Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 79 - Other Policies Relating to Providers of Medical and Remedial Care › Rule 441-79.8 - Requests for Prior Authorization

Current through Register Vol. 47, No. 3, July 24, 2024
This rule governs requests for prior authorization for
				  services not provided through a managed care organization. For services
				  provided through a managed care organization, the prior authorization request
				  is submitted, reviewed, and authorized by the managed care organization.
(1)
Making the request.
a. Providers may submit requests for prior
				authorization for any items or procedures by mail or by facsimile transmission
				(fax) using Form 470-0829, Request for Prior Authorization, or electronically
				using the Accredited Standards Committee (ASC) X12N 278 transaction, Health
				Care Services Request for Review and Response. Requests for prior authorization
				for drugs must be submitted on any Request for Prior Authorization form
				designated for the drug being requested in the preferred drug list published
				pursuant to Iowa Code chapter 249A.
b. Providers shall send requests for prior
				authorization to the Iowa Medicaid enterprise. The request should address the
				relevant criteria applicable to the particular service, medication or equipment
				for which prior authorization is sought, according to rule
				441-78.28 (249A). Copies of
				history and examination results may be attached to rather than incorporated in
				the letter.
c. If a request for
				prior authorization submitted electronically requires attachments or supporting
				clinical documentation and a national electronic attachment has not been
				adopted, the provider shall:
(1) Use Form
				470-0829, Prior Authorization Attachment Control, as the cover sheet for the
				paper attachments or supporting clinical documentation; and
(2) Reference on Form 470-0829 the attachment
				control number submitted on the ASC X12N 278 electronic transaction.
(2) The policy applies to services or items
				specifically designated as requiring prior authorization.
(3) The provider shall receive a notice of
				approval or denial for all requests.
a. In
				the case of prescription drugs, notices of approval or denial will be faxed to
				the prescriber and pharmacy.
b.
				Decisions regarding approval or denial will be made within 24 hours from the
				receipt of the prior authorization request. In cases where the request is
				received during nonworking hours, the time limit will be construed to start
				with the first hour of the normal working day following the receipt of the
				request.
(4) Prior
				authorizations approved because a decision is not timely made shall not be
				considered a precedent for future similar requests.
(5) Approved prior authorization applies to
				covered services and does not apply to the recipient's eligibility for medical
				assistance.
(6) If a provider is
				unsure if an item or service is covered because it is rare or unusual, the
				provider may submit a request for prior approval in the same manner as other
				requests for prior approval in 79.8(1).
(7) Requests for prior approval of services
				shall be reviewed according to rule
				441-79.9 (249A) and the
				conditions for payment as established by rule in 441-Chapter 78.
a. Where ambiguity exists as to whether a
				particular item or service is covered, requests for prior approval shall be
				reviewed according to the following criteria in order of priority:
(1) The conditions for payment outlined in
				the provider manual with reference to coverage and duration.
(2) The determination made by the Medicare
				program unless specifically stated differently in state law or rule.
(3) The recommendation to the department from
				the appropriate advisory committee.
(4) Whether there are other less expensive
				procedures which are covered and which would be as effective.
(5) The advice of an appropriate professional
				consultant.
b. When the
				Iowa Medicaid enterprise has not reached a decision on a request for prior
				authorization after 60 days from the date of receipt, the request will be
				approved.
(8) The
				amount, duration and scope of the Medicaid program is outlined in 441-Chapters
				78, 79, 81, 82 and 85. Additional clarification of the policies is available in
				the provider manual distributed and updated to all participating
				providers.
(9) The Iowa Medicaid
				enterprise shall issue a notice of decision to the recipient upon a denial of
				request for prior approval pursuant to 441-Chapter 16. The Iowa Medicaid
				enterprise shall mail the notice of decision to the recipient within five
				working days of the date the prior approval form is returned to the
				provider.
(10) If a request for
				prior approval is denied by the Iowa Medicaid enterprise, the request may be
				resubmitted for reconsideration with additional information justifying the
				request. The aggrieved party may file an appeal in accordance with 441-Chapter
				7.
This rule is intended to implement Iowa Code section
				  249A.4.