Sec. 10.09.53.06. Preauthorization Requirements

A. The Department or the Department's designee shall preauthorize nursing services, according to medical necessity, frequency, and duration, as a prerequisite to payment beyond the initial assessment.

B. Preauthorization is issued when:

(1) Program procedures are met;

(2) Program limitations are met;

(3) The requirements specified in this chapter are met; and

(4) The Department or the Department's designee determines that the services are medically necessary.

C. The provider shall request the Department or the Department's designee to authorize the initiation or continuance of nursing services before the initiation or continuation of services unless services are rendered to a participant in need of emergency or urgent medical services.

D. The provider shall request the Department or the Department's designee to authorize emergency or urgent medical services rendered to a recipient not later than the close of business the next business day after the emergency or urgent service is rendered.

E. If nursing services in excess of the initial authorized amount are necessary, then:

(1) The assigned nurse or registered nurse supervisor shall contact the primary medical provider for approval of additional hours; and

(2) The provider shall request the Department or the Department's designee to authorize the increase in services before the initiation of change for nonemergency and nonurgent changes and not later than the close of business the next business day after the emergency or urgent service is rendered.

F. An existing preauthorization shall remain in effect when a recipient is discharged from a hospital admission of less than or equal to 72 consecutive hours and there is no substantive change in the recipient's plan of care requiring a change in the number of authorized units of nursing services.

G. Since preauthorization does not guarantee Program eligibility, the provider is responsible for checking for Program eligibility on the date of service.

H. Preauthorization is only valid for services initiated within the period authorized by the Department or the Department's designee.

I. Preauthorization is only valid for services rendered over a fixed period of time, such as:

(1) The periods designated for recipients who are served under COMAR 10.09.27;

(2) For the designated time initially ordered by the recipient's primary care provider, up to 30 days; and

(3) For intervals of 60 days after that or as considered necessary by the Department or the Department's designee.

J. Authorization shall be rescinded by the Department or the Department's designee when:

(1) The recipient is terminated from care;

(2) The participant is admitted to a residential treatment center, an intermediate care facility for individuals with intellectual disabilities, or a nursing facility;

(3) The recipient is discharged from a hospital admission of less than or equal to 72 consecutive hours resulting in a change in the recipient's plan of care;

(4) The recipient is admitted to a hospital for a period of more than 72 consecutive hours; or

(5) The Department or the Department's designee determines that the care is no longer medically necessary.