2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Appendix F. Prior Authorization GuideCovered Servicesrespite(ABCB service**)(SDCB service***)rural health clinic (RHC)servicesschool-based servicesskilled maintenance therapyservices(ABCB service**)(SDCB Service***)Is PriorAuthorizationRequired?YesServices providedby RHC havesamerequirements asother providersNoYesExclusions and Limitations*• B. Fertility drugs• C. In vitro fertilization• D. Artificial insemination• E. Elective procedures to terminate pregnancy• F. Hysterectomies performed for the sole purpose of family planning• A. Respite services are limited to a maximum of 100 hours annually per care planyear, provided there is a primary caretaker. Additional hours may be requested if amember’s health and safety needs exceed the specified limit. For members up to21 years of age diagnosed with a serious emotional or behavioral health disorder,respite services are limited to 720 hours a year or 30 days.• B. Respite services are only for those who qualify for Nursing Facility Level of Careor for select behavioral health patients.Services furnished in school settings are subject to the limitations and coveragerestrictions that exist for other Medicaid services. See 8.301.3 NMAC [MAD-602],General Noncovered Services. PHP does not cover the following specific services:• A. Services classified as educational• B. Services to non-Medicaid eligible individuals• C. Services furnished by providers outside their area of expertise• D. Vocational training that is related solely to specific employment opportunities,work skills, or work settings• E. Services that duplicate services furnished outside the school setting, unlessdetermined to be medically necessary, and given prior authorization by the medicalassistance division or its designee• F. Services not identified in the recipient’s Individual Education Program orIndividualized Family Service Plan, and not authorized by the recipient’s PCP• G. Transportation that a recipient would otherwise receive in the course of attendingschool• H. Transportation for a recipient with special education needs under the Individualswith Disabilities Education Act (IDEA), who rides the regular school bus to and fromschool with other non-disabled children• A. A signed therapy referral for treatment must be obtained from the recipient'sprimary care physician. The referral includes frequency, estimated duration oftherapy, and treatment/procedures to be rendered.• B. Only for those who qualify for Nursing Facility Level of Care.• C. Member must be at least 21 years of age.smoking cessation services NoMember must be over the age of 18. Coverage is limited to two 90-day courses oftreatment per calendar year.• A. Experimental or prohibited treatments and goods are excluded. Related goodsspecialized therapiesare limited to $500 per person per care plan year.Yes(SDCB service***)• B. Only for those who qualify for Nursing Facility Level of Care and select Self-Directed Community Benefits.speech and languagetherapyYesThis benefit is only provided to adults with short-term needs because of an acute event.swing bed hospital servicesYestelehealth services(provider telehealth, nothome-based telehealth)NoF-132014 Practitioner and Provider Manual - Ver. 3