N.H. Admin. Code § He-W 574.08

Current through Register No. 36, September 5, 2024

Section He-W 574.08 - Prior Authorization

(a) All drivers shall contact the department to obtain prior authorization for general medical transportation services when:

(1) Transportation is needed out of area;

(2) Transportation is to a medicaid enrolled provider that is not the nearest available provider of the covered medical or dental service;

(3) Transportation is by means other than private transportation or bus; or

(4) The recipient requires assistance from the department because all other transportation resources have been exhausted by the recipient.

(b) The recipient shall provide the following information for out of area transportation as described in (a) (1) above:

(1) The recipient's name and address;

(2) The recipient's medicaid identification number; and

(3) A letter from the recipient's primary care physician or referring physician with the following information:

a. Details describing the illness or condition sufficient to enable the department to understand the physical and/or emotional condition of the recipient and the reason(s) for which the medical or dental service is required;

b. That the needed medical or dental services cannot be obtained in New Hampshire, Vermont, Massachusetts, or Maine;

c. The expected outcome and recommended timetable of the prescribed medical or dental service; and

d. The name and address of the medicaid enrolled provider.

(c) The recipient shall provide the following information for prior authorization of transportation as described in (a) (2) above:

(1) The recipient's name and address;

(2) The recipient's medicaid identification number; and

(3) A letter from the recipient's primary care physician or referring physician with the following information:

c. The expected outcome and recommended timetable of the prescribed medical or dental service; and

d. The name and address of the medicaid enrolled provider.

(d) The recipient shall provide the following information for prior authorization by means other than private transportation or bus as described in (a) (3) above:

(1) The recipient's name and address;

(2) The recipient's medicaid identification number; and

(3) A letter from the recipient's primary care or referring physician which includes the following information:

b. That the type of specialized transportation service is medically necessary;

c. The expected outcome and recommended timetable of the prescribed medical or dental service; and

d. The name and address of the medicaid enrolled provider.

(e) The recipient shall provide following information when requesting assistance from the department as described in (a) (4) above:

(1) The recipient's name and address;

(2) The recipient's medicaid identification number;

(3) Information that explains how the recipient has attempted to obtain transportation and has been unable to do so; and

(4) The name and location of the medicaid enrolled provider the recipient is trying to access.

(f) Requests for prior authorization shall be approved if:

(1) All of the required information described in (b), (c), (d), or (e) above is received; and

(2) The department determines, based on the information provided, that the transportation is necessary and appropriate for the recipient's medical or dental condition, as supported by the information provided in the request.

(g) The department shall deny requests for prior authorization if the provisions set forth in (f) above are not met.

(h) If prior authorization is approved, payment for general medical transportation shall still comply with all of the provisions of He-W 574.

(i) If advanced authorization is denied, the recipient may appeal this decision pursuant to He-W 574.11.

(j) If a recipient requires general medical transportation for which advanced authorization as described in (a) is required, but the need arises outside of the department's normal working hours, the request to the department for prior authorization shall be made within 3 business days of the trip.

(k) If the request for prior authorization in (j) above is not made within 3 business days of the trip, the transportation claim shall be denied.

N.H. Admin. Code § He-W 574.08

(See Revision Note at chapter heading He-W 500); ss by #6163, eff 1-4-96, EXPIRED: 1-4-04

New. #8732, eff 9-30-06; ss by #10810, eff 4-9-15

Amended byVolume XXXV Number 18, Filed May 7, 2015 , Proposed by #10810, Effective 4/9/2015, Expires4/9/2025.