§ 49-4-169.3 - Requirements relating to administrative prior approval for services and appeals; statutory construction - Georgia Statutes

O.C.G.A. 49-4-169.3 (2010)
49-4-169.3. Requirements relating to administrative prior approval for services and appeals; statutory construction

(a) The department shall develop and implement for itself, the care management organizations with which it enters into contracts, and its utilization review vendors consistent requirements, paperwork, and procedures for utilization review and prior approval of physical, occupational, or speech language pathologist services prescribed for children. Prior approval for therapy services shall be for a period of up to six months as consistent with the needs of the individual recipient.

(b) The department, its utilization review vendors, or the care management organizations with which it contracts shall give notice to affected Medicaid recipients of the following information in cases where prior approval is denied:

(1) The medical procedure or service for which such entity is refusing to grant prior approval;

(2) Any additional information needed from the recipient's medical provider which could change the decision of such entity; and

(3) The specific reason used by the entity to determine that the procedure is not medically necessary to the Medicaid recipient, including facts pertinent to the individual case.

(c) Notwithstanding any other provision of law, the department, its utilization review vendors, or its care management organizations shall grant prior approval for requests for therapy services when the recipient is eligible for Medicaid services and the services prescribed are medically necessary.

(d) In cases where prior approval is required under this article, it shall be decided with reasonable promptness, not to exceed 15 business days, and may not be denied until it has been evaluated under the EPSDT Program.

(e) Prescriptions and prior approval for services shall be for general areas of treatment, treatment goals, or ranges of specific treatments or processing codes. Clinical coverage criteria or guidelines, including restrictions such as location of service and prohibitions on multiple services on the same day or at the same time, shall not be the sole determinant used by the department, its utilization vendors, or its care management organizations to limit the EPSDT standards or its medically necessary definition in this article. Any such restrictions shall be waived under the EPSDT Program or this article if the prescribed services are medically necessary.

(f) Nothing in this article shall be construed to prohibit the department, its utilization review vendors, or its care management organizations from performing utilization reviews of the diagnosis or treatment of a child receiving therapy services pursuant to the EPSDT Program, the amount, duration, or scope or the actual performance or delivery of such services by providers, so long as such utilization review does not unreasonably deny or unreasonably delay the provision of medically necessary services to the recipient.

(g) Nothing in this article shall be deemed to prohibit or restrict the department, its utilization review vendors, or its care management organizations from denying claims or prosecuting or pursuing beneficiaries or providers who submit false or fraudulent prescriptions, forms required to implement this article, or claims for services or whose eligibility as a beneficiary or a participating provider has been based on intentionally false information.