La. Admin. Code tit. 50 § XVII-101

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

Section XVII-101 - Purchase and Repairs

A. Prior authorization is required before payment can be issued for the purchase or repair of prosthetics and orthotics.

B. Prior authorization is performed by the Medicaid fiscal intermediary under contractual arrangement with the Bureau of Health Services Financing and is the responsibility of the Prior Authorization Unit (PAU).

C. Every prior authorization request shall contain:

1. medical information from a physician, including:

a. a written prescription from a licensed physician or a physician's order form signed by the prescribing physician;

b. the diagnosis related to the request; and

c. other medical information to support the need for the requested item, including documentation that the medical criteria specific to the requested items are met;

2. if pertinent, a statement from the prescribing physician or appropriate licensed rehabilitation therapist as to whether the recipient's age and circumstances indicate that he can adapt to or be trained to use the item effectively; and

3. any other pertinent information, such as measurements to assure correct size of the prosthetic or orthotic item.

D. Emergency Requests. Emergency requests for prior authorization decisions may be considered for prosthetics or orthotics requested during hospitalization of a recipient which is medically necessary for hospital discharge and is to be furnished for use in an outpatient setting.

E. Requests for Repairs, Modification, or Additional Components to Equipment

1. Requests for basic repairs to a prosthetic or orthotic item shall contain medical information from a physician that is required for purchase of the item.

2. Requests for repairs or replacements of original equipment components or parts that were previously approved for purchase by Medicaid do not require a submittal of a new prescription or medical information unless the provider does not have the following identified information:

a. a copy of the original request for approval;

b. the original prior authorization number; or

c. a copy of the original prescription.

F. If one or more of these items are available, the provider may submit the prior authorization request with the original prescribing physician = s name, prescription date, and diagnosis codes. The original approval date or prior authorization number shall be noted on the request form or a copy of the original prescription attached.

G. If these items are not available, a new request with all required information must be submitted for approval.

La. Admin. Code tit. 50, § XVII-101

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 31:85 (January 2005), repromulgated LR 31:1597 (July 2005).

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