Download the PDF version of this page: Frequently Asked Questions about Medicaid: Prior Authorization

Contents

What is prior authorization?

Certain medical services and equipment require you to get permission from your Medicaid agency before they will cover the costs.  “Prior authorization” is a process for a Medicaid agency to review a request for services or equipment before the services or equipment are provided to you.

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When do I need to request prior authorization?

There are many types of medical services and equipment that require prior authorization.  There is not a comprehensive list, but some examples are:

  • Some home health services, including private duty nursing
  • Some durable medical equipment, such as wheelchairs, speech generating devices, hearing aids, orthopedic shoes, compression garments, hospital beds, and some repairs to previously purchased equipment
  • Some brand name prescriptions
  • Dentures and braces
  • Specialty optical items, including contact lenses, tinted lenses, prosthetic eyes, and low-vision aids
  • Services for children under Early Periodic Screening, Diagnosis, and Treatment (EPSDT or Healthchek) in excess of the amount of services that adults can receive, such as speech therapy or physical therapy
  • Some mental health services
  • Some surgical procedures, including organ, bone marrow, or stem cell transplants
  • Funding for Individual Options Waiver services above the individual’s funding range

If you do not know whether a service or equipment requires prior authorization, you or your medical provider should contact Ohio Medicaid. Managed care plans often require prior authorization for additional services or equipment, such as home health services.  Your member handbook or your managed care organization can tell you which services or equipment require prior authorization.

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How do I request prior authorization?

If you need services or equipment that require prior authorization, then your medical provider of that service or equipment will submit a request for prior authorization to the Medicaid agency.  You should work with your provider to ensure that they have all of the information they need for the prior authorization request.

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Is the prior authorization process the same for requests for additional Individual Options Waiver funding?

No, the process is different.  An individual’s yearly funding range for Individual Options (IO) Waiver services is determined by the Ohio Developmental Disabilities Profile (ODDP).  For some people, the ODDP funding range is not high enough. Requests for additional funding must be made to the county board of developmental disabilities. The county board will prepare the prior authorization request, and submit it to the Ohio Department of Developmental Disabilities (DODD) with a statement that either they support or do not support the prior authorization request. DODD will review the request and recommend to the Ohio Department of Job and Family Services (ODJFS) whether to approve or deny the request. ODJFS will make a final decision and notify the individual.

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How will I know if my prior authorization request has been approved or denied?

If the prior authorization request is approved, then your provider will be notified that the service or equipment can be provided to you.  If the Medicaid agency needs more information in order to approve or deny the request, then your provider will be notified that they need to submit additional information.

If the prior authorization request is denied, then you will receive a notice in the mail.  The notice will tell you that the request has been denied, the reason for the denial, and how you can appeal if you disagree.

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How can I appeal the denial of a prior authorization request?

If your request for prior authorization is denied, you can appeal the denial through the state hearing process. If your managed care plan denies your prior authorization request, then you also have the option of appealing through the managed care organization’s appeal process.  Your denial notice will provide you with information about your appeal options, and the timeline for requesting an appeal.  You must request an appeal within 90 days of the mailing date of the denial notice.

Before the hearing, you should try to gather documents, letters, and other evidence from your doctors/health care providers that prove why you need the service or equipment that was requested. At the hearing, you will give these documents to the hearing officer, and tell them why the service or equipment is medically necessary for you.

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