1. (a) Prior authorization shall be required for services described in He-W 546.05(c) and (e).

2. (b) Requests for prior authorization shall include the following:

   1. (1) The recipient’s name, address, and medicaid identification number;
   2. (2) The recipient’s diagnosis and prognosis, including an indication of whether the diagnosis is a pre-existing condition or a presenting condition;
   3. (3) An estimation of the effect on the recipient if the requested service is not provided;
   4. (4) The medical justification for the services or equipment being requested;
   5. (5) The recommended timetable of the prescribed treatment;
   6. (6) A discussion of why the service is medically necessary as defined in He-W 546.01;
   7. (7) The expected outcome of providing the requested service;
   8. (8) The recommended timeframe to achieve the expected outcome;
   9. (9) A summary of any previous treatment plans, including outcomes, which were used to treat the diagnosed condition for which the requested service is being recommended;
   10. (10) Listings of individuals or agencies to whom the recipient is being referred; and
   11. (11) Assurance that the requested service is the least restrictive, most cost-effective service available to meet the recipient’s needs.
3. (c) Requests for prior authorization shall include a statement signed by a provider acting within their scope of practice indicating that they concur with the request.
4. (d) Prior authorizations for coverage of services requested in accordance with He-W 546.06 shall be approved by the department if the department determines that the information provided in (b) above demonstrates medical necessity.
5. (e) Confirmation of department approvals shall be sent to the treating provider in writing.
6. (f) Providers shall be responsible for determining that the recipient is medicaid eligible on the date of service.

7. (g) If the requested service is denied, or denied in part, by the department, the department shall forward a notice of denial to the recipient and the treating provider with the following information:

   1. (1) The reason for, and the legal basis of, the denial; and
   2. (2) Instructions that a fair hearing on the denial may be requested by the recipient within 30 calendar days of the date on the notice of the denial, in accordance with He-C 200.
8. (h) Decisions made by the department in accordance with (d) and (g) above shall not be superseded by the treating or consultative provider’s prescription, orders, or recommendations.

Source. (See Revision Note at chapter heading He-W 500); ss by #5532, eff 12-17-92, EXPIRED: 12-17-98 New. #6940, eff 1-30-99; ss by #8782, eff 1-1-07; ss by #10829, eff 5-19-15; ss by #14383, eff 9-20-25, EXPIRES: 9-20-35