HAR §17-1739.1-4. Authorization of services

(a) The department shall provide: (1) Methods of administration necessary for the proper operation of the Medicaid program; and UNOFFICIAL 1739.1-4 (2) Procedures relating to the utilization of and the payment for care and services available under the program. Among the procedures the department may employ shall be a system of authorization of selected types of costly health care. (b) Authorizations shall insure that: (1) Requested services and materials are medically necessary; (2) Any adequate and less expensive alternatives are considered; and (3) Any services and materials provided conform to currently accepted community standards of the profession involved. (c) Authorization may be required when the department considers or has found a service to be associated with, but not necessarily limited to: (1) High or excessive costs provided over extended periods of time without evidence of benefit; (2) Questionable or limited value, or both; or (3) Subject to abuse; (d) The authorization function may be contracted to certain individuals or organizations, including the State’s fiscal agent. (e) The department, through its medical consultants, may place appropriate limits on a Medicaid service based on such criteria as medical necessity or utilization control procedures. The department shall pay for health care services when the department’s medical consultants determine that the services are necessary to the patient’s well-being and the services are provided under standards accepted by the medical profession. However, no payment shall be made in a situation where the program rules were violated or when services furnished did not involve economical or effective health care management of the patient. (f) A request for medical authorization, which does not require prior authorization, must be submitted for approval within sixty calendar days before or thirty calendar days after the initial date the service is rendered. Authorization may be obtained by submission of an authorization request adequately justifying the service and signed and dated by the requesting physician. Requests not received within thirty calendar days after the initial date of UNOFFICIAL 1739.1-5 service shall be denied. The following services require medical authorization: (1) Short-term inpatient psychiatric admission; (2) Outpatient electroconvulsive therapy; and (3) Purchase or rental of durable medical equipment, or the purchase of medical supplies totaling more than a $50 billed charge per line item per month. (g) The following services require medical authorization prior to the service being rendered. A request for authorization may be submitted up to sixty days prior to the services being rendered. (1) Obtaining special medical services from other United States jurisdictions; (2) Termination of regulatory controls, for example, release from physicians' management (reference is to recipients assigned to a primary physician); (3) Rental or purchase of hearing aids; (4) Replacement glasses, special glasses, or other visual aids; (5) Physical therapy and occupational therapy for outpatients other than ultrasound therapy for musculoskeletal problems; (6) Outpatient speech therapy; (7) Lodging, meals, and transportation for recipients and medical attendants to accompany a recipient for medical purposes, including out-of state and inter-island transportation by scheduled carrier, air ambulance, ground ambulance, handicab, or taxi; (8) Detoxification; (9) Psychiatric outpatient visits (individual or group) and psychological tests on an outpatient basis; (10) Certain dental services; (11) Admission and Medicaid coverage of persons in long-term care facilities and subacute level of care; (12) All surgical procedures that are performed in the outpatient and inpatient hospital settings by podiatrists and for all surgical procedures costing more than $100 that are performed in the office by podiatrists; (13) Home pharmacy services; (14) Sleep laboratory and sleep disorder center services; UNOFFICIAL 1739.1-6 (15) Augmentative communicative devices; and (16) Other medical services as may be identified by the department. (h) Services provided without the necessary prior authorizations are subject to denial of payment. (i) A request for authorization shall be acted upon within thirty calendar days for a non-urgent request and two working days for an urgent request. An exception to this provision is a request for authorization for augmentative communicative devices (ACD’s) as indicated in subsection (o). If the request is deferred or denied, a notice to include a reason for the deferral or denial, shall be sent to the provider(s) and the recipient. (j) An authorization request that requires urgent medical action, shall be acted upon within two working days. For the purpose of this section, an “urgent” medical service or item is a service or item for the diagnosis or treatment of a medical condition which is serious but not an immediate threat to life. The service or item is medically needed by the patient within two working days of request to preserve an essential bodily function or prevent a serious complication. (k) Services which necessitate immediate professional medical action shall not be subject to prior authorization if obtaining prior authorization may delay service and place a patient in jeopardy. The request for authorization must be submitted within thirty calendar days after the initial date of service. The request shall then be processed in accordance with the procedures stated in this section. Requests not received within thirty calendar days after the initial date of service shall be denied. (l) When a request for authorization is submitted for services which require prior authorization but have already been rendered, an explanation for the delay in submittal must be provided for consultant review. If the explanation adequately justifies the untimely submittal, the request shall be processed in accordance with the procedures stated in this section. If the explanation does not justify the untimely submittal, the request shall be denied. Requests not received within thirty calendar days after the initial date of service shall be denied. (m) An incomplete authorization form shall UNOFFICIAL 1739.1-7 be returned to the sender. The form shall be deemed incomplete if the following is incomplete, illegible, or missing: (1) The name and the identification number of the recipient; (2) The requesting physician’s signature, date, and provider number; (3) The supplier’s name, provider number, dates of service or period requested as determined by begin and end dates, and signature, if the service or item is not being provided by the requesting physician; (4) The diagnostic code or description; (5) The procedure code; and (6) For non-urgent requests, all attached copies of the form must be submitted together intact. When the newly completed form is received, the form shall be processed in accordance with the procedures stated in this section from the date the completed form is received. (n) When a request for authorization is deferred due to lack of supportive documentation to justify a service: (1) The provider(s) shall be notified of the deferral. The notice shall include a reason for the deferral giving twenty-one calendar days from the date of the deferral notice to submit the requested information; and (2) If the requested information is not received within twenty-one calendar days from the date of the deferral notice, the request shall be denied; or (3) If all necessary information is received within twenty-one calendar days from the date of the deferral notice, the request for authorization shall be acted upon within twenty-one calendar days by a DHS consultant or an authorized representative. If the request is denied, a notice to include a reason for the denial, shall be sent to the provider(s) and the recipient. (o) A request for authorization relating to the purchase, repair, or rental of augmentative communicative devices shall be acted upon within two working days of receipt for an urgent request and within twenty-one calendar days of receipt for a non- urgent request. If the request is approved, the UNOFFICIAL 1739.1-8 vendor shall be notified. If the request is denied, a notice of denial to include a reason for the denial and appeal rights shall be sent to the recipient and the requesting provider(s). When a request for authorization is deferred due to lack of supportive documentation to justify a service: (1) The provider(s) and the recipient shall be notified of the deferral. The notice shall include: (A) A reason for the deferral, identifying the additional information needed to process the request; and (B) Where to send the additional information; giving twenty-one calendar days to submit the requested information; and (2) If the requested information is not received within twenty-one calendar days from the date the request was sent, the request shall be denied; or (3) If all necessary information is received within twenty-one days from the date the request was sent, the request for authorization shall be acted upon within two working days for an urgent request and twenty-one days for a non-urgent request by a DHS consultant or an authorized representative. If the request is denied, a notice to include a reason for the denial, shall be sent to the provider(s) and the recipient. (p) An approved authorization request and treatment plan shall be initiated within sixty calendar days of the signed approval by the department. (1) If an approved service is not rendered within sixty calendar days of the signed approval, a new request for authorization shall be submitted. (2) If an extension is needed for partially completed service or if the approved service is not completed within sixty calendar days of the signed approval, a new request for authorization shall be submitted for the new period. (q) The department, through its medical consultants, may permit exceptions and determine level of care, medical appropriateness, and medical UNOFFICIAL 1739.1-9 necessity. In disagreements between the provider and DHS’s authorized agent(s) regarding authorization of services and level of care determinations, the department’s medical consultant’s decision shall be final. Further appeal shall be pursued through the appeal administrator’s office or the courts. [Eff 10/26/01; am 05/10/03; am 03/11/04 ] (Auth: HRS §346-59) (Imp: 42 C.F.R. §§456.1, 456.2, 456.3; 42 U.S.C. §1396r(8)(d)(5))