The medical provider applies to Medicaid for prior approval or authorization for medical services by submitting documentation of medical necessity and the patient qualification clinical coverage criteria from Medicaid. The medical provider submitting the documentation must bill the service, states the North Carolina Department of Health and Human Services, or NC DHHS.
The medical provider determines what treatment options are available, but Medicaid patients need approval from Medicaid prior to undergoing a medical procedure or treatment or filling a medication prescription. The medical provider submits all required documents to Medicaid and receives a response within 24 hours for medication requests and within 15 days for treatment or procedure requests, says NC DHHS.
Limits placed on the approval must be followed. No services other than those requested should be performed within the specified time frame, states NC DHHS. Prior approval does not guarantee Medicaid payment for service, nor does it prevent a post-service review to determine the necessity of the service or guarantee that the patient was still eligible for approval on the date of service.
Although the DHHS is federally funded, the prior approval process must follow state and federal laws and statutes to ensure compliance with Medicaid guidelines. Claims submitted for approval must be rendered and billed by the submitting medical provider or the claim will be denied, states NC DHHS.