Section 69-10.6 - Prior Approval Request Process

69-10.6 Prior Approval Request Process.

(a) Expenses that require prior approval. Assistive technology, vehicle modifications, environmental modifications, myo-electric limbs, certain types of transportation for medical care and services (including travel involving overnight accommodations), private duty nursing, treatment with a specialty drug, experimental treatment for which the enrollee's provider has submitted documentation that complies with the same standards set out in section 4910(2)(b)(i)-(iii) of the Public Health Law, custom-made durable medical equipment, hearing aids, and more than 1080 hours of respite care in a calendar year.

(b) Prior approval requests, other than emergency requests as set forth in § 69-10.15, will be determined within thirty days from the date all necessary documentation in support of the request has been received.

(c) General documentation requirements. In the absence of more specific requirements for particular types of expenses, every request for prior approval except for private duty nursing, which is subject to the requirements of § 69-10.10, must be accompanied by a written statement from the enrollee's treating physician stating why the service, equipment, or treatment in issue is necessary.

Effective Date: 
Wednesday, June 18, 2014
Doc Status: 
Complete