CRITERIA FOR APPROVAL OF PRIOR AUTHORIZATION REQUEST

A request for prior authorization of a health service shall be evaluated by consultants using the criteria given in items A to F. A health service meeting the criteria in this part shall be approved, if the health service is otherwise a covered service under the MA or GAMC programs. The health service must: A. be medically necessary as determined by prevailing medical community standards or customary practice and usage; B. be appropriate and effective to the medical needs of the recipient; C. be timely, considering the nature and present state of the recipient's medical condition; D. be furnished by a provider with appropriate credentials; E. be the least expensive appropriate alternative health service available; and F. represent an effective and appropriate use of program funds.