Medical Exception Process
Exceptions to Prior Authorization Requirements and Non-Covered Services
Overview
The Medicaid exception process is the way providers request coverage for products/services not normally covered under the Utah State Plan. Section 1905(a)(4)(B) and (r) of the Social Security Act (SSA) entitles eligible children under the age of 21 to Medicaid coverage of healthcare, diagnostic services, treatment, and other measures described in section 1905(a) that are medically necessary to correct or ameliorate defects and physical and mental illnesses and conditions, whether or not such services are covered under the State Plan. This is the foundation for the Medicaid Early, Periodic, Screening, Diagnosis, and Treatment (EPSDT) program.
Medicaid members under the age of 21 are eligible for EPSDT. The goal of EPSDT is to get children the healthcare they need, when they need it, in the most appropriate setting.
While this process is required for EPSDT requests, it is also used for requests and appeals of adverse coverage determinations for members who are not eligible for EPSDT.
Is it possible to be reimbursed for medically necessary services that are not typically covered by Medicaid?
Yes. Medicaid has a process to approve requests for non-covered services that are determined to be medically necessary. This is explained in the Section I: General Information provider manual, Chapter 8-1 Medical Necessity. These exceptions are reviewed and approved on a case-by-case basis through the Medicaid exception process.
When a determination of coverage of an otherwise non-covered service is made, it is done on a single case assessment. This does not reflect a permanent change in the coverage policy for the requested services.
For example, if a provider gets an exception for a service that is normally limited to once per day, this exception will apply to that single service date for the applicable member only. If the provider later files a similar claim for the same service that also exceeds the policy limitation of “once per day”, the request would be denied for exceeding utilization limitations.
Prior authorization (PA) does not guarantee reimbursement. All submitted claims must be reported using correct coding (NCCI) guidelines and adhere to all other Medicaid requirements in order to receive reimbursement for services approved using the exception process.
How does a provider request an exception for services not typically covered by Medicaid?
There are two ways a provider may request coverage for medically necessary services that are not covered by Medicaid:
- A provider may file an appeal for an adverse coverage determination, including:
- A denied claim submitted to Medicaid.
- A denied prior authorization request.
- The provider can submit a request for an exception directly to the prior authorization department for a non-covered service for an EPSDT eligible member.
In either case, the submission needs to be reviewed and approved through the Medicaid exception process before the services are rendered and paid. An exception to this policy can be made for requests that meet criteria for retro-authorization. This is explained in the Section I: General Information provider manual Chapter 10-3 Retroactive Authorization.
What documents are needed to request for an exception?
A provider must submit the following information with either the exception request submitted to the prior authorization department or with the request for a hearing submitted in response to an adverse coverage determination:
- A PA request must be submitted through PRISM for the service you are requesting, if the request will be submitted directly to the PA department.
- The appropriate code for the requested services and/or any comparison codes that should be considered for the request.
- The provider’s acquisition cost or usual and customary charges for the item(s) or service.
- The acquisition cost, or purchase price, is the amount paid by the provider for an asset or product, either through purchasing the product directly from a manufacturer or the cost incurred by the provider to manufacture the product. The acquisition cost is not the manufacturer’s suggested retail price (MSRP). Submissions that include only MSRP information for items will be returned, without processing, for the required acquisition cost.
- Justification of medical necessity, including (where applicable):
- Any peer reviewed scientific literature that explains the efficacy of the service and how the approach is either the best treatment alternative and/or the least costly treatment approach.
- H&P and/or other relevant clinical documentation.
- Non-pharmaceutical treatment history specific for length of time (e.g. activity modification, physical therapy, external support).
- Associated medications with duration and outcome (e.g. NSAID trial, corticosteroid injections, oral contraceptives),
- If a patient has a known contraindication to above medications and/or treatments, include contraindication in documentation (e.g. allergic to NSAIDs, history of breast cancer so cannot take oral contraceptive pills, unable to obtain MRI due to pacemaker).
- Previous treatments, therapies, diagnostic studies with included relation, duration, and outcome (e.g. lab, imaging, and ablation).
- Outpatient therapies
- In addition to other required documentation, include previous therapy visit notes showing what progress the patient has made when asking for additional therapy visits (physical, occupational, and speech).
- Medical supplies and durable medical equipment (DME)
- Photocopy of any DME item(s) requested, if applicable.
- In addition to the relevant items from above, a current physician’s order is required for DME and medical supplies.
- Wheelchairs
- In addition to other supporting documents, the following are required:
- A current physician’s order
- Medical documentation from the member’s primary care provider for a one-year period prior to the date of service
- The Wheelchair Initial Evaluation Form
- The Wheelchair Training Checklist, when applicable
- A photocopy of the existing wheelchair, when applicable
- Documentation of medical necessity
- Documentation showing the requested item is the least costly alternative
- Wheelchairs and associated accessories which require prior authorization and have no published clinical criteria are reviewed using medical review tool criteria, when available. If the medical review tool criteria does not exist for the item requested, the request will be reviewed on a case-by-case basis by DHHS medical staff.
- Federally required forms
- Any request for a Medicaid covered service that has a federal/state requirement, for consent or acknowledgment, must include the appropriate completed form. Federally required forms include, but are not limited to:
- In addition to other supporting documents, the following are required:
Note: The prior authorization reviewer may request additional documentation to establish medical necessity for the service(s). A list of available prior authorization forms are available for download on the PA Forms website.
How long will it take for the request to be reviewed?
The exception process can take extra time to complete because it does not follow the normal prior authorization process. In most cases a provider can expect to wait 3-4 weeks for a final decision. It is possible to expedite the processes in cases that are time sensitive, such as for emergency surgeries.
Who can I contact with questions about the exception process?
Call the prior authorization department at (801) 538-6155, option 3, option 3, and then choose the appropriate program. Or send an email to: emailmedicaidcriteria@utah.gov.
Where do I submit an exception request?
In the event of a denied prior authorization request or claim, the provider will get a hearing request form that informs the provider of their right to appeal. The hearing request form will include the information about where the request can be submitted.
All other requests for exception need to be submitted to Medicaid’s prior authorization department using PRISM