Section 513.6 - Evaluation of requests.

513.6 Evaluation of requests. (a) Requests will be evaluated in accordance with:

(1) the specific statutory and regulatory standards and benefit limits governing the furnishing of the requested care, services or supplies;

(2) the utilization control criteria promulgated by this department; and

(3) the medical necessity of the medical, dental and remedial care, services or supplies to prevent, diagnose, correct or cure a condition of the recipient which:

(i) causes him or her acute suffering;

(ii) endangers his or her life;

(iii) results in his or her illness or infirmity;

(iv) interferes with his or her capacity for normal activity; or

(v) threatens him or her with a significant handicap.

(b) The determination to grant, modify or deny a request initially must be made by qualified Department of Health professional staff exercising professional judgment based upon objective criteria and the written guidelines of the Department of Health and the regulations of this Department, and commonly accepted medical practice.

(c) Staff assigned to review initial prior approval requests may discuss the request with the recipient, or the ordering or treating practitioner or potential provider, propose alternatives or consult with specialists.

(d) The assigned staff of the Department of Health must consider:

(1) the opinions of the ordering or treating practitioners, if given, and all other information submitted by or on behalf of a recipient; and

(2) any other information it has available.

(e) When the opinion of the ordering or treating practitioner is on matters within the ordering or treating practitioner's professional expertise and within the range of commonly accepted medical practice for the profession, it is entitled to significant weight in reaching a determination and cannot be outweighed solely by the opinions of nonmedical personnel or persons not within the same medical profession as the ordering or treating practitioner.

Doc Status: 
Complete
Effective Date: 
Wednesday, March 28, 2012