Prior authorization and limits on services
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This bulletin governs Simply Healthcare Plans' temporary changes to prior authorization and service limits for Florida Medicaid members during the COVID-19 state of emergency, affecting providers delivering inpatient, outpatient, home health, DME, pharmacy and related services.
Simply will waive initial and ongoing prior authorization requirements for a broad set of services.
All prior authorization requirements (except pharmacy) are waived for services necessary to evaluate and treat members diagnosed with COVID-19.
Simply will waive limits on medically necessary services (frequency, duration, scope) when exceeding limits is needed for members with COVID-19 or to keep enrollees safely at home.
Limits on early prescription refills for maintenance medications are lifted for 60 days except for controlled substances.
Temporary Coverage Flexibilities
Waivers and limits
Temporary coverage flexibilities during the state of emergency:
ALL of the following
ONE of
- Waive limits on medically necessary services (frequency, duration, scope) when exceeding limits is needed to maintain the health and safety of members diagnosed with COVID-19 or to keep an enrollee safely at home; examples include the 45-day inpatient hospital limit, home health services, durable medical equipment, in-home physician visits, and the $1,500 outpatient limit.
- Lift all limits on early prescription refills for maintenance medications, except controlled substances; the edits prohibiting early refills will remain lifted for 60 days in accordance with Governor's Executive Order #2020-52, and Simply will reimburse for a 90-day supply when requested and available.
ALL of the following
- Noncovered services continue to require authorization review despite waivers and limits being lifted.
ALL of the following
ONE of
- Waive initial and ongoing prior authorization requirements for skilled nursing facilities, long-term acute care hospitals, hospital services, physician services, advanced practice registered nursing, physician assistant services, home health services, and durable medical equipment and supplies (except where services are noncovered).
- Waive all prior authorization requirements (except pharmacy) for services necessary to evaluate and treat members diagnosed with COVID-19; providers should follow CDC diagnosis coding guidance and are encouraged to notify Simply promptly of transfers for discharge planning.
Diagnosis Coding & Refill Edits
| No codes listed |
Provider Requirements and Prior Authorization Waivers
Waive initial and ongoing PA for listed services
Simply will waive initial and ongoing prior authorization (PA) requirements for skilled nursing facilities, long-term acute care hospitals, hospital services, physician services, advanced practice registered nursing services, physician assistant services, home health services, and durable medical equipment and supplies.
Waive PA for COVID-19 evaluation and treatment (except pharmacy)
Simply will waive all prior authorization requirements (except pharmacy services) for services necessary to appropriately evaluate and treat members diagnosed with COVID-19; follow the CDC diagnosis coding guidance.
- Providers are highly encouraged to notify Simply of transfers promptly for discharge planning.
Noncovered services still require authorization review
Noncovered services remain subject to authorization review despite other PA waivers.
Key Terms
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