La. Admin. Code tit. 50 § XV-7307

Current through Register Vol. 50, No. 11, November 20, 2024

Section XV-7307 - Prior Authorization

A. EPSDT personal care services are subject to prior authorization (PA) by BHSF or its designee. A face-to-face medical assessment shall be completed by the practitioner. The beneficiary's choice of a personal care services provider may assist the practitioner in developing a plan of care which shall be submitted by the practitioner for review/approval by BHSF or its designee. The plan of care shall specify:

1. the specific personal care service(s) to be provided (i.e., activities of daily living for which assistance is needed); and

2. the minimum and maximum frequency and the minimum duration of each of these services.

B. Dates of service not included in the plan of care or provided prior to approval of the plan of care by BHSF or its designee are not reimbursable. The beneficiary's attending practitioner shall review and/or modify the plan of care and sign off on it prior to the plan of care being submitted to BHSF or its designee. A copy of the practitioners prescription for EPSDT PCS shall be included with the plan of care at the time of submission for prior authorization and may not be dated after delivery of services has started. A copy of the prescription shall be retained in the EPSDT PCS providers files.

C. A new plan of care shall be submitted at least every 180 days (rolling six months) with approval by the beneficiary's attending practitioner. The plan of care shall reassess the patients need for EPSDT PCS, including any updates to information which has changed since the previous assessment was conducted (with explanation of when and why the change(s) occurred).

D. Amendments or changes in the plan of care shall be submitted as they occur and shall be treated as a new plan of care which begins a new six-month service period. Revisions of the plan of care may be necessary because of changes that occur in the beneficiary's medical condition which warrant an additional type of service, a change in frequency of service or a change in duration of service. Documentation for a revised plan of care is the same as for a new plan of care. Both a new start date and reassessment date shall be established at the time of reassessment. The EPSDT PCS provider may not initiate services or changes in services under the plan of care prior to approval by BHSF or its designee.

E. Beneficiaries who have been designated by BHSF as chronic needs are exempt from the standard prior authorization process. Although a new request for prior authorization shall still be submitted every 180 days, the EPSDT PCS provider shall only be required to submit a PA request form accompanied by a statement from a practitioner verifying that the beneficiary's condition has not improved and the services currently approved must be continued. Only BHSF or its designee can grant the designation of a chronic needs case to a beneficiary.

La. Admin. Code tit. 50, § XV-7307

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 21:947 (September 1995), repromulgated for LAC codification, LR 29:177 (February 2003), amended LR 30:253 (February 2004), Amended by the Department of Health, Bureau of Health Services Financing, LR 45906 (7/1/2019).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.