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State Authorization Requirements and Clinical Criteria

DELAWARE AUTHORIZATION REQUIREMENTS AND CLINICAL CRITERIA

A. Prior Authorization of Non-Urgent Healthcare Service (HB 381)

  1. NIA/Magellan acting on behalf of the Health Plan must make an authorization or non-authorization determination and notify the subscriber (member) and provider of the non-electronic determination/decision within 8 business days of receipt of preauthorization request that contains all necessary information not to exceed 15 calendar days.
  2. NIA/Magellan acting on behalf of the Health Plan must make an authorization or non-authorization determination and notify the subscriber (member) and provider of the electronic determination/decision within 5 business days of receipt of the complete electronic request not to exceed 15 calendar days.

  3. Preauthorization for a health care service shall be valid for a reasonable and customary period of time for the service but no less than 60 days from the date that the provider receives the preauthorization, subject to confirmation of continued coverage and eligibility. 

  4. Any written clinical criteria can be found on RadMD.com.

Services requiring preauthorization for Delaware Health Plans:

CT Scan of:  head/brain/sinus/soft tissue of the neck/ chest (non coronary)/ pelvis/cervical spine/lumbar spine/ thoracic spine/lower extremity/abdomen/heart/heart congenital studies, noncoronary arteries

CT angiography of:  chest/pelvis/upper extremity/lower extremity/ abdomen/pelvis/abdominal arteries/

MRI of:  the face/neck/brain/cervical spine/lumbar spine/ thoracic spine/upper joint extremity/lower extremity/hip/abdomen/heart/breast

MRA of:  head/neck/ chest (excluding myocardium)/ spinal canal/pelvis/upper extremity/lower extremity/abdomen/

PET scan of:  heart/brain (or all? - not sure if we need this list as it seems to imply all PET require preauth) PET PET Scan with concurrently acquired CT for attenuation correction and anatomic, localization. PET imaging whole body, melanoma for non-covered indications/ PET imaging, any site, not otherwise specified/ PET imaging, initial diagnosis of breast cancer and/or surgical planning for breast cancer

Diagnostic CT colonoscopy (virtual colonoscopy, CT colonography)

Coronary Artery Ca Score, Heart Scan, Ultrafast CT Heart, Electron Beam CT

CTA coronary arteries (CCTA)

MR Spectroscopy

Myocardial Perfusion Imaging - Nuclear Cardiology Study

Low Dose CT For Lung Cancer Screening

Mandatory notification required for stress Echocardiography


ARKANSAS AUTHORIZATION REQUIREMENTS AND CLINICAL CRITERIA
A. Prior Authorization of Non-Urgent Healthcare Service (A.C.A. 23-99-1105)

NIA acting on behalf of the Health Plan must make an authorization or non-authorization determination and notify the subscriber (member) and provider of the determination/decision within 2 business days of obtaining all information needed to make the determination.
B. Prior Authorization of Urgent Healthcare Service (A.C.A. 23-99-1106)

NIA acting on behalf of the Health Plan must make an expedited authorization or adverse determination on an urgent request and notify the subscriber(member) and provider of the determination no later than 1 business day after receipt of all information needed to complete the review.
C. Retrospective Denial (A.C.A. 23-99-1108)
1. NIA may not revoke (cancel), limit, condition, or restrict an authorization for a period of 45 business days from the date the provider received the authorization.
2. Any correspondence, contact, or other action by NIA that disclaims, denies, or attempts to disclaim, or attempts to deny payment for services that have been authorized within the 45-day period is void.
D. Written Clinical Criteria

Any written clinical criteria can be found on RadMD.com and on the Arkansas Clinical Guidelines page.
Per AR SB 318 (ACA 23-99-1104) statistics are made readily available regarding prior authorization approvals and denials.

 

MASSACHUSETTS AUTHORIZATION REQUIREMENTS AND CLINICAL CRITERIA
A. Prior Authorization of Non-Urgent Healthcare Service
NIA acting on behalf of the Health Plan must make an authorization or non-authorization determination and notify the subscriber (member) and provider of the determination/decision within two (2) business days of obtaining all information needed to make the determination. The rendering provider must be notified of the decision by telephone within twenty-four (24) hours thereafter.
B. Prior Authorization of Urgent Healthcare Service
NIA acting on behalf of the Health Plan must make an expedited authorization or adverse determination on an urgent request and notify the subscriber (member) and provider of the determination no later than seventy-two (72) hours of receipt of request.