Minnesota Administrative Rules

9505.5030 CRITERIA FOR APPROVAL OF PRIOR AUTHORIZATION REQUEST.

A request for prior authorization of a health service shall be evaluated by consultants using the criteria given in items A to F. A health service meeting the criteria in this part shall be approved, if the health service is otherwise a covered service under the MA or GAMC programs. The health service must:

A.

be medically necessary as determined by prevailing medical community standards or customary practice and usage;

B.

be appropriate and effective to the medical needs of the recipient;

C.

be timely, considering the nature and present state of the recipient's medical condition;

D.

be furnished by a provider with appropriate credentials;

E.

be the least expensive appropriate alternative health service available; and

F.

represent an effective and appropriate use of program funds.

Statutory Authority:

MS s 256.991

History:

10 SR 842

Published Electronically:

August 12, 2008