Current through Register No. 40, October 3, 2024
(a) The following
diagnostic radiological services shall require prior authorization:
(1) Computerized tomography (CT);
(2) Magnetic resonance imaging (MRI)
;
(3) Magnetic resonance
angiography (MRA);
(4) Positive
emission tomography (PET); and
(5)
Nuclear cardiology.
(b)
Diagnostic radiological services specified in (a) above shall be exempt from
prior authorization requirements when services are provided:
(1) As part of a hospital emergency
department visit;
(2) As part of a
recipient's inpatient hospitalization; or
(3) Concurrently with, or on the same day as,
an urgent care facility visit.
(c) The ordering practitioner shall initiate
the prior authorization process on behalf of the recipient by submitting a
completed Form 272X, Request for Prior Authorization for Diagnostic Imaging
(January 2014), and clinical information supporting the medical necessity for
the request, including, but not limited to, the medical care plan, relevant
diagnostic tests, and progress notes, to the PA agent by mail, fax, or via the
agent's website.
(d) When a
completed prior authorization request is submitted in accordance with (c)
above, the department's PA agent shall:
(1)
Make a decision on the prior authorization request based on Milliman Care
Guidelines, 17th edition (February/March 2013), available as noted in Appendix
A;
(2) Respond to the prior
authorization request by telephone or other telecommunication device within 2
business days of the initial request, by:
a.
Approving the request if it meets the criteria as set forth in the Milliman
Care Guidelines, 17th edition (February/March 2013), available as noted in
Appendix A;
b. Suggesting an
alternative imaging service other than the one requested to better meet the
clinical need based on the clinical guidelines as set forth in the Milliman
Care Guidelines, 17th edition (February/March 2013), available as noted in
Appendix A;
c. Denying the request
if it does not meet the criteria as set forth in the Milliman Care Guidelines,
17th edition (February/March 2013), available as noted in Appendix A;
or
d. Requesting more information
from the provider to better determine whether the criteria for approval have
been met as set forth in the Milliman Care Guidelines, 17th edition
(February/March 2013), available as noted in Appendix A; and
(3) Send a written notice of
decision to the recipient and the ordering practitioner within 2 business days
of the decision being made.
(e) Written denial notices, provided in
accordance with (d) (2) c. above shall include the following:
(1) The reason for, and the legal basis of,
the denial;
(2) A copy of the
clinical guidelines used to make the decision; and
(3) 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
#6575, eff 9-12-97; ss by #8400, INTERIM, eff 8-20-05, EXPIRES: 2-16-06; ss by
#8562, eff 2-7-06; amd by #10342, eff 6-1-13; ss by #10517, eff
2-7-14
