Section He-W 573.10 - Service Limit Override and Review(a) All requests for consideration of additional wheelchair van services beyond the 24 trip limit shall require prior authorization from the department before the recipient receives the additional services in accordance with He-W 530.07(a) -(f) and this section.(b) The wheelchair van provider shall make requests for additional wheelchair van services beyond the 24 trip limit by submitting a copy of Form 975 "Documentation to Support the Use of Wheelchair Van Services" (May 2014), completed in accordance with He-W 573.08(a) above, to the department's prior authorization agent.(c) A request for a service limit override submitted in accordance with (a) through (b) above shall be approved by the department's prior authorization agent when the department's prior authorization agent determines that the recipient meets the eligibility requirements described in He-W 573.02.(d) If the department's prior authorization agent approves the service limit override request in accordance with (c) above, the state's fiscal agent shall send written confirmation of the approval to the provider.(e) The department's prior authorization agent shall deny a request for a service limit override when the department's prior authorization agent determines that the recipient does not meet the eligibility requirements of He-W 573.02.(f) If the department's prior authorization agent denies the request for a service limit override, the department's prior authorization agent shall forward a notice of denial to the recipient and the wheelchair van provider.(g) The notice of denial shall contain the information required by 42 CFR 431.210, including: (1) The reason for, and legal basis of, the denial; and(2) Information that an appeal of the denial may be requested, in accordance with He-C 200, within 30 calendar days of the date on the notice of the denial.N.H. Admin. Code § He-W 573.10
#8563, eff 2-7-06; amd by #10016, ef 11-1-11
Amended byVolume XXXIV Number 24, Filed June 12, 2014, Proposed by #10605, Effective 5/23/2014, Expires 5/23/2024.