10.09.04.06

.06 Preauthorization Requirements.

A. Preauthorization is required for:

(1) More than one visit per type of service per day;

(2) Any service or combination of services specified in Regulation .04 of this chapter and rendered during any 30-day period for which the provider anticipates payments from the program in excess of the Medicaid average nursing facility rate;

(3) Four or more hours of care per day whether the 4-hour limit is reached in one visit or in several visits in one day; and

(4) Any instances in which home health aide services without skilled nursing services are provided.

B. Preauthorization may be:

(1) Issued by telephone when the provider submits to the Department or its designee adequate documentation demonstrating that the service or services are medically necessary.

(2) Denied when the Department, after taking into consideration the particular circumstances of the participant, determines the payments to the provider for any service or combination of services rendered during any 30-day period would exceed the cost to the program of any alternative services which could be used for the same purpose.