Prior Approval and Due Process

Medicaid Recipient Due Process Rights

Prior Approval

  • Prior approval (PA) may be required for some services, products or procedures to verify documentation of medical necessity.
  • Prior approval is for medical approval only and must be obtained before rendering a service, product or procedure that requires prior approval.
  • The ordering provider is responsible for obtaining PA; however, any provider can request PA when necessary.
  • Prior approval is issued to the ordering and the rendering providers.

Obtaining prior approval does not:

  • Guarantee payment
  • Ensure beneficiary eligibility on the date of service
  • Guarantee that a post-payment review that verifies a service medically necessary will not be conducted

A beneficiary must be eligible for Medicaid coverage on the date the service or procedure is rendered. It is the responsibility of the provider to clearly document that the beneficiary has met the clinical coverage criteria for the service, product or procedure.

Services must be performed and billed by the rendering provider. The service must be provided according to service limits specified and for the period documented in the approved request unless a more stringent requirement applies. Services must be provided according to state and federal statutes, rules governing the NC Medicaid Program, state licensure and federal certification requirements, and any other applicable federal and state statutes and rules. Claims submitted for prior-approved services rendered and billed by a different provider will be denied.

Retroactive Prior Approval

Retroactive prior approval is considered when a beneficiary, who does not have Medicaid coverage at the time of the procedure, is later approved for Medicaid with a retroactive eligibility date. Exceptions may apply.

Prior Approval for Medicaid for Pregnant Women

Prior approval is required for Medicaid for Pregnant Women beneficiaries when the physician determines that services are needed for the treatment of a medical illness, injury or trauma that may complicate the pregnancy.

Submitting Requests for Prior Approval

The preferred method to submit prior approval requests is online using the NCTracks Provider Portal. However, providers can also submit paper forms via mail or fax. PA forms are available on NCTracks.

All requests for PA must be submitted according to DMA clinical coverage policies and published procedures.

Providers must request reauthorization of a service before the end of the current authorization period for services to continue. The date that the request is submitted affects payment authorization for services that are denied, reduced or terminated.

Providers must request authorization of a continuing services 10 calendar days before the end of the current authorization period for authorization to continue without interruption for 10 calendar days after the date an adverse decision notice (change notice) is mailed to the Medicaid beneficiary or to the beneficiary's legal guardian and copied to the provider.

Some requests are submitted for review to a specific utilization review contractor, as described on the Prior Approval Fact Sheet on NCTracks.

Review Process Timeframe

For prescription drugs requiring PA, a decision will be made within 24 hours of receipt of the request. For all other types of PA requests, Medicaid will make every effort possible to make a decision within 15 business days of receipt of the request unless there is a more stringent requirement. However, there may be a delay in making a decision if Medicaid needs to obtain additional information about the request.

Once a complete request has been submitted, Medicaid may:  

  • Approve the request
  • Deny or terminate the request
  • Reduce the request
  • Request additional information

Medicaid notifies the provider following established procedures of approvals, including service, number of visits, units, hours or frequency.

Review Criteria

Medicaid reviews requests according to the clinical coverage policy for the requested service, procedure or product. If the beneficiary is under 21 years of age and the policy criteria are not met, the request is reviewed under Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) criteria.

Medicaid researches requests to determine the effectiveness of the requested service, procedure or product to determine if the requested service is safe, generally recognized as an accepted method of medical practice or treatment, or experimental/investigational.