Benefit Exhaustion (Benefit Exception Requests)
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Defines criteria and process for evaluating requests to exceed annual Medicaid benefit limits for Alliance Health Tailored Plan members, including EPSDT considerations for beneficiaries under 21.
Added policy hierarchy and scope; clarified benefit exception criteria; standardized documentation requirements; aligned EPSDT language; added guardrail section.
Removed State-Funded Programs from the CCP.
Coverage Criteria for Benefit Exception Requests
Benefit Exception (Over the Annual Benefit Limit) Criteria
Coverage of services exceeding an annual benefit limit may be considered only as a rare, individualized exception when ALL of the following are met:
Alliance applies NCDHHS Clinical Coverage Policies and MCG guidance when evaluating medical necessity; EPSDT applies for beneficiaries under age 21.
Eligibility and EPSDT
Eligibility and EPSDT requirements (apply in addition to core criteria):
Exceptions will not be approved when the requested service is not medically necessary, when the desired outcome can be achieved through covered services within the benefit limit, when coverage is prohibited by NC Medicaid policy or federal/state law, or when the member is enrolled in a program or waiver that explicitly prohibits exceeding established limits. Members enrolled in programs or waivers with explicit service limits (for example, Innovation Waiver, TBI Waiver, 1915(i)) are not eligible for benefit exceptions unless the governing policy explicitly allows limits to be exceeded.
Requests for benefit exceptions are not medically necessary and will not be approved if the requested service is not medically necessary or if the desired outcome can be achieved within the applicable benefit limit. Coverage that would exceed a specific service limit established by a governing Clinical Coverage Policy will not be provided unless that governing policy explicitly permits exceeding the limit.
What Providers Must Do
Prior authorization required
All requests to exceed an annual benefit limit (benefit exceptions) must be submitted and approved through the prior authorization process.
Evidence of prior trials
Approval requires documentation that covered alternatives within the benefit limit have been trialed, considered, or are clinically inappropriate prior to granting an exception.
- Documentation must show prior trials of covered alternatives and their outcomes.
Required documentation
Submit an individualized care plan, clear clinical rationale with supporting medical records, evidence of clinical value and anticipated outcome, prior trial documentation, and an individualized risk assessment; use Alliance’s Clinical Specialist and Medical Director templates in the healthcare management platform.
- Individualized care plan identifying the unmet need.
- Clinical rationale and supporting medical records.
- Evidence of clinical value and anticipated outcome.
- Documentation of prior trials and explanation why alternatives are ineffective when applicable.
- Individualized risk assessment.
- Use required Clinical Specialist and Medical Director templates in Alliance's platform.
Denial triggers
Benefit exception requests will be denied when the requested service is not medically necessary, the desired outcome can be achieved within the benefit limit, coverage is prohibited by NC Medicaid or federal/state law, or the member’s program/waiver explicitly prohibits exceeding limits.
- Not medically necessary.
- Desired outcome achievable within benefit limits.
- Coverage prohibited by NC Medicaid policy or federal/state law.
- Member enrolled in a program/waiver that explicitly prohibits exceeding limits (e.g., Innovation Waiver, TBI Waiver, 1915(i)).
Key Definitions
Background and Scope
This policy governs rare, individualized approvals to exceed an annual benefit limit when failure to provide the service would jeopardize the member’s life, physical or mental health, or ability to attain, maintain, or regain maximum function. Such benefit exceptions are considered only when all core criteria are met and require prior authorization. For beneficiaries under age 21, EPSDT protections apply and services exceeding annual limits may be considered when medically necessary to correct or ameliorate a condition identified through screening, consistent with federal and state EPSDT requirements.
Policy Revision History
Added policy hierarchy and scope; clarified benefit exception criteria; standardized documentation requirements; aligned EPSDT language; added guardrail section.
Policy became effective as the Clinical Coverage Policy governing benefit exhaustion and benefit exception requests.
Removed State-Funded Programs from the Clinical Coverage Policy.
Reviewed and approved at the February Medical Policy Committee.
Original approval of the policy (initial publication).
Document retracted and provider notification completed related to the retraction.
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