Prior authorizations - Retrospective reviews

If the Department of Human Services requires a provider to justify the medical necessity of a service through prior authorization, the department shall not later take the position that the services were not medically necessary, unless the retrospective review establishes that: (1) The previous authorization was based upon misrepresentation by act or omission; (2) The services billed were not provided; or (3) An unexpected change occurred that rendered the prior-authorized care not medically necessary. Amended by Act 2013, No. 562,§ 5, eff. 8/16/2013. Acts 2005, No. 1758, § 1. If the Department of Human Services requires a provider to justify the medical necessity of a service through prior authorization, the department shall not later take the position that the services were not medically necessary, unless the retrospective review establishes that: (1) The previous authorization was based upon misrepresentation by act or omission; (2) The services billed were not provided; or (3) An unexpected change occurred that rendered the prior-authorized care not medically necessary. Amended by Act 2013, No. 562,§ 5, eff. 8/16/2013. Acts 2005, No. 1758, § 1.