Sec. 10.09.18.06. Prepayment Authorization Requirements

A. The following items require a written prepayment authorization:

(1) Nasal continuous positive pressure (NCPAP) system;

(2) Custom made tracheostomy tubes; and

(3) Intermittent positive pressure breathing (IPPB) machine.

B. Prepayment authorization is issued when:

(1) Program procedures are met;

(2) Program limitations are met; and

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

C. The prescriber shall submit requests for prepayment authorization in writing using the format and procedures designated by the Department.

D. Prepayment authorization, when required, may be requested via a facsimile machine to expedite hospital, nursing facility, or other medical institutional discharge or in emergency situations approved by the Program. In this case, the facsimile of the completed prepayment authorization form shall be followed by a written request, using the original of the form, which shall be submitted immediately to the Department.

E. Written prepayment authorization is valid for a period to be determined by the Program but not to exceed a maximum of 365 days beginning with the date of issue by the Program, and is contingent on the recipient's continuing eligibility.

F. Prepayment authorization normally required by the Program is waived when the services are covered and approved by Medicare. However, if the entire 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 prepayment authorization according to §§A-E of this regulation.