Prior Approval and Due Process

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

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 recipient 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 Automated Voice Response (AVR) system.

Additional information is available in Section 6 of the Basic Medicaid Billing Guide.

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.

Additional information is available in Section 6 of the Basic Medicaid Billing Guide.

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 recipient.  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 recipients 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.

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.

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 recipient are notified in writing that the request was denied for insufficient information. A new PA request may be submitted at any time.

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

• Recipient 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 recipient 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.

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.

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

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

For recipients under 18 years of age or for recipients 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 recipient or parent/guardian notifies Medicaid that the recipient’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. 

Providers must request reauthorization of a service prior to the end of the current authorization period in order for services to continue unless the recipient 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.

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 recipient 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 recipient 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 recipient 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 recipient changes providers during the appeal process, authorization for payment must be transferred to the new provider as specified in the section on changing providers.

Recipients may change providers at any time as specified below.

1. For Medicaid recipients 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 recipient’s condition meets coverage criteria and acceptance of all associated responsibility; and either:
   • Written permission of recipient 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 recipients may change providers at any other time.  However, the discharging provider and the new provider must follow all policy requirements and these procedures.