1. (a) The broker shall contact the department to obtain prior authorization for non-emergency medical transportation services when transportation is needed outside of the mileage limits in He-W 574.10(b).

2. (b) The recipient shall receive prior authorization for transportation outside the mileage limits as described in (a)(1) above, based on the following information:

   1. (1) The recipient’s name and address;
   2. (2) The recipient’s medicaid identification (MID) number;
   3. (3) Details describing the illness or condition sufficient to enable the department to understand the physical or emotional condition of the recipient and the reason(s) for which the medical, dental, or behavioral health service is required;
   4. (4) That the needed medical, dental, or behavioral health services cannot be obtained within the mileage limits in He-W 574.10(b);
   5. (5) The expected outcome and recommended timetable of the prescribed medical, dental, or behavioral health service; and
   6. (6) The name and address of the medicaid enrolled provider.

3. (c) Requests for prior authorization shall be approved if:

   1. (1) All of the required information described in (b) above is received; and
   2. (2) The department determines, based on the information provided, that the transportation is necessary and appropriate for the recipient’s medical, dental, or behavioral health condition, as supported by the information provided in the request.

4. (d) The department shall deny requests for prior authorization if:

   1. (1) The provisions set forth in (c) above are not met; or
   2. (2) The department determines that the recipient does not meet the eligibility requirements of He-W 574.02.
5. (e) If prior authorization is approved, payment for non-emergency medical transportation shall still comply with all of the provisions of He-W 574.
6. (f) If prior authorization is denied, the department shall forward a notice of denial to the recipient and the provider.

7. (g) The notice of denial shall contain the information required by 42 CFR 431.210, including:

   1. (1) The reason for, and legal basis of, the denial; and
   2. (2) Information that an appeal of the denial may be requested, in accordance with He-C 200, within 30 calendar days of the date on the notice of the denial.

Source. (See Revision Note at chapter heading He-W 500); ss by #6163, eff 1-4-96, EXPIRED: 1-4-04 New. #8732, eff 9-30-06; ss by #10810, eff 4-9-15; ss by #14393 (formerly He-W 574.08), eff 10-1-25, EXPIRES: 10-1-35