Section He-W 571.05 - Prescription, LMN, and Prior Authorization Requirements(a) The prescription required in He-W 571.04(a) -(c) above shall be written by the provider and include the following: (1) The recipient's name, address, date of birth, and NH medicaid identification number (MIN);(2) The specific monthly quantity(s) to be dispensed, not to exceed the limits set forth in this rule;(3) The specific type of item(s) to be dispensed;(4) The frequency of use for the medical supply(s) being dispensed; and(5) The dated signature or electronic signature of the provider.(b) The LMN required in He-W 571.04(b) -(c) above shall be written by the provider and include the following: (1) The recipient's name, address, date of birth, and NH MIN;(2) A narrative description of the recipient's medically diagnosed health condition, illness, or injury, including an indication of whether the diagnosis is a pre-existing condition or a presenting condition;(3) The recipient's prognosis;(4) An estimation of the effect on the recipient if the requested item(s) is not provided;(5) The medical justification for the item(s) being requested, including its contribution to the treatment of the recipient's illness or injury or to the improvement of the recipient's physical condition;(6) The anticipated length of time the item(s) is expected to be needed;(7) The expected outcome of providing the requested item(s);(8) The recommended timeframe to achieve the expected outcome;(9) A summary of any previous treatment plans, including outcomes, which were used to treat the diagnosed condition for which the requested item(s) is being recommended;(10) A statement, with supporting documentation, assuring that the requested item(s) is the least restrictive, least costly item available to meet the recipient's needs;(11) Supporting documentation that demonstrates the medical need for the item(s); and(12) The dated signature, or electronic signature, of the provider.(c) The prescription and LMN described in (a) and (b) above shall: (1) Not be written retroactively; and(2) Be valid for one year from the date written so long as the medical treatment remains unchanged.(d) All PA requests shall be sent to the department for review and approval, and include the following documentation: (1) A copy of the prescription, as described in (a) above;(2) An LMN containing all of the information specified in (b) above; and(3) A completed PA form specific to the item being requested, as follows: a. For all DME, a completed Form 272D, "Durable Medical Equipment Prior Authorization Request" form (January 2016) shall be signed and dated by an authorized representative of the NH medicaid enrolled dispensing provider;b. For all disposable incontinence supplies, a completed Form 272DIA, "Incontinence Products Prior Authorization Request Form" (January 2016) shall be completed by an authorized representative of the NH medicaid enrolled dispensing provider;c. In addition to submitting the forms required by a. above, requests for all wheelchairs, scooters, and customized strollers must also include a completed Form 272M, "Mobility Evaluation Form" (January 2016), including the following: 1. A dated signature and printed name of the provider completing the evaluation;2. A dated signature and printed name of the recipient or the recipient's parent or legal guardian, if applicable;3. A dated signature and printed name of an authorized representative of the NH medicaid enrolled dispensing provider; and4. A copy of the manufacturer's invoice or quote, which includes the Manufacturer's Suggested Retail Price (MSRP) and acquisition cost;d. In addition to the requirements specified in (3) c. above, PA request for the purchase of accessories for a wheelchair shall also include the following documentation from the ordering physician: 1. Documentation that the ordering physician has assessed the recipient for the accessory within 60 days of making the PA request;2. A written diagnosis, including a brief medical history justifying the need for the accessory; and3. When applicable, an estimate of the length of time the accessory will be required; ande. In addition to submitting the form required by a. above, requests for all standers, gait trainers, and bath and toileting items shall also include a completed Form 272EQ, "Medical Equipment Request Evaluation Form Non-Wheelchair" (January 2016), including the following: 1. A dated signature and printed name of the provider completing the evaluation;2. A dated signature and printed name of the recipient or the recipient's parent or legal guardian, if applicable;3. A dated signature and printed name of an authorized representative of the NH Medicaid enrolled dispensing provider; and4. A copy of the manufacturer's invoice or quote, which includes the MSRP and acquisition cost.(e) A dispensing provider may complete and submit Form 272REV "Incontinence Products Prior Authorization Revision Request Form" (October 2015) in order to provide products which better suit a recipient's needs when such changes are to: (1) Product size that will result in a new T-code or modifier;(2) Product absorbency that will result in a new T-code or modifier; or(3) Product style that will result in a new T-code or modifier.(f) Requests for PA shall be approved by the department if the department determines the following:(1) With the exception of disposable incontinence supplies, the item meets the definition of DME, prosthetic devices, medical supplies, or orthotic devices as defined in He-W 571.01;(2) The medical documentation was completed and submitted in accordance with (d) above;(3) The PA request demonstrates that the item is consistent with the established diagnosis or treatment of the recipient's illness, injury, disease, or its symptoms as determined by a review of the coverage criteria set forth in He-W 571.04 above; and(4) The item is cost effective, as determined by a finding that: a. There is no other less costly item, as identified by the department that would effectively meet the recipient's needs; orb. Less expensive, appropriate alternatives are not covered or generally not available.(g) A dispensing provider shall request and obtain prior authorization from the department before providing the item(s) .(h) A provider shall conduct and document a face-to-face encounter with the recipient no earlier than 60 days prior to submitting a prior authorization request and the provider's written order shall include the date of the encounter and the primary clinical reason the recipient needs the item(s) .(i) Requests for a PA shall be denied by the department if the department determines that the requirements set forth in (f) above have not been met.(j) Decisions made by the department in accordance with this section shall not be superseded by the treating, ordering, or consultative health care provider's prescription, orders, or recommendations.(k) If the department approves the PA request, the state's fiscal agent shall send written confirmation of the approval to the dispensing provider.(l) If the department denies the PA request or partially denies it, the state's fiscal agent shall forward a notice of denial to the recipient and the provider, which includes the following information: (1) The reason for, and legal basis of, the denial or partial denial; and(2) Information that a fair hearing on the denial may be requested within 30 days of the date on the notice of the denial, in accordance with He-C 200.(m) The dispensing provider shall be responsible for determining that the recipient is eligible for NH medicaid on the date of service as defined in He-W 571.01(a) .N.H. Admin. Code § He-W 571.05
(See Revision Note at chapter heading He-W 500); ss by #6158, eff 12-29-95, EXPIRED: 12-29-03
New. #8961, eff 8-20-07; amd by #8983, INTERIM, eff 9-21-07, EXPIRES: 3-19-08 (deletion of former subparagraph (b)(6) and renumbering remaining subparagraphs)
Amended by Volume XXXVI Number 10, Filed March 10, 2016, Proposed by #11046, Effective 2/27/2016, Expires 2/27/2026.