Prior approval submission requirements and timing

All requests for prior approval must include appropriate documentation and be completed for each resident. Prior authorization requests must be submitted to the resident's MCO by fax or the designated MCO email address. The NF must submit the initial NF LOC packet to the MCO no later than 30 calendar days after admission. All prior authorization requests must be submitted on the NF LOC Notification Form.

• Include a completed MDS with all locator fields clearly marked.
• Include a valid order signed and dated by physician/NP/CNS/PA that indicates HNF or LNF (telephone/verbal orders permitted if documented by RN/LPN with originator identified).
• Submit the NF LOC Notification Form and any accompanying documentation within 30 calendar days of admission.

RFI and technical denial process

When required documentation is missing the MCO will generate an RFI and attempt contact three times during a 14-business day period; if the NF does not provide the requested documentation within 14 business days the request will be technically denied.

• MCO will transmit a technical denial via the ASPEN interface within 24 hours of no response.

Prior approval for additional reserve bed days

Requests for additional discharge reserve bed days must be submitted by the NF to the resident's MCO for prior approval and must follow the MCO's written submission process.

• Medicaid covers an additional six reserve bed days per calendar year with prior approval to enable acclimation as part of the discharge plan.

Reserve Bed Day Prior Approval Requirements

Prior approval requests for discharge reserve bed days must include the resident's name, Medicaid number, requested dates, a copy of the discharge plan, name and address of caregivers for the visit or placement, and a written physician order for the trial placement, and be submitted following the MCO's written process.

• Resident name and Medicaid number
• Requested approval dates
• Copy of the discharge plan showing objectives and relation to discharge implementation
• Name and address of individuals who will care for the resident during the visit or placement
• Written physician order for trial placement

Initial, Redetermination, and Continued Stay Prior Authorization

Initial NF LOC documents must be completed and submitted within 30 calendar days of admission. Redetermination documentation must be faxed to the MCO a minimum of 60 days prior for LNF and 30 days prior for HNF. Continued stay requests must be received by the MCO thirty days before the current certification expires; the MCO will transmit the NF LOC determination via the ASPEN interface within 24 hours of making the determination.

• Initial HNF length of stay not to exceed 30 days; initial LNF not to exceed 90 days.
• HNF continued stay certifications up to 90 days; LNF continued stay certifications up to 365 days.

Retroactive Eligibility Prior Approval Timing

Written requests for prior approval based on retroactive Medicaid eligibility must be reviewed by the MCO within 30 calendar days of the eligibility determination date; requests will not be accepted after 180 days from the Medicaid eligibility determination date.

• NF must submit all appropriate medical documentation to the MCO for the NF LOC determination.
• MCO will transmit the determination via the ASPEN interface within 24 hours of making the determination.

Transfer and LOC Change Notifications

Transfers and changes in level of care require submission of a new notification form to the MCO within 30 calendar days; the type of request box must indicate 'Transfer' or 'LOC Change' and the NF must provide a signed and dated physician/NP/PA order plus supporting documentation.

• For transfers: notify the MCO by telephone with transfer date and write 'Transfer' in the type of request box on the notification form.
• For LOC changes: submit a new notification form within 30 calendar days, include a signed and dated order, and state the date the LOC change occurred.

Re-review process

A Re-review must be requested in writing within ten (10) calendar days after the date on the MCO's written decision; the MCO will complete and return a written Re-review decision to the NF within six (6) business days of receipt.

• If providers miss the 10-day Re-review window they may request Reconsideration.

Reconsideration process

A Reconsideration request must be submitted in writing and received by the MCO within thirty (30) calendar days after the date on the Re-review decision notice; the MCO will issue a written Reconsideration decision within ten (10) business days of receipt. The MCO may allow up to a 14-calendar-day filing extension for 'good cause' if documented.

• Reconsideration request must include a statement requesting reconsideration, reference to the challenged decision, basis for the challenge, and copies of pertinent documents and claim forms if applicable.

Appeals and administrative hearing

If a reconsideration determination is adverse to the member, the member may request an MCO appeal per 8.308.15 NMAC; after exhausting MCO appeals, parties may request a State Administrative Fair Hearing per 8.352.2 NMAC. The MCO/UR Contractor must develop a Summary of Evidence for hearings and provide testimony for NF LOC denials.

• Appeals and hearings procedures and timeframes are provided in the notice sent with reconsideration and reconsideration-adverse decisions.