that the treatment requested is appropriate, cost effective and supported by the documentation submitted in accordance with (b) through (f) above.

(h) If the department approves the prior authorization request, the state's fiscal agent shall send written notification of the approval to the provider.

(i) Prior authorization requests for comprehensive and interceptive orthodontic treatment that do not have enough information as required in accordance with He-W 566.05(g) and (c) through (f) above for an approval or denial decision shall be returned to the provider.

(j) All prior authorizations approved shall be provider-specific and shall be non-transferable between providers.

(k) Prior authorization requests for services and procedures specified in (a)(2)-(5) above that do not have enough information as required in accordance with (c) through (e) above for an approval or denial decision shall be returned to the provider.

(l) Providers shall be responsible for determining that the recipient is medicaid eligible on the date of service.

(m) If the department denies the prior authorization request, the department shall forward a notice of denial to the recipient and the provider on the department's 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.

(n) Decisions made by the department in accordance with (g)-(i) and (k) above shall not be superseded by the treating or consultative health care professional's prescription, orders, or recommendations.

(See Revision Note at chapter heading He-W 500); ss by #5639, eff 6-17-93; ss by #7012, eff 6-15-99; ss by #7912, eff 7-1-03; ss by #9902, eff 6-1-11; amd by #10031, eff 11-19-11

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