Sec. 10.09.15.06. Preauthorization

A. Preauthorization is required for any procedure not included in the current fee schedule.

B. Preauthorization is issued when:

(1) Program procedures are met;

(2) The provider submits to the Department adequate documentation demonstrating that the service to be preauthorized is medically necessary.

C. Preauthorization is valid only for services rendered or initiated within 90 days of the date issued.

D. Preauthorization normally required by the Program is waived when the service is covered and approved by Medicare. However, if the entire claim or any part of a claim is rejected by Medicare, and the claim is referred to the Program for payment, payment will be made for services covered by the Program only if authorization for those services has been obtained before billing. Non-Medicare claims require preauthorization according to §§A-C of this regulation.