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NC Department of Health and Human Services
NC Division of
Medical Assistance
 
 

Prior Approval and Due Process

 

Due Process Resource Documents

Prior Approval

Prior approval (PA) may be required for some services, products or procedures to verify documentation of medical necessity.

Prior approval is for medical approval only and must be obtained before rendering a service, product or procedure that requires prior approval. Obtaining prior approval does not guarantee payment, ensure beneficiary eligibility on the date of service or guarantee that a post-payment review to verify that the service was appropriate and medically necessary will not be conducted. A beneficiary must be eligible for Medicaid coverage on the date the service or procedure is rendered.

The ordering provider is responsible for obtaining PA; however, any provider can request PA when necessary. Prior approval is issued to the ordering and the rendering providers. It is the responsibility of the provider to clearly document that the beneficiary has met the clinical coverage criteria for the service, product or procedure.

Services must be performed and billed by the rendering provider. The service must be provided in accordance with the service limits specified and for the time frame documented in the approved request unless a more stringent requirement applies.

Additionally, services must be provided in accordance with all State and federal statutes and rules governing the N.C. Medicaid Program, State licensure and federal certification requirements, and all other applicable federal and State statutes and rules.

Claims submitted for prior-approved services rendered and billed by a different provider will be denied. Refer to the frequently asked questions below regarding changing providers.

Retroactive Prior Approval

Retroactive prior approval is considered when a beneficiary, who does not have Medicaid coverage at the time of the procedure, is later approved for Medicaid with a retroactive eligibility date.  Exceptions may apply.

Prior Approval for Medicaid for Pregnant Women (MPW)

Prior approval is required for MPW beneficiaries when the physician determines that any of the services listed below are needed for the treatment of a medical illness, injury, or trauma that may complicate the pregnancy.

  1. Podiatry;
  2. Chiropractic;
  3. Optometric and optical services;
  4. Home health;
  5. Personal care services;
  6. Hospice;
  7. Private duty nursing;
  8. Home infusion therapy; or,
  9. Durable medical equipment.

Refer to the specific clinical coverage policies on DMA’s Web site at www.ncdhhs.gov/dma/mp/ for specific requirements for prior approval for MPW beneficiaries.

Clinical Coverage Policy 4A, Dental Services (www.ncdhhs.gov/dma/mp/), describes dental services available to beneficiaries with MPW. These services require the same prior approval as dental services to any other beneficiaries with full Medicaid coverage and are covered through the day of delivery.

Submitting Requests for Prior Approval

All requests for PA must be submitted in accordance with DMA’s clinical coverage policies and published procedures.

Providers must request reauthorization of a service prior to the end of the current authorization period in order for services to continue. The date that the request is submitted impacts payment authorization for services that are denied, reduced or terminated.

Specifically, the provider must request authorization of a continuing services 10 calendar days prior to the end of the current authorization period for authorization to continue without interruption for 10 calendar days after the date an adverse decision notice (Change Notice) is mailed to the Medicaid beneficiary or to his/her legal guardian and copied to the provider.

Some requests are submitted for review to a specific utilization review contractor.

Contractor Services Contact Information
CSC (NCTracks)
  • Certain medical and surgical procedures
  • Out-of-state elective services
  • Out-of-state and state-to-state ambulance services
  • Pharmacy PA and Pharmacy Claims
HP Enterprise Services Preadmission Screening and Resident Reviews (PASRR) for individuals before admission to North Carolina's nursing facilities
Liberty Healthcare - NC Personal Care Services
Independent Assessments
Carolinas Center for Medical Excellence (CCME) Outpatient Specialized Therapies (physical, respiratory, occupational, and audiology/speech language therapy treatments)
  • 800-228-3365 or 919-461-5500
  • Website External link
MedSolutions Non-emergency outpatient high-tech radiology and ultrasound procedures
ValueOptions Behavioral Health Services

 

Effective June 1, 2014, PA requests for Behavioral Health services should be submitted to ValueOptions for:

  • Medicaid legal aliens;
  • Medicaid children 0-3 years of age;
  • Health Choice beneficiaries: and
  • Medicaid admissions to Cumberland Hospital.

For Medicaid admissions to Cumberland hospital, providers need to contact the appropriate LME-MCO to facilitate coordination of care and transition to community services. If you have additional questions, please contact ValueOptions or the LME/MCO for your area.

Refer to the following document and slide presentation, which provide instructions for Medicaid beneficiary due process rights and prior approval procedures for N.C. Medicaid providers and all agency staff and contractors that perform utilization review functions on behalf of DMA.

Review Process Timeframe

For prescription drugs requiring PA, a decision will be made within 24 hours of receipt of the request. For all other types of PA requests, Medicaid will make every effort possible to make a decision within 15 business days of receipt of the request unless there is a more stringent requirement.  However, there may be a delay in making a decision if Medicaid needs to obtain additional information about the request.

Once it has been established that a complete request has been submitted, Medicaid may:   

  • Approve the request;
  • Deny or terminate the request;
  • Reduce the request; or
  • Request additional information.

Medicaid notifies the provider following established procedures of approvals, including service, number of visits, units, hours, or frequency.

Review Criteria

Medicaid reviews requests according to criteria documented in the clinical coverage policy specific to the requested service, procedure or product. If the beneficiary is under 21 years of age and the policy criteria are not met, the request is reviewed under Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) criteria.

Additionally, Medicaid researches requests to determine the effectiveness of the requested service, procedure or product to determine if the requested service is safe, generally recognized as an accepted method of medical practice or treatment, or experimental/investigational. 

Medicaid may also research best practice standards or evidence-based practices by utilizing a variety of best practice guidelines including, but not limited to

Forms

To clearly demonstrate medical necessity, it is recommended that providers use the designated program-specific forms or, where appropriate, the general forms when requesting PA; however, Medicaid will consider all relevant information that is submitted, regardless of whether it is included on a particular form.

Program-specific PA forms (such as dental services, visual aids, behavioral health, etc.) are available on the Provider Forms page or from the specific Programs and Services page.

General PA forms (for medical and surgical procedures, hearing aids, etc.) are also available on Provider Forms page.

Additional Information

Frequently Asked Questions

 


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Why is prior approval required?

Prior approval may be required to verify documentation of compliance with Medicaid clinical coverage policy and medical necessity.

What services require prior approval?

Medicaid policy determines when a service requires PA.  Individual policies state whether or not PA is required for that service and how to submit the request for review.  In addition, if a beneficiary under 21 years of age needs to access a service covered by 42 USC 1905(a) of the Social Security Act but it is not covered by N.C. Medicaid, does not meet established policy criteria for a covered service, or exceeds policy limits, prior approval is required.   

To determine if a procedure requires PA, refer to DMA’s clinical coverage policies. Providers may also call the NCTracks Automated Voice Response (AVR) system at 1-800-723-4337.

 

Can I obtain a verbal approval?

Some requests may be approved verbally but must be followed up with a written request. For services where verbal authorization is allowed, approval is tentatively effective on the date of the call and is contingent upon receipt of the written request and validation of documentation that supports the verbal information within 10 days of the call unless there is a more stringent requirement.

If the written request is not received within the required timeframe or the documentation does not support the verbal information, the request will be denied.

 

How are requests evaluated?

Medicaid will consider all relevant information that is submitted, regardless of whether it is included on a particular form.  Providers are encouraged to supplement the information requested on prior approval forms and plan of care forms with other recent clinical information that documents medical necessity if the provider believes the information requested on the form is not sufficient to fully document medical necessity for the requested service.

This additional documentation may include recent evaluation reports from clinicians, recent treatment records, and letters signed by treating clinicians which explain why the service is medically necessary. 

For children under the age of 21, documentation must also show how the service will correct or ameliorate a defect, physical or mental illness, or a condition [health problem] as well as meet all other EPSDT criteria.

From time to time and prior to the decision on a request for prior approval, Medicaid may need to contact the provider or the beneficiary.  These contacts (including telephone and email contacts) will be limited to those needed to obtain more information about the service request and/or to provide education about Medicaid-covered services. 

Providers and beneficiaries will not be asked to withdraw or modify a request for PA of Medicaid services in order to accept a lesser number of hours or less intensive type of service or to modify a SNAP score or other clinical assessment. Nothing in this paragraph should be construed to prevent clinical or treatment discussions.

How will I know if additional information is required for a prior approval request?

At the discretion of the reviewer, Medicaid or its contractors may ask for additional information because the PA request does not contain sufficient information for Medicaid to determine whether the request should be approved or denied.  The provider will be contacted by phone or will be notified in writing that the request lacks the necessary documentation for review of the request. 

A deadline date for submission of the additional information by the provider will be specified in the notification as well as where and how to submit the information.

How long do I have to submit additional documentation requested by Medicaid?

Additional documentation as specified by Medicaid staff or contractors must be submitted within 10 business days (all providers except orthodontists and dentists) of the date the notice for additional information was mailed.  Orthodontists and dentists must submit the requested documentation within 15 business days of the date the notice was mailed. 

If the provider or if the provider does not submit the additional information within the required time period as specified above, the provider and beneficiary are notified in writing that the request was denied for insufficient information. A new PA request may be submitted at any time.

Is there any reason why a request would not be reviewed?

In order for Medicaid to review a request and render a decision, all of the requirements listed below must be included in the request.

  • beneficiary name, address, Medicaid identification number (MID), date of birth (DOB)
  • Identification of service or procedure code requested
  • Provider name, Medicaid provider number who is to perform the service or procedure
  • Date the service is requested to begin or be performed
  • All required signatures on forms required by statute
  • Documents or forms required by State or federal statute in order to commence a review for prior authorization

If the request is found to be missing any of the above requirements, no further action, including medical review, is taken. The request is returned to the provider as "unable to process." The provider must notify the beneficiary that the request could not be processed as submitted. Appeal rights do not apply to a request that was unable to be processed. A new request with all required information may be submitted at any time.

When a continuing request for a service is submitted 10 calendar days prior to the expiration of the current authorization period and if a decision is not made by the utilization review vendor on the new request before the current authorization expires, should the service continue to be provided until the decision is made on the new request?

If the utilization review vendor cannot issue a decision within 15 business days on a request to continue authorization of a service, on day 16 the UR vendor must enter authorization for the service to continue at the prior level until the effective date of its decision on the request. This applies as long as the request was submitted before the authorization period expired.

What happens if a prior approval request is not approved?

Should a request be denied, reduced, terminated or suspended, the beneficiary/legal guardian will be notified of the decision in writing by trackable mail.  The notice states the effective date of the action, adverse action taken, reason for the adverse action, citation to support the action, and an explanation of appeal rights. 

The beneficiary’s mailing will contain the notice and a pre-populated beneficiary appeal request form.  This pre-populated form allows the Office of Administrative Hearings and Medicaid to affiliate the correct appeal form to the correct beneficiary, which is vital as some beneficiaries may have filed more than one appeal.  Therefore, beneficiaries and providers are asked to use only the pre-populated form enclosed in the beneficiary's mailing. Providers should explain to beneficiaries the importance of accepting trackable mail from Medicaid or its vendors.

Notices are mailed to the last known address filed by the beneficiary with the county Department of Social Services, which is the address maintained in the state’s Eligibility Information System (EIS), or to the beneficiary's parent/legal guardian.  (It is the responsibility of the beneficiary and his/her legal guardian to ensure that the address is up to date.) 

For beneficiaries under 18 years of age or for beneficiaries who have been adjudicated as incompetent, notices shall be mailed to the provider and the parent or guardian listed in the N.C Eligibility Information System/ NC FAST/ SSI Database. If any beneficiary or parent/guardian notifies Medicaid that the beneficiary’s notice was not received, a duplicate notice will be issued. 

Duplicate copies of notices for adults or children may also be obtained by contacting Medicaid directly at 919-855-4260. 

Can services be provided during the appeal process?

Providers must request reauthorization of a service prior to the end of the current authorization period in order for services to continue unless the beneficiary loses his/her Medicaid eligibility or gives up his/her right to the service during the appeal process. Services must continue to be medically necessary. Additionally, services must be provided in accordance with all State and federal statutes and rules governing the N.C. Medicaid Program, State licensure and federal certification requirements, and all other applicable federal and State statutes and rules.

Will I receive payment for services rendered during the appeal process?

  1. If a provider requests authorization of a service 10 days prior to the end of the current authorization period, payment authorization will continue without interruption until 10 days after the date a Change Notice is mailed to the beneficiary or his/her legal guardian and copied to the provider.
  2. Within five business days after the utilization vendor is notified of the filing of a hearing request with OAH that occurs within 10 calendar days after the date the Change Notice is mailed, maintenance of service (MOS) authorization in the computer system must be entered beginning with the effective date of the decision and authorization at the prior level of service (or the amount requested if less) must continue without interruption until the utilization vendor is notified that the appeal has been resolved, either through mediation, dismissal, or a final agency decision, as long as the beneficiary does not give up this right and as long as he/she remains otherwise eligible for the service and the Medicaid Program. This right exists regardless of whether the provider submitted the reauthorization request 10 days before the end of the authorization period so long as the request was made by the end of the authorization period.
  3. Within five business days after the UR Vendor is notified of the filing of a hearing request with OAH that occurs more than ten calendar days but within 30 calendar days of the date the Change Notice is mailed, authorization for payment must be reinstated, retroactive to the date the completed appeal request form is received by the OAH.  Authorization for payment must be at the level required to be authorized on the day immediately preceding the adverse determination or the level requested by the provider, whichever is less.
  4. If a beneficiary appeals more than 30 days after the date of the notice, maintenance of services does not apply and will not be paid.
  5. When a beneficiary changes providers during the appeal process, authorization for payment must be transferred to the new provider as specified in the section on changing providers.

Can a beneficiary change providers once prior approval is issued or before the current authorization expires?

Beneficiaries may change providers at any time as specified below.

  1. For Medicaid beneficiaries who have appealed an adverse decision, or whose provider agency is going out of business, or have changed providers for CAP services or are changing providers for another service with an authorization period of six months or more, the current authorization for services will transfer to the new provider within five (5) business days of notification by the new provider to the appropriate utilization review vendor and upon submission of written attestation that provision of the service meets Medicaid policy and the beneficiary’s condition meets coverage criteria and acceptance of all associated responsibility; and either:
    • Written permission of beneficiary or legal guardian for transfer; or
    • Copy of discharge from previous provider.
  2. Authorization shall be effective the date the new provider submits a copy of the written attestation.
  3. Following the appeal or prior to the end of the current authorization period, the new provider must submit a request for reauthorization of the service in accordance with the clinical coverage policy requirements and these procedures.
  4. Medicaid beneficiaries may change providers at any other time.  However, the discharging provider and the new provider must follow all policy requirements and these procedures.

 

 

 

 

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