N.H. Admin. Code § He-W 543.04

Current through Register No. 45, November 7, 2024

Section He-W 543.04 - Prior Authorization

(a) Out-of-state hospitals shall obtain prior authorization (PA) from the department before providing inpatient hospital services to recipients, except that authorization for emergency hospital services shall be obtained within 72 hours of admission.

(b) Inpatient hospital services at out-of-state hospitals shall be limited as follows:

(1) For recipients who are absent from the state, one of the following conditions shall be met:

a. Medical services are needed because of a medical emergency;

b. Medical services are needed and the recipient's health would be endangered if he or she were required to travel to his or her state of residence; or

c. Needed medical services, or necessary supplementary resources, are more readily available in the other state; or

(2) For recipients who are in state but request to receive services out of state, one of the following conditions shall be met:

a. Medical services are needed because of a medical emergency;

b. The recipient's attending physician has:

1. Proposed out-of-state hospitalization;

2. Determined that the proposed treatment plan is medically necessary; and

3. Determined that the proposed treatment is not available from resources and facilities within the state;

c. The recipient's attending physician has:

1. Proposed out-of-state hospitalization;

2. Determined that the proposed treatment plan is medically necessary; and

3. Determined that redirection to an in-state facility would jeopardize either the treatment of an episode of care or a long standing medical relationship between the recipient and a specific physician;

d. The recipient is age 18 or younger and the recipient's attending physician has:

1. Proposed out-of-state hospitalization;

2. Determined that the proposed treatment plan is medically necessary; and

3. Determined that referral to a pediatric specialist is appropriate and there is no such pediatric specialist available in New Hampshire;

e. The out-of-state hospital is an enrolled provider and only the medicare deductible and co-insurance are to be billed to NH medicaid;

f. The out-of-state hospital care is provided prior to a recipient's eligibility determination and coverage is retroactive to the time period in which the hospitalization occurred and the hospital is a medicaid enrolled provider; or

g. It is the general practice for recipients in a particular NH locality to use medical resources in another state and the costs of obtaining care at the out-of-state hospital will result in no higher costs than the costs of obtaining in state hospital care.

(c) Prior authorization requests shall be submitted as follows:

(1) On Form 272H, "Request for Prior Authorization for Out of State Inpatient Admission" (10/2015 edition);

(2) The form shall be signed and dated by a primary care physician, treating physician, or advanced practice registered nurse requesting the service;

(3) The person in (2) above shall certify that "...the requested treatments and/or procedures are medically necessary and cost effective in obtaining measurable, realistic goals for the above-named recipient"; and

(4) The form shall be submitted with physician's notes and clinical notes supporting the medical necessity for the requested services, including, but not limited to, the medical care plan, relevant diagnostic tests, and progress notes.

(d) The department shall grant prior authorization if the documentation on Form 272H supports the requirements in (b) above.

(e) If the department approves the PA request, the state's fiscal agent shall send written confirmation of the approval to the provider.

(f) The provider shall be responsible for determining that the recipient is medicaid eligible on the date of service.

(g) If the department denies the PA request, the department shall forward a notice of denial to the recipient and the ordering provider on the department Form 272a, "Medical Assistance Program Denial for Prior Authorized Services," which includes the following information:

(1) The reason for, and legal basis of, the denial; and

(2) Information that a fair hearing on the denial may be requested within 30 calendar days of the date on the notice of the denial, in accordance with He-C 200.

N.H. Admin. Code § He-W 543.04

(See Revision Note at chapter heading He-W 500); ss by #5897, eff 9-19-94, EXPIRED: 9-19-00

New. #7399, eff 11-2-00, EXPIRED: 11-2-08

New. #9324, eff 11-21-08; amd by #10031, eff 11-19-11

Amended by Volume XXXVII Number 10, Filed March 9, 2017, Proposed by #12103, Effective 2/9/2017, Expires 2/9/2027.