2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Appendix F. Prior Authorization GuideCovered Servicesphysician visitspodiatry servicespregnancy terminationprocedurespreventative servicesprivate duty nursing foradults(ABCB service**)(SDCB service***)prosthetics and orthoticspsychosocial rehabilitationservicesIs PriorAuthorizationRequired?Not for PCP visits,but specialtyreferrals mayrequire a referral toobtain anauthorization #Certain servicesrequireauthorizationNoNoYesYesYesExclusions and Limitations*• A. Routine foot care is not covered except as indicated under “covered services” foran eligible recipient with systemic conditions meeting specified class findings.Routine foot care is defined as:• (1) trimming, cutting, clipping, and debriding toenails• (2) cutting or removal of corns, calluses, or hyperkeratosis• (3) other hygienic and preventative maintenance care such as cleaning andsoaking of the feet, application of topical medications, and the use of skin creamsto maintain skin tone in either ambulatory or bedfast patients• (4) any other service performed in the absence of localized illness, injury orsymptoms involving the foot• B. Services directed toward the care or correction of a flat foot condition. “Flat foot”is defined as a condition in which one or more arches of the foot have flattened out.• C. Orthopedic shoes and other supportive devices for the feet are generally notcovered. This exclusion does not apply if the shoe is an integral part of a leg braceor therapeutic shoes furnished to diabetics.• D. Surgical or nonsurgical treatments undertaken for the sole purpose of correctinga subluxated structure in the foot as an isolated condition are not covered.Subluxations of the foot are defined as partial dislocations or displacements of jointsurfaces, tendons, ligaments, or muscles of the foot.• E. Orthotripsy is not a covered service.This benefit is only for those who qualify for Nursing Facility Level of Care. The membermust be 21 years of age or older. All services provided under private duty nursingrequire the skills of a Licensed Registered Nurse or a Licensed Practical Nurse underwritten physician’s order in accordance with the New Mexico Nurse Practice Act, Code ofFederal Regulation for Skilled Nursing.Private duty nursing services are subject to the limitations and coverage restrictionswhich exist for other Medicaid services. See 8.301.3 NMAC, General NoncoveredServices. PHP 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 for the condition of therecipient• C. Services which are not within the scope of practice of the nursing professionNONCOVERED SERVICES:Prosthetic and orthotic services are subject to the limitations andcoverage restrictions that exist for other Medicaid services. See 8.301.3 NMAC, GeneralNoncovered Services [MAD-602]. In addition to the services identified in 8.301.3 NMAC[MAD-602], General Noncovered Services, the following services are not covered:• A. Orthotic supports for the arch or other supportive devices for the foot, unlessthey are integral parts of a leg brace or therapeutic shoes furnished to diabetics• B. Prosthetic devices or implants that are used primarily for cosmetic purposesPHP covers only those psychosocial rehabilitation services which comply with DOHmental health standards as detailed in the psychiatric rehabilitation user’s manual andF-102014 Practitioner and Provider Manual - Ver. 3