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 575 - AUGMENTATIVE AND ALTERNATIVE COMMUNICATION AID SERVICES
Section He-W 575.06 - Prior Authorization

Universal Citation: NH Admin Rules He-W 575.06

Current through Register No. 40, October 3, 2024

(a) An AAC provider shall request and obtain a prior authorization from the department on behalf of a recipient for the purchase, rental, or repair of AAC aids and accessories.

(b) Prior authorization requests for purchases and rentals shall include the following:

(1) A statement from the recipient's physician that includes:
a. An explanation of the medical need of the AAC aid being requested;

b. A statement that the physician concurs with the recommendation of the AAC evaluation, conducted in accordance with He-W 575.07; and

c. When the request is for a rental, an indication of which of the coverage criteria has been met per He-W 575.04(b) above;

(2) An AAC evaluation as described in He-W 575.07; and

(3) A completed Form #288-Q, "Quote for Augmentative and Alternative Communication (AAC) Aids Funding Request" (June 2014), completed and signed by a NH Medicaid DME provider.

(c) Prior authorization requests for repairs shall include the following:

(1) The all-inclusive cost of the repair;

(2) Replacement cost of the current AAC aid;

(3) A letter from a licensed speech language pathologist (SLP) that establishes the recipient's prognosis for continued use of the current AAC aid, including the expected life-span of the AAC aid with repair;

(4) A copy of the safeguarding plan, as described in He-W 575.07(c) (10) b., that is less than one year old and contains current contact information; and

(5) A signed statement from the recipient attesting that the need for the repair is not the result of any of the condition listed in He-W 575.05(q) .

(d) Prior authorization requests for modification of an existing AAC aid shall include the following:

(1) The all-inclusive cost of the modification;

(2) A justification of need, as described in He-W 575.07(c) (6) , from a licensed SLP, including updated clinical information; and

(3) The results of an AAC evaluation completed in accordance with He-W 575.07 within the last 3 years.

(e) In addition to the requirements of (c) and (d) above, prior authorization requests for the repair or modification of an existing AAC aid shall include current clinical information regarding the recipient's use of the AAC aid, as well as current contact information of the individuals listed in He-W 575.07(c) (2) .

(f) Prior authorization requests shall be approved when the department's prior authorization agent determines that the purchase, rental, or repair of the AAC aid being requested is determined to be the most clinically appropriate and least costly alternative, as supported by the documentation submitted in accordance with (b), (c), or (d) above.

(g) The department's prior authorization agent shall forward written confirmation of the department's approval of a prior authorization request to the provider.

(h) The AAC provider shall be responsible for determining that the recipient is Medicaid eligible on the date of service.

(i) The department's prior authorization agent shall deny a PA request if the agent determines that the requirements set forth in this part have not been met.

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

(k) The notice of denial shall contain the information required by 42 CFR 431.210, including:

(1) The reason for, and legal basis of, the denial; and

(2) That a fair hearing on the denial may be requested within 30 calendar days of the date on the notice of the denial.

#10636, eff 7-12-14

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