Pennsylvania Code & Bulletin
COMMONWEALTH OF PENNSYLVANIA

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 51 Pa.B. 1768 (March 27, 2021).

55 Pa. Code § 1101.67. Prior authorization.

§ 1101.67. Prior authorization.

 (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.

Authority

   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).

Source

   The provisions of this §  1101.67 amended November 30, 1984, effective December 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 October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial pages (124108) to (124110).

Cross References

   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).

Notes of Decisions

   Applicability

   Petitioner claimed the Department was required to comply with her request for equipment since the Department failed to notify her of its decision within the prescribed 21-day time period. However, since the request was for a noncovered item, the 21-day response requirement is not applicable. Zatuchni v. Department of Public Welfare, 784 A.2d 242 (Pa. Cmwlth. 2001).

   Optometrists’ invoices for services rendered to qualified participants in the Medical Assistance Program submitted to the Department after 180 days of the service shall be rejected unless exceptions apply. Department of Public Welfare v. Soffer, 544 A.2d 1109 (Pa. Cmwlth. 1988).



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