2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Appendix F. Prior Authorization GuideCovered ServicesIs PriorAuthorizationRequired?Exclusions and Limitations*classification of diseases (ICD) or the current version of diagnostic statistical manual(DSM)• C. Services for which prior authorization was not obtained• D. Services in freestanding psychiatric hospital for eligible recipient 21 years of ageor older• E. Services furnished after the determination by PHP or its designee has beenmade that the eligible recipient no longer needs hospital care• F. Formal educational or vocational services related to traditional academic subjectsor vocational training; PHP only covers non-formal education services if they arepart of an active treatment plan for an eligible recipient under the age of 21 receivinginpatient psychiatric services; see 42 CFR Section 441.13(b)• G. Experimental or investigational procedures, technologies, or non-drug therapiesand related services or treatment• H. Drugs classified as "ineffective" by the FDA drug evaluation• I. Activity therapy, group activities, and other services primarily recreational ordiversional in nature• J. PHP covers “awaiting placement days” in freestanding psychiatric hospitals whenthe PHP utilization review contractor determines that an eligible recipient under 21years of age no longer meets acute care criteria and the children’s mental healthservices review panel determines that the eligible recipient requires a psychosocialresidential level of care which cannot be immediately located• K. Those days during which the eligible recipient is awaiting placement to the lowerlevel of care are termed awaiting placement days• L. Payment to the hospital for awaiting placement days is made at the weightedaverage rate paid by PHP for psychosocial accredited residential services foreligible recipients classified as Level III, IV, or IV+ plus five percent; a separateclaim form must be submitted for awaiting placement daysICF/MR Yes Must meet Nursing Facility Level of Care criteria. member must be 18 years or older.IV OP serviceslab servicesmedical services providersmedication assistedmedical treatment (Tx) foropioid dependencemidwife servicesmulti-systemic therapy(MST) servicesnon-accredited residentialTx centers and grouphomesYesNo except forselect high-costtestsNo, but reserverights to implementprocess foroverutilizersYes formedications only,not for office visitYesYesYes for specificdefined criteriaMedicaid does not cover the following specific services furnished by midwives:• A. Oral medications or medications, such as ointments, creams, suppositories,ophthalmic, and otic preparations which can be appropriately self-administered bythe recipient• B. Services furnished by an apprenticeMST intervention is typically three to six months. Weekly interventions may range fromthree to 20 hours a week. The number might be less as a case nears closure.Member must be under 21 years of age. PHP does not cover the following specificactivities furnished in non-accredited residential treatment centers or group homes:• A. Services not considered medically necessary for the condition of the recipients,as determined by PHP• B. Room and board• C. Services for which prior approval was not obtainedF-82014 Practitioner and Provider Manual - Ver. 3