Title: Section 511.5 - Applications for utilization threshold increases and exemptions.

511.5 Applications for utilization threshold increases and exemptions.

(a) An MA recipient, or a provider on behalf of a recipient, may apply to the department on a State-prescribed form for an increase in or exemption from a utilization threshold. Such an application may be made at any time the recipient or provider determines that there will be a medical need for care, services, or supplies in excess of the threshold amount. Recipients and providers are encouraged to apply as soon as they determine that an increase or exemption will be necessary.

(b) A recipient who requests an increase or exemption must submit medical documentation from his/her provider to the department or must arrange for the provider to submit medical documentation to the department on his/her behalf. The documentation must contain sufficient factual data and medical evidence to enable the department to objectively determine the medical need for the increase or exemption.

(c) A provider may not charge or collect any fee from an MA recipient for completing and submitting an application, on the MA recipient's behalf, for an increase in or exemption from a utilization threshold. Charging or collecting a fee in such circumstances is an unacceptable practice and the provider may be subject to a sanction in accordance with Part 515 of this Title.