Section 513.4 - Obligations and responsibilities of the ordering practitioner and potential provider

513.4 Obligations and responsibilities of the ordering practitioner and potential provider. (a) The ordering practitioner and the potential provider of the requested care, services or supplies must assist the recipient in obtaining any information and documentation necessary and appropriate to support a request, and provide all such information, together with the request, to the Department of Health using the forms and procedures prescribed by the Department of Health.

(b) The ordering practitioner is responsible for verifying the recipient's eligibility for MA as of the date of the order and certifying the medical necessity of the requested medical, dental and remedial care, services or supplies. The potential provider is responsible for verifying the recipient's eligibility for MA as of the date of the request.

(c) The ordering practitioner and potential provider are responsible for assuring that, in their best professional judgment, the ordered and requested medical, dental and remedial care, services or supplies will meet the recipient's medical needs; reduce the recipient's physical or mental disability; restore the recipient to his or her best possible functional level; or improve the recipient's capacity for normal activity; and that they are necessary to prevent, diagnose, correct or cure a condition in light of the recipient's specific circumstances and the recipient's functional capacity to make use of the requested care, services or supplies.

(d) The ordering practitioner and potential provider are responsible for assuring that adequate and less expensive alternatives have been explored and, where appropriate and cost effective, are requested and that the medical, dental and remedial care, services or supplies to be provided conform to accepted professional standards.

(e) The ordering practitioner and potential provider must cooperate with the Department of Health in its evaluation of the request and take such actions as the Department of Health may reasonably request to assure proper and timely evaluation of the request.

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