Missouri Code of State Regulations › Title 22 - MISSOURI CONSOLIDATED HEALTH CARE PLAN › Division 10 - Health Care Plan › Chapter 2 - State Membership › Section 22 CSR 10-2.045 - Plan Utilization Review Policy

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule establishes the policy of the
				  board of trustees in regard to the Plan Utilization Review Policy of the
				  Missouri Consolidated Health Care Plan Medical Plans.
(1) Clinical Management-Certain benefits are
				subject to a utilization review (UR) program. The program has the following
				components:
(A) Preauthorization-The claims
				administrator must authorize some services in advance. Preauthorization is to
				determine if the procedure or treatment is medically necessary. The claims
				administrator will determine what procedures or treatments are subject to
				preau-thorization. Without preauthorization, any claim that requires
				preau-thorization will be denied for payment. Members who have another primary
				carrier, or who are enrolled in the Medicare Advantage Plan are not subject to
				this provision except for those services that are not covered by the other
				primary carrier, but are otherwise subject to preauthorization under this rule.
				Preauthorizations found to have a material misrepresentation or intentional or
				negligent omission about the person's health condition or the cause of the
				condition may be rescinded.
1. A list of
				medical services for which preauthorization is required may be obtained at any
				time from the claims administrator.
A.
				Ambulance services for non-emergent use, whether air or ground;
B. Anesthesia and hospital charges for dental
				care for children younger than five (5) years, the severely disabled, or a
				person with a medical or behavioral condition that requires
				hospitalization;
C. Applied
				behavior analysis for autism at initial service;
D. Auditory brainstem implant
				(ABI);
E. Bariatric
				surgery;
F. Cardiac rehabilitation
				after thirty-six (36) visits within a twelve- (12-) week period;
G. Chelation therapy;
H. Chemotherapy for cancer
				diagnosis;
I. Chiropractic services
				after twenty-six (26) visits annually;
J. Cochlear implant device;
K. Dental care;
L. Dialysis
M. Durable medical equipment (DME) over one
				thousand five hundred dollars ($1,500) or DME rentals over five hundred dollars
				($500) per month;
N. Genetic
				testing or counseling;
O. Hearing
				Aids;
P. Home health
				care;
Q. Hospice care and
				palliative services;
R. Hospital
				inpatient services;
S. Imaging
				(diagnostic non-emergent outpatient), including magnetic resonance imaging
				(MRI), magnetic resonance angiography (MRA), positron emission tomography
				(PET), computerized tomography scan (CT), computerized tomography angiography
				(CTA), electron-beam computed tomography (EBCT), and nuclear
				cardiology;
T. Maternity coverage
				for maternity hospital stays longer than forty-eight (48) hours for vaginal
				delivery or ninety-six (96) hours for cesarean delivery;
U. Nutritional counseling after six (6)
				sessions annually;
V. Orthognathic
				surgery;
W. Orthotics over one
				thousand dollars ($1,000);
X.
				Physical, speech, and occupational therapy and rehabilitation services
				(outpatient) after sixty (60) combined visits per calendar year;
Y. Procedures with procedure codes ending in
				"T" (temporary procedure codes used for data collection, experimental,
				investigational, or unproven procedures);
Z. Prostheses over one thousand dollars
				($1,000);
AA. Pulmonary
				rehabilitation after thirty-six (36) visits within a twelve- (12-) week
				period;
BB. Skilled nursing
				facility;
CC. Specialty
				injectables;
DD. Surgery
				(outpatient)-The following outpatient surgical procedures: cornea transplant,
				potential cosmetic surgery, sleep apnea surgery, implantable stimulators,
				stimulators for bone growth, spinal surgery (including, but not limited to,
				artificial disc replacement, fusions, nonpulsed radiofrequency denervation,
				vertebroplasty, kyphoplasty, spinal cord stimulator trials, spinal cord
				stimulator implantation, and any unlisted spinal procedure), total hip
				arthroplasty, total knee arthroplasty, and oral surgery (excisions of tumors
				and cysts of the jaw, cheeks, lips, tongue, roof, and floor of the mouth when
				such conditions require pathological exams); and
EE. Transplants, including requests related
				to covered travel and lodging.