N.H. Code Admin. R. He-M 517.08 - Utilization Control

(a) Recipients shall undergo an initial determination of eligibility and annual reassessment of the need for continued services. The bureau shall determine the need for services based on the criteria specified in He-M 517.03.

(b) To request determination of eligibility and service authorization for home and community-based care services for an individual, the area agency shall complete and submit to the bureau through Xerox Provider Services a "NH bureau of developmental services functional screen for waiver services" form (edition 5/22/13) at least 30 days prior to initiation of the services or at least 30 days prior to expiration of the current authorization.

(c) In the case of environmental modification or vehicle requests in excess of $5,000, each request shall include 2 cost estimates.

(d) To request prior authorization of a change in covered services within a current authorization period, the area agency shall complete and submit:

(1) A written request for authorization of the change; and

(2) An updated "NH bureau of developmental services functional screen for waiver services" form (edition 5/22/13) .

(e) The bureau shall approve or deny requests for prior authorization of services following determination of the need for services pursuant to He-M 517.03.

(f) If information submitted pursuant to (b) or (d) above, or similar information obtained at any other time by the bureau, indicates that an individual might no longer meet the criteria for home and community-based care specified in He-M 517.03(a) (4) a. or b., the bureau shall redetermine the individual's eligibility pursuant to (b) -(e) above.

(g) For initial service determinations and annual reviews of eligibility, the department shall notify:

(1) The area agency, the department's district office, and Xerox of approvals; and

(2) The area agency of denials, including the reason.

(h) In every case of denial of a request for prior authorization of services, the area agency shall notify the individual affected, in writing, of the decision and the reasons for the denial.

(i) Notification pursuant to (g) above shall include:

(1) The specific rules that support, or the federal or state law that requires, the action;

(2) An explanation of the individual's right to request an appeal and the procedure and timelines set forth in He-M 517.09;

(3) Notice that the individual has the right to have representation with an appeal by:

a. Legal counsel;

b. A relative;

c. A friend; or

d. Another spokesperson;

(4) Notice that neither the area agency nor the bureau is responsible for the cost of representation; and

(5) Notice of organizations that might offer assistance or representation to the individual, including pro bono or reduced fee assistance.

Notes

N.H. Code Admin. R. He-M 517.08

#4315, eff 9-25-87; EXPIRED: 9-25-93

New. #6360, eff 10-23-96, EXPIRED: 10-23-04

New. #8195, INTERIM, eff 10-29-04, EXPIRED: 4-27-05

New. #8424, eff 9-1-05; amd by #9370, eff 1-24-09; ss by #10454, eff 10-31-13