Section He-E 802.05 - Clinical Eligibility Determination for NF Services(a) The department shall make the clinical eligibility determination of the applicant as follows:(1) Skilled professional medical personnel appropriately trained to use the assessment instrument and employed by the department or designated by the department shall: a. Conduct an on-site, face-to-face visit with the applicant;b. Perform a clinical assessment of the applicant; andc. Develop a list of identified needs for the applicant; and(2) The applicant shall sign the following:a. A consent for receiving NF services, as applicable;b. An authorization for release of information, as applicable; andc. An authorization for release of protected health information, as applicable.(b) Pursuant to RSA 151-E:3, IV, if the department is unable to determine an applicant clinically eligible based on the assessment in (a) above, the department shall send notice to the applicant and the applicant's licensed practitioner(s), as applicable, requesting additional clinical information within 30 calendar days of the notice and stating that the failure to submit the requested information will impede processing of the application and delay service delivery.(c) Within the 30 day period in (b) above, if the requested information is not received within 20 calendar days, the department shall send a second notice to the applicable licensed practitioner(s) with a copy to the applicant requesting the information.(d) Upon request from the treating licensed practitioner or applicant, the department shall extend the deadline in (b) above for a maximum of 30 days if the practitioner or applicant states that he or she has documentation that supports eligibility and will provide it within that time period.(e) If the information required by (b) above is not received by the date specified in the notice, or as extended by the department in accordance with (d) above, clinical eligibility shall be denied pursuant to RSA 541-A:29.(f) The applicant shall be determined clinically eligible if it is determined that the applicant meets the financial eligibility requirements described in He-W 600 and the clinical eligibility requirements of He-E 802.03 and 802.04.(g) Upon a determination of eligibility, the applicant or his or her representative and the NF shall be sent an approval notice, including:(1) The type of services approved, based on criteria described in He-E 802.04;(2) The name of the facility where the individual will be receiving care; and(3) The eligibility start date and, if applicable, the service end date.(h) Upon a determination of ineligibility, because the applicant does not meet the eligibility requirements of He-E 802.03 and He-E 802.04 or because required information is not received pursuant to (e) above, the applicant or his or her representative and the NF shall be sent a notice of denial, including:(1) A statement regarding the reason and legal basis for the denial;(2) Information concerning the applicant's right of appeal pursuant to He-C 200, including the requirement that the applicant has 30 calendar days from the date of the notice of denial to file such an appeal;(3) An explanation that an applicant who is denied services and who chooses to appeal this denial pursuant to He-C 200 shall not be entitled to Medicaid payments for NF services pending the appeal hearing decision; and(4) The medical credentials of the skilled professional medical personnel making the determination of ineligibility.(i) If an administrative appeal is requested and the result is a reversal of the bureau's decision, retroactive payment shall be made to the NF or, if the individual is occupying a swing bed, to the hospital where the swing bed is located.N.H. Code Admin. R. He-E 802.05
(See Revision Note at part heading for He-E 802) #9888-A, eff 3-19-11
Amended by Volume XXXIX Number 16, Filed April 18, 2019, Proposed by #12741, Effective 3/20/2019, Expires 9/16/2019.Amended by Volume XL Number 46, Filed November 12, 2020, Proposed by #13130, Effective 10/30/2020, Expires 10/29/2030.