Title: Section 511.7 - Additional service units pending determination of applications.

511.7 Additional service units pending determination of applications.

(a) When an MA recipient applies for an increase in or an exemption from a utilization threshold for a particular provider service type pursuant to sections 511.4 and 511.5 of this Part, the recipient is automatically eligible for additional service units of that provider service type, in addition to any medical care, services or supplies required to address an urgent medical need or medical emergency, if:

(1) the application indicates that the recipient has received notification pursuant to section 511.2(c) of this Part that he/she has reached the utilization threshold; and

(2) the application is rejected during the automated review process

(for reasons other than the inability to verify the applicant's status as an MA recipient) or the application is referred to the medical review team.

(b) An MA recipient who has reached the utilization threshold for a particular provider service type and whose application for an increase in or exemption from the threshold has been denied is eligible for additional service units of that provider service type, provided that the recipient requests a fair hearing to challenge such denial within 10 days of mailing of the determination denying the increase or exemption. The department will authorize these additional service units within 10 working days after receipt of the request for a fair hearing.

(c) An MA recipient who meets the requirements of subdivisions (a) or

(b) of this section will be authorized to receive additional service units as follows:

(1) for physician/medical clinic services, two encounters;

(2) for pharmacy services, six formulary codes;

(3) for laboratory services, four procedures; and

(4) for psychiatrist/mental health clinic services, four encounters.

 

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VOLUME C (Title 18)

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