(a)
This section does not apply to noncompensable items or services. Medical
services and items that require prior authorization are designated in Chapter
1150 (relating to MA Program payment policies) and the MA Program Fee Schedule
and may also be addressed in the specific provider chapters. Providers shall
follow the instructions in the provider handbook for processing prior
authorization requests. Services and items that require prior authorization
shall be prescribed or ordered by a licensed practitioner.
(b) If a recipient is not notified of a
decision on a request for a covered service or item within 21 days of the date
the written request is received by the Department, the authorization is
automatically approved.
(1) For services prior
authorized at the State level, the 21 day time period will be satisfied if the
Department mails to the recipient, the recipient's practitioner or provider, a
notice of approval or denial of prior authorization request on or before the
18th day after receipt of the request at the address specified in the handbook.
If the notice is not mailed within 18 days from the date of receipt at the
address specified in the handbook, the request is automatically
authorized.
(2) The Department
will, if necessary, ask the practitioner for additional information to assist
the Department's medical consultants to reach a decision. If the practitioner
fails to provide the additional information in sufficient time for the
Department to consider it before the time for the Department's acting on the
request expires, prior authorization will be denied.
(c) Prior authorization is not required in a
medical emergency situation. For the purposes of prior authorization, emergency
situations are those which meet the Federal Medicaid definition of medical
emergency as it may be amended in the future. The definition is codified at
42 CFR
440.170(e)(1) (relating to
any other medical care or remedial care recognized under State law and
specified by the Secretary) and is a situation when immediate medical services
are necessary to prevent death or serious impairment of the health of the
individual.
Notes
The
provisions of this § 1101.67 amended November 30, 1984, effective
12/1/1984, 14 Pa.B. 4370, and by
approval of the court of a joint motion for modification of a consent agreement
dated February 11, 1985 in Turner v. Beal, et al., C.A. No. 74-1680 (E.D. Pa.
1975); amended September 30, 1988, effective 10/1/1988, 18 Pa.B.
4418.
The provisions of this § 1101.67 issued under sections
403(a) and (b) and 443.6 of the Public Welfare Code (62 P. S. §§
403(a) and (b) and
443.6).
This section cited in 55 Pa. Code §
1121.52 (relating to payment
conditions for various services); 55 Pa. Code §
1123.55 (relating to oxygen and
related equipment); 55 Pa. Code §
1123.58 (relating to prostheses
and orthoses); 55 Pa. Code §
1123.60 (relating to limitations
on payment); 55 Pa. Code §
1141.53 (relating to payment
conditions for outpatient services); 55 Pa. Code §
1143.53 (relating to payment
conditions for outpatient services); 55 Pa. Code §
1149.52 (relating to payment
conditions for various dental services); and 55 Pa. Code §
1150.63 (relating to
waivers).
