Section He-W 531.07 - Prior Authorization(a) The following services and procedures, as described in He-W 531.05, shall require prior authorization from the department's prior authorization agent:(1) All organ transplants, except kidney transplants;(2) Bariatric surgical procedures;(3) Breast reduction surgery;(6) Septoplasty and rhinoplasty.(b) Prior to payment by the department, requests for prior authorization of services and procedures described in He-W 531.05 shall:(1) Be submitted in advance of rendering the service;(2) Be submitted in writing to the department's prior authorization agent via mail or fax on Form 273S "Physician Request for Prior Authorization for Certain Surgical Procedures, Including Organ Transplants" (02/2020), along with any supporting documentation;(3) Be signed by the provider; and(4) Be based on the provider's medical care plan developed for the recipient.(c) Requests for prior authorization shall include a physician's order, letter of medical necessity, and clinical notes to enable the department's prior authorization agent to evaluate the request.(d) Prior authorization requested in accordance with (a) through (c) above shall be approved by the department's prior authorization agent if the department's prior authorization agent determines that the submitted documentation supports the applicable requirements in He-W 531.05.(e) If the department approves the prior authorization request, the department's fiscal agent shall send written confirmation of the approval to the provider.(f) The provider shall be responsible for determining that the recipient is Title XIX eligible on the date of service.(g) 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 ordering provider on the department Form 272a, "Medical Assistance Program Denial for Prior Authorized Services," including the following:(1) The reason for, and legal basis of, the denial; and(2) 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.N.H. Admin. Code § He-W 531.07
Amended by Volume XXXIV Number 16, Filed April 17, 2014, Proposed by #10531, Effective 3/29/2014, Expires3/29/2024.Amended by Volume XL Number 11, Filed March 12, 2020, Proposed by #12999, Effective 3/5/2020, Expires 3/5/2030.