1. How long should I wait for a response from the Prior Authorization/Program Exception (1150 Waiver) area?
Response: The patient and the prescribing/rendering provider should receive a written response to a request for Prior Authorization/Program Exception (for a patient under 21 years of age) within 21 days. Per Regulation 1101.67 (relating to prior authorization) which requires a decision on requests for prior authorization within 21 days does not apply to requests for program exception for a patient 21 years of age or older. If the patient and/or prescribing/rendering provider does not receive a written response, the patient or his representative may call the PA Recipient Hotline at 1-800- 537-8862, option #2 to request information on the authorization. The provider may call the provider inquiry unit at 1-800-537-8862, option #1 to request information on the authorization or to check the status of a request.
2. What is an MA 97 form? What is an ADA 2006 form? How can I obtain a PA request form? How do I complete it? Where do I send the completed form?
The MA 97 - Outpatient Services Authorization Request
form is used to request a medical service/supply that requires prior authorization/program exception. The ADA 2006 form is used to request dental services that require prior authorization.
3. Is prior authorization required on a service provided when the hospital is an out-of-state facility? How does the out-of-state facility bill?
Response: Prior authorization is not required by an out-of-state facility when services are provided in accordance with Regulation 1163.65. Out-of-state facilities will need to obtain a Benefit Limit Exception for inpatient hospital stays that exceed the Benefit Limits established. For questions related to services provided and billing, call the Practitioner Inquiry Lines at 1-800-537-8862. Prior authorization is now required for "non-emergent/urgent Out of State Services" as per Place of Service Review Procedures on MAB 01-06-01; 02-06-01; 14-06-01; 31-06-01; 27-06-02.
4. Is prior authorization required for MRIs, CT Scans, and other advanced radiologic imaging services?
For dates of service on or after September 1, 2008, the following advanced radiologic imaging services require prior authorization review by calling 1-800-424-4213: CT Scans, MRA/MRI Scans, MRS Scans, Nuclear Medicine cardiology Scans, PET Scans and SPECT Scans. Please refer to MA Bulletin 99-08-08
for more information.