Prior Authorization
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This policy defines prior authorization types and requirements for Home and Community Based Services (HCBS) under the Severe and Disabling Mental Illness (SDMI) waiver and describes which services require prior authorization and by whom.
No material clinical or coverage changes in this revision.
Prior Authorization and Coverage Criteria
Prior authorization criteria
Services and situations requiring prior authorization:
ALL of the following
UM prior authorization (department designee)
- Specialized medical equipment or supplies in excess of $500 — CMT must request UM prior authorization by the department's designee (see SDMI HCBS 385).> $500
- Environmental accessibility adaptations — CMT must request UM prior authorization by the department's designee (see SDMI HCBS 325).
Department prior authorization required services
- Homemaker core — CMT must request prior authorization by the department (see SDMI HCBS 335).
- Behavioral intervention assistant — CMT must request prior authorization by the department (see SDMI HCBS 305).
Billing, Codes, and Cost Thresholds
| No codes listed |
Provider Responsibilities and Prior Authorization Process
Types/levels of prior authorization (system, department, UM)
Prior authorization is approval for payment of certain services before they are rendered; the policy defines three distinct types: (a) system prior authorization conducted by the case management team (CMT) for provider payment processing; (b) prior authorization by the department for services that require department approval prior to authorization; and (c) utilization management (UM) prior authorization performed by the Quality Improvement Organization that requires medical necessity review.
CMT must request UM prior authorization for high‑cost equipment or adaptations
The case management team (CMT) must request UM prior authorization from the department's designee when a member requires specialized medical equipment or supplies costing in excess of $500 or environmental accessibility adaptations.
- Specialized medical equipment or supplies in excess of $500 (see SDMI HCBS 385).
- Environmental accessibility adaptations (see SDMI HCBS 325).
CMT must request department prior authorization for specific services
The CMT must request prior authorization by the department for homemaker core and behavioral intervention assistant services.
- Homemaker core (see SDMI HCBS 335).
- Behavioral intervention assistant (see SDMI HCBS 305).
Key Terms
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