Prior authorization required; 90‑day continued stay review and resubmission

No additional payment above the facility’s current nursing facility daily rate will be allowed until the ventilator-dependent service is prior authorized by the Department’s Medical Management Contractor. Prior authorization covers a maximum 90-day period; the nursing facility must resubmit requests for continued stay prior to PA expiration and the resident’s clinical condition must be reviewed every 90 days to confirm continued need. If the resident no longer requires a ventilator, the provider must not bill the ventilator-dependent reimbursement beyond the facility’s standard Medicaid nursing home per diem rate.

• Obtain PA from the Department’s Medical Management Contractor before billing any additional ventilator-dependent per diem amounts.
• Ensure clinical review and PA renewal every 90 days; resubmit prior to PA expiration for continued stay.
• Stop billing the ventilator-dependent per diem when the resident no longer requires ventilator use.

File Request for Reconsideration within 30 days; follow prescribed exchange and timelines

Providers dissatisfied with a base year rate determination or final settlement must file a written Request for Reconsideration with the Medical Assistance Division Director within 30 days of the determination notice, identifying each point in dispute and including all documentation, citation of authority, and argument. The Medical Assistance Division will forward materials to the Audit Agent and facilitate an exchange of responses and any additional submittals within the specified timelines; the Secretary or designee will issue written determinations and mail them to each party within 30 days of receipt of the materials, and that decision is final.

• File Request for Reconsideration with Director, Medical Assistance Division, within 30 days of the determination notice.
• Include identification of each disputed point plus all supporting documentation, citations, and arguments—issues not raised in the original request may not be raised later.
• Expect Medical Assistance Division to transmit request to the Audit Agent (Agent must respond within 30 days) and allow both parties up to 15 days for follow-up submittals after transmittal letters.
• Final determination made by the Secretary or designee, who will issue written findings and mail them within 30 days of delivery of materials; the Secretary’s decision is final.