N.J. Admin. Code § 10:52A-4.5

Current through Register Vol. 56, No. 17, September 3, 2024

Section 10:52A-4.5 - Prior authorization for APH services

(a) APH services provided to beneficiaries age 22 years or older require prior authorization for such services. Initial length of service requests for APH shall not exceed a maximum of seven business days, while awaiting prior authorization approval when the beneficiary is referred to adult acute partial hospital service by the local designated screening center or an inpatient psychiatric facility. Following the initial seven business days of service, prior authorization through a DMAHS concurrent utilization process review will be required for the remainder of the time the service is provided. Prior authorization in APH is required every 90 days for up to a maximum of six months.

(b) When requesting prior authorization, Forms FD-07 and FD-07A, "Request for Authorization of Mental Health Services and/or Mental Health Rehabilitation Services" and "Request for Prior Authorization: Supplemental Information" shall be completed and forwarded to the Medical Assistance Customer Center (MACC) that serves the county in which the services are rendered. (The forms may be obtained through the website www.njmmis.com or by contacting Unisys Provider Relations at 1-800-776-6334.) The "Brief Clinical History" and "Present Clinical Status" sections of the FD-07A "Request for Prior Authorization: Supplemental Information" form are particularly important and shall provide sufficient medical information to justify and support the proposed treatment request. A request for additional information may be made at the discretion of the Medicaid reviewer if the reviewer believes that insufficient medical information has been provided for the Division to make a determination. Failure to comply with such a request may result in a result in a reduction or denial of requested services.

(c) Each request for prior authorization shall reflect the criteria listed in 10:52A-3.1.

(d) The notification of the disposition (approved, modified, denied, or suspended) of a prior authorization request will be made by the Division.

N.J. Admin. Code § 10:52A-4.5