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 567 - HEARING AID SERVICES
Section He-W 567.07 - Prior Authorization of Binaural Hearing Aids for Recipients 21 Years of Age or Older

Universal Citation: NH Admin Rules He-W 567.07

Current through Register No. 40, October 3, 2024

(a) Providers shall direct requests for prior authorization, as required in He-W 567.05(c) (2) a. above, to the department.

(b) Requests for prior authorization shall be submitted in writing and include, at a minimum:

(1) The recipient's name;

(2) The recipient's medicaid program identification number;

(3) The recipient's diagnosis;

(4) The provider's medicaid ID number;

(5) Clinical documentation that addresses how the request for binaural hearing aids meets the criteria outlined in He-W 567.05(c) (2) b.; and

(6) The signature of the provider.

(c) Prior authorization requested in accordance with (b) above shall be approved by the department if the department determines that the request demonstrates the criteria outlined in He-W 567.05(c) (2) b. have been met.

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

(e) 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 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.

(f) The provider shall be responsible for determining that the recipient is medicaid eligible on the date of service.

#10342, eff 6-1-13

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