Section 3-9 - Prior authorization (a) Procedures. A provider seeking reimbursement for services that require prior authorization as specified in the rules of the Department must: - (i) Submission of information. The provider shall submit a written request to the Division, on the forms specified by the Division, requesting prior authorization before providing services. The Division may request additional information as necessary to review the request.
- (ii) Criteria for review. Prior authorization shall be granted if the proposed services:
- (A) Are covered services;
- (B) Are consistent with the recipients diagnosis;
- (C) Are medically necessary;
- (D) Meet the criteria established by the rules of the Department; and
- (E) Are not reimbursable by any third party payer.
- (iii) Denial of prior authorization.
- (A) If a request for prior authorization is denied, the provider may submit a revised request for prior authorization or additional documentation as necessary for the Division to reconsider the matter; or
- (B) The recipient may request reconsideration of the denial of prior authorization pursuant to Chapter 1.
- (C) The denial of prior authorization precludes Medicaid reimbursement for the services in question.
- (iv) Failure to timely request prior authorization. The failure to obtain prior authorization before providing services precludes Medicaid reimbursement for such services.
- (v) Effect of prior authorization. Granting prior authorization shall constitute approval for the provider to receive Medicaid reimbursement for the approved services to be furnished, subject to the other requirements of this rule and post payment review. Prior authorization is not a guarantee of the recipient's eligibility or a guarantee of Medicaid payment.
(b) Relationship to Chapter 8. The prior authorization provision of this section are separate and apart from the admission certification requirements of Chapter 8.