Current through Register No. 40, October 3, 2024
(a) All drivers shall contact the department
to obtain prior authorization for general medical transportation services when:
(1) Transportation is needed out of
area;
(2) Transportation is to a
medicaid enrolled provider that is not the nearest available provider of the
covered medical or dental service;
(3) Transportation is by means other than
private transportation or bus; or
(4) The recipient requires assistance from
the department because all other transportation resources have been exhausted
by the recipient.
(b)
The recipient shall provide the following information for out of area
transportation as described in (a) (1) above:
(1) The recipient's name and
address;
(2) The recipient's
medicaid identification number; and
(3) A letter from the recipient's primary
care physician or referring physician with the following information:
a. Details describing the illness or
condition sufficient to enable the department to understand the physical and/or
emotional condition of the recipient and the reason(s) for which the medical or
dental service is required;
b. That
the needed medical or dental services cannot be obtained in New Hampshire,
Vermont, Massachusetts, or Maine;
c. The expected outcome and recommended
timetable of the prescribed medical or dental service; and
d. The name and address of the medicaid
enrolled provider.
(c) The recipient shall provide the following
information for prior authorization of transportation as described in (a) (2)
above:
(1) The recipient's name and
address;
(2) The recipient's
medicaid identification number; and
(3) A letter from the recipient's primary
care physician or referring physician with the following information:
a. Details describing the illness or
condition sufficient to enable the department to understand the physical and/or
emotional condition of the recipient and the reason(s) for which the medical or
dental service cannot be obtained closer to the recipient's home;
c. The expected outcome and recommended
timetable of the prescribed medical or dental service; and
d. The name and address of the medicaid
enrolled provider.
(d) The recipient shall provide the following
information for prior authorization by means other than private transportation
or bus as described in (a) (3) above:
(1) The
recipient's name and address;
(2)
The recipient's medicaid identification number; and
(3) A letter from the recipient's primary
care or referring physician which includes the following information:
a. Details describing the illness or
condition sufficient to enable the department to understand the physical and/or
emotional condition of the recipient and the reason(s) for which the medical or
dental service is required;
b. That
the type of specialized transportation service is medically
necessary;
c. The expected outcome
and recommended timetable of the prescribed medical or dental service;
and
d. The name and address of the
medicaid enrolled provider.
(e) The recipient shall provide following
information when requesting assistance from the department as described in (a)
(4) above:
(1) The recipient's name and
address;
(2) The recipient's
medicaid identification number;
(3)
Information that explains how the recipient has attempted to obtain
transportation and has been unable to do so; and
(4) The name and location of the medicaid
enrolled provider the recipient is trying to access.
(f) Requests for prior authorization shall be
approved if:
(1) All of the required
information described in (b), (c), (d), or (e) above is received; and
(2) The department determines, based on the
information provided, that the transportation is necessary and appropriate for
the recipient's medical or dental condition, as supported by the information
provided in the request.
(g) The department shall deny requests for
prior authorization if the provisions set forth in (f) above are not
met.
(h) If prior authorization is
approved, payment for general medical transportation shall still comply with
all of the provisions of He-W 574.
(i) If advanced authorization is denied, the
recipient may appeal this decision pursuant to
He-W
574.11.
(j) If a recipient requires general medical
transportation for which advanced authorization as described in (a) is
required, but the need arises outside of the department's normal working hours,
the request to the department for prior authorization shall be made within 3
business days of the trip.
(k) If
the request for prior authorization in (j) above is not made within 3 business
days of the trip, the transportation claim shall be denied.
(See Revision Note at chapter heading He-W 500); ss by
#6163, eff 1-4-96, EXPIRED: 1-4-04
New. #8732, eff 9-30-06; ss by
#10810, eff 4-9-15
