Section He-W 569.06 - Prior Authorization and Review(a) The following diagnostic radiological services shall require prior authorization: (1) Computerized tomography (CT);(2) Magnetic resonance imaging (MRI) ;(3) Magnetic resonance angiography (MRA);(4) Positive emission tomography (PET); and(b) Diagnostic radiological services specified in (a) above shall be exempt from prior authorization requirements when services are provided: (1) As part of a hospital emergency department visit;(2) As part of a recipient's inpatient hospitalization; or(3) Concurrently with, or on the same day as, an urgent care facility visit.(c) The ordering practitioner shall initiate the prior authorization process on behalf of the recipient by submitting a completed Form 272X, Request for Prior Authorization for Diagnostic Imaging (January 2014), and clinical information supporting the medical necessity for the request, including, but not limited to, the medical care plan, relevant diagnostic tests, and progress notes, to the PA agent by mail, fax, or via the agent's website.(d) When a completed prior authorization request is submitted in accordance with (c) above, the department's PA agent shall: (1) Make a decision on the prior authorization request based on Milliman Care Guidelines, 17th edition (February/March 2013), available as noted in Appendix A;(2) Respond to the prior authorization request by telephone or other telecommunication device within 2 business days of the initial request, by: a. Approving the request if it meets the criteria as set forth in the Milliman Care Guidelines, 17th edition (February/March 2013), available as noted in Appendix A;b. Suggesting an alternative imaging service other than the one requested to better meet the clinical need based on the clinical guidelines as set forth in the Milliman Care Guidelines, 17th edition (February/March 2013), available as noted in Appendix A;c. Denying the request if it does not meet the criteria as set forth in the Milliman Care Guidelines, 17th edition (February/March 2013), available as noted in Appendix A; ord. Requesting more information from the provider to better determine whether the criteria for approval have been met as set forth in the Milliman Care Guidelines, 17th edition (February/March 2013), available as noted in Appendix A; and(3) Send a written notice of decision to the recipient and the ordering practitioner within 2 business days of the decision being made.(e) Written denial notices, provided in accordance with (d) (2) c. above shall include the following: (1) The reason for, and the legal basis of, the denial;(2) A copy of the clinical guidelines used to make the decision; and(3) 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 569.06
(See Revision Note at chapter heading He-W 500); ss by #6575, eff 9-12-97; ss by #8400, INTERIM, eff 8-20-05, EXPIRES: 2-16-06; ss by #8562, eff 2-7-06; amd by #10342, eff 6-1-13; ss by #10517, eff 2-7-14