2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Appendix F. Prior Authorization GuideCovered ServicesEPSDT private duty nursing(ABCB service**)(SDCB service***)EPSDT rehabilitationservices(ABCB service**)(SDCB service***)family planningfamily supportfederally qualified healthcenter serviceshearing aids and relatedevaluationsIs PriorAuthorizationRequired?YesYesNoNoNoYes for hearing aidonly not forevaluationExclusions and Limitations*• B. Services that are not in the recipient’s approved treatment plan and for whichprior approval has not been received;.• C. Services not considered medically necessary by PHP or its designee for thecondition of the recipient.These services are limited to members under the age of 21. Also, private duty nursingservices must be furnished by a registered nurse or a licensed practical nurse in arecipient’s home or in a school setting, if it is medically necessary for school attendance.The goal of the provision of care is to avoid institutionalization and maintain therecipient’s function level in a home setting.• A. EPSDT private duty nursing services” means nursing services for recipientsunder 21 years of age who require more individual and continuous care than can bereceived through the home health program.• B. EPSDT private duty nursing services must be ordered by the recipient’sphysician and must be included in the recipient’s approved treatment plan. Servicesfurnished must be medically necessary and be within the scope of the nursingprofession.NONCOVERED SERVICES: Private duty nursing services are subject to the limitationsand coverage restrictions which exist for other Medicaid services.Medicaid does not cover the following specific services:• A. Services for which prior approval has not been received or which are notincluded in the recipient’s approved treatment plan• B. Services not considered medically necessary by PHP or its designees for thecondition of the recipient• C. Services which are not within the scope of practice of the nursing professionThese services are limited to members under the age of 21.NONCOVERED SERVICES:• A. Services furnished by speech and language pathologists, physical therapists andoccupational therapists are subject to the limitations and coverage restrictions thatexist for other Medicaid services.• B. Medicaid does not cover these specific services:• (1) Services furnished to individuals who are not eligible for EPSDT services• (2) Services for which prior approval has not been received• (3) Services that are not within the scope of practice of the speech and languagepathologist physical therapist or occupational therapist• (4) Services furnished without the order or prescription of a physician or PCP• (5) Services that are primarily educational or vocational in nature• (6) Services related to activities for the general good and welfare of recipients,such as general exercises to promote overall fitness and flexibility and activities toprovide general motivation, are not considered physical or occupational therapy forMedicaid reimbursement purposesHearing aid and related evaluation services are subject to the limitations and coveragerestrictions that exist for other Medicaid services. Medicaid does not pay for “hearing aidchecks” (assessing a hearing aid for functionality). Hearing aid selection and fitting isconsidered included in the hearing aid dispensing fee, and is not reimbursed separately.F-62014 Practitioner and Provider Manual - Ver. 3