Iowa Admin. Code r. 441-79.11

Current through Regsiter Vol. 46, No. 26, June 12, 2024

Rule 441-79.11 - Requests for preprocedure surgical review

The Iowa Medicaid enterprise (IME) medical services unit conducts a preprocedure review of certain frequently performed surgical procedures to determine the necessity of the procedures and if Medicaid payment will be approved according to requirements found in 441-subrules 78.1(19), 78.3(18), and 78.26(3).

(1) The physician must request approval from the IME medical services unit when the physician expects to perform a surgical procedure appearing on the department's preprocedure surgical review list published in the Medicaid provider manual. All requests for preprocedure surgical review shall be made according to instructions issued to physicians, hospitals and ambulatory surgical centers appearing in the Medicaid provider manual and instructions issued to providers by the IME medical services unit.

(2) The IME medical services unit shall issue the physician a validation number for each request and shall advise whether payment for the procedure will be approved or denied.

(3) Medicaid payment will not be made to the physician and other medical personnel or the facility in which the procedure is performed, i.e., hospital or ambulatory surgical center, if the IME medical services unit does not give approval.

(4) The IME medical services unit shall issue a denial letter to the patient, the physician, and the facility when the requested procedure is not approved. The patient, the physician, or the facility may request a reconsideration of the decision by filing a written request with the IME medical services unit within 60 days of the date of the denial letter.

(5) The aggrieved party may appeal a denial of a request for reconsideration by the IME medical services unit in accordance with 441-Chapter 7.

(6) The requirement to obtain preprocedure surgical review is waived when the patient is enrolled in the managed health care option known as patient management and proper authorization for the procedure has been obtained from the patient manager as described in 441-Chapter 73.

This rule is intended to implement Iowa Code section 249A.4.

Iowa Admin. Code r. 441-79.11

Adopted by IAB January 06, 2016/Volume XXXVIII, Number 14, effective 1/1/2016