2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Appendix F. Prior Authorization GuideCovered Servicesambulatory surgical centerservicesanesthesia servicesassertive communitytreatment servicesassisted living(ABCB service**)behavior management skillsdevelopment servicesIs PriorAuthorizationRequired?YesYes for selectservicesYesYesYesExclusions and Limitations*NONCOVERED SERVICES: If the surgery is non-covered, the anesthesia is noncovered.• A. Direct payment to physician. Ambulatory surgical centers are not reimbursed byPHP for physician fees. Reimbursement for physician fees is made directly to theprovider of the service.• B. Services furnished to dual-eligible recipients. By federal regulation, the Medicareprogram pays ambulatory surgical centers only for an approved list of specificsurgical procedures. Medicare is the primary payment source for individuals whoare eligible for both Medicare and Medicaid. For these recipients, Medicaid doesnot pay an ambulatory surgical center for a surgical procedure denied by Medicare.Ambulatory surgical centers must refer these recipients to facilities where Medicarepays for the surgical procedure, such as an outpatient hospital.Anesthesia for pain management and dental procedures require prior authorization.Electronic Claims Transmission (ECT) does not require a separate authorization foranesthesia.• A. When a provider performing the medical or surgical procedure also provides alevel of anesthesia lower in intensity than moderate or conscious sedation, such asa local or topical anesthesia, payment for this service is considered to be part of theunderlying medical or surgical service and is not covered in addition to theprocedure.• B. An anesthesia service is not payable if the medical or surgical procedure is not aMedicaid or other health care benefit.• C. Separate payment is not allowed for qualifying circumstances; payment isconsidered bundled into the anesthesia allowance.• D. Separate payment is not allowed for modifiers (modifiers that begin with theletter “P”) that are used to indicate that the anesthesia was complicated by thephysical status of the patient.Pending final determination of behavioral health UM criteria.This benefit is only for those who qualify for Nursing Facility Level of Care and selectagency based community benefits. The following services are not provided to recipientsin assisted living facilities: personal care, respite, environmental modifications,emergency response or adult day health. The assisted living program is responsible forall of these services at the assisted living facility and are included in the cost of room andboard.PHP does not cover the following specific services in conjunction with behaviormanagement services:• A. Formal educational or vocational services related to traditional academicsubjects or vocational training• B. Activities which are not designed to accomplish the objectives delineated incovered services and which are not included in the behavioral managementtreatment plan• C. Residential treatment careELIGIBLE RECIPIENTS:• A. Behavior management services can be furnished only to Medicaid recipientsunder 21 years of age who:• (1) Are at risk for out-of-home placement because of unmanageable behavior athome or within the community• (2) Need behavior management intervention to avoid inpatient hospitalizations orresidential treatment• (3) Require behavior management support following institutional or other out-of-F-22014 Practitioner and Provider Manual - Ver. 3