Author: Clinical Policy and Programs
As a reminder, providers are to request and obtain proper PA before services are scheduled or rendered. Contractually, CSRA (Medicaid’s fiscal vendor) has five business days (excluding holidays and weekends) to process a PA request once all required information is obtained. Medical necessity cannot be determined with a partial or incomplete clinical picture.
Failure to obtain PA, rendering services before PA is granted, or the inappropriate use of diagnosis codes or modifiers to bypass the PA requirement will result in claim denials or potential recoupments.
North Carolina Administrative Code 22J .0106 prohibits the billing of Medicaid beneficiaries when a claim is denied due to a provider failing to follow program regulations or if a claim is denied due to lack of medical necessity.
Not all procedures and services require prior approval. Providers will find current PA requirements for each clinical coverage policy on the Medicaid Clinical Coverage Policy web pages.