PM 20-03-01: Prior Approval

WAG 20-03-01.

Some medical services or items have to be approved by HFS before they are provided. The office that makes the prior approval decision, the standard, and the timeframes depend on the type of service or item. To receive prior approval, services or items must be appropriate to the client's needs, medically necessary, cost-effective, and non-experimental.

Requests for prior approval must be on the correct form and must include the following information:

  • case name;
  • patient name;
  • case ID number;
  • recipient number;
  • patient's birthdate and address (noting if patient lives in a group care facility);
  • provider ID;
  • description of the item or service; and
  • treatment plan.

Requests should also include the following information when it is appropriate:

  • how long the service or item is needed;
  • cost for purchase or rental;
  • how the service or item will help the client;
  • how the requested treatment plan is better than other treatments commonly used; and
  • anything unique about the client's medical condition or situation that affects the choice of treatment.

Only the provider who received the prior approval can provide the service or item. The client must be eligible when the service is provided. If a provider received prior approval but the client was not eligible, HFS will not pay the bill. When prior approval is given for spenddown clients, the provider will not be paid unless the client was in "met" status when the service was provided.

HFS does not give prior approval when:

  • a less expensive service or item can meet the client's need;
  • the client already has equipment that meets their needs.

If the request for prior approval does not have all the needed information, the office processing the request must contact the provider to get what is missing. For requests that must have a decision in less than 14 days, the missing information has to be requested within 7 days. If the missing information is not requested from the provider within 14 days after the request for prior approval was received, the decision is based on the information available.

The timeframe for making a decision depends on the type of service or item. Start counting on the day all necessary information is received, including any information submitted later than the original request. The client must be told the decision within the timeframe for the service or item. If the client is not told within the timeframe, the request is automatically approved, effective when the timeframe ran out.

Oral notice is given for approved requests for transportation. Written notice is given for all other requests, including denied transportation requests.