Authorization of Services

A consumer’s right to particular services depends heavily on assessment by the managed care organization (MCO) of his or her needs. Two types of assessments are performed in Medicaid managed care systems: 1. an assessment to determine the services required by a consumer, and 2. an initial assessment to determine whether the consumer is eligible for Medicaid-funded long-term services and supports (LTSS) generally.

In some cases, a MCO must give prior authorization for a service to be provided. Service providers should have the freedom to recommend the services that they feel are necessary; a consumer should have the right to obtain second opinions as appropriate.

Contents – To access the full text, please click each sub-topic.

Assessments for MCO Service Provision

  • Assessment by MCO must include face-to-face interview with consumer and others identified by consumer as important: Wisconsin a
  • Assessment by MCO must include many items, including consumer’s assessment of strengths and needs, available support and social resources, environmental assessment with health and safety risks, accessibility issues, and risk for fall or other injury: New Mexico b
  • MCO must contact consumer’s HCBS providers at least annually to discuss consumer’s needs: Florida c
  • Comprehensive needs assessment must include physical, behavioral, functional, and psychosocial needs, and financial health: Tennessee d
  • Needs assessment must be conducted in consumer’s home: Tennessee e

  • MCO must conduct assessment within first 30 calendar days, with services initiated within 7 days after assessment: New Mexico f
  • MCO must make best effort to conduct health risk assessment of each consumer within 30 days of enrollment, and annually thereafter: Minnesota g
  • MCO must conduct comprehensive reassessment annually or upon change of condition for consumers living in community: Minnesota h
  • MCO must complete comprehensive reassessment at least once every 6 months or more often as warranted by consumer’s condition: New York i
  • MCO must conduct comprehensive needs assessment annually and as care coordinator deems necessary: Tennessee j
  • Consumer must be present for, and included in, onsite visit: Florida k
  • Individual assessment must include risk assessment to identify safety, health, and behavioral risks: Florida l

  • MCO must use qualified assessors with relevant degrees and experience in home based services, plus training and certification specific to assessment and consultation services for long-term care services: Minnesota m
  • Assessors must be recertified every three years: Minnesota n

  • MCO must not prohibit provider from discussing treatment options that may be uncovered or otherwise contrary to MCO’s position: Florida o
  • MCO must not prohibit MDs or other health care professionals from advocating on consumer’s behalf regarding treatment options: Florida p, Hawaii q
  • MCO must not prohibit provider from advocating on consumer’s behalf in an grievance system or utilization review process: Florida r
  • Physician incentives must not be designed to induce provides to reduce consumer access to services: Texas s
  • Consumer has right to no-charge second opinion: Florida t  

  • Help line must be open 24/7 to respond to prior authorization requests: Florida u
  • MCO must submit report on prior authorization requests that have been denied or deferred: Hawaii v
  • To help in keeping prior authorization requirements to minimum, MCO must make quarterly reports to state on all procedures for which prior authorization is required, including number of requests submitted and percentage that were approved and denied: New Mexico w

  • Defining medical necessity with reference to state law: Minnesota x
  • Definition of medically necessary must be no more restrictive than that used by Medicaid: New Mexico y
  • Determination of medical necessity should consider consumer’s views and choices: New Mexico ``  

  • Services should be provided without regard to frequency or cost of service relative to rate received by MCO from state: Florida aa
  • Contracts for utilization review must not provide financial incentive for denying or limiting services: Kansas bb
  • MCO’s compensation system must not create incentives within utilization review process for denial or limitation of necessary services: Hawaii cc, New Mexico dd, Wisconsin ee
  • Utilization review must be set up to detect underutilization of services, as well as overutilization: Kansas ff
  • Utilization review decision must be made by health care professional with appropriate clinical expertise in treating consumer’s condition: Kansas gg
  • Utilization review must follow state’s medical necessity definition: Kansas hh
  • MCO must have written description for utilization review program, including clinical review criteria and relevant information sources: Texas ii  

  • MCO must submit reports to state on over- and under-utilization of services and medications: Hawaii jj
  • MCO must submit utilization management reports to state: New Mexico  kk

Assessments for Eligibility Determination

  • MCO must be separated from initial eligibility determination and enrollment counseling functions, consistent with state and federal guidelines: Wisconsin ll
  • MCO cannot contract with provider of case management services or eligibility assessments: Kansas mm  

  • MCO must reimburse subcontracted providers for provision of HCBS while consumer is in Medicaid-pending status, i.e., consumer has been found to be clinically eligible, but state is in process of determining consumer’s financial eligibility: Florida nn
  • MCO must assist Medicaid-pending consumer with completing financial eligibility process: Florida oo
  • MCO must not deny or delay services based on Medicaid-pending status: Florida pp
  1. Wis. Contract, p. 51.  (back)
  2. N.M. Contract, pp. 44-45.  (back)
  3. Fla. Contract, Atch. II, Exh. 5, p. 42.  (back)
  4. Tenn. Contract, p. 127.  (back)
  5. Tenn. Contract, p. 145.  (back)
  6. N.M. Contract, p. 23.  (back)
  7. Minn. Contract, p. 109  (back)
  8. Minn. Contract, pp. 111-112.  (back)
  9. N.Y. Medicaid Advantage Plus Contract, Sect. 10, p. 9.  (back)
  10. Tenn. Contract, p. 127.  (back)
  11. Fla. Contract, Atch. II, Exh. 5, p. 34.  (back)
  12. Fla. Contract,  Atch. II, Exh. 5, p. 36.  (back)
  13. Minn. Contract, p. 126.  (back)
  14. Minn. Contract, p. 126.  (back)
  15. Fla. Contract, Atch. II, p. 73.  (back)
  16. Fla. Contract, Atch. II, p. 73.  (back)
  17. Haw. RFP, p. 87.  (back)
  18. Fla. Contract, Atch. II, p. 74.  (back)
  19. Tex. Contract, p. 8-48.  (back)
  20. Fla. Contract, Atch. II, p. 94; N.M. Contract, p. 32.  (back)
  21. Fla. Contract, Atch. II, p. 81.  (back)
  22. Haw. RFP, pp. 261-62.  (back)
  23. N.M. Contract, p. 160.  (back)
  24. Minn. Contract, p. 26.  (back)
  25. N.M. Contract, p. 57.  (back)
  26. N.M. Contract, p. 72.  (back)
  27. Fla. Contract, Atch. II, p. 40.  (back)
  28. Kan. RFP, p. 86.  (back)
  29. Haw. RFP, p. 218  (back)
  30. N.M. Contract, p. 56.  (back)
  31. Wis. Contract, p. 69.  (back)
  32. Kan. RFP, p. 86.  (back)
  33. Kan. RFP, p. 87.  (back)
  34. Kan. RFP, p. 88.  (back)
  35. Tex. Contract, p. 8-49.  (back)
  36. Haw. RFP, pp. 262-63.  (back)
  37. N.M. Contract, p. 43.  (back)
  38. Wis. Contract, p. 21.  (back)
  39. Kan. RFP, p. 40.  (back)
  40. Fla. Contract, Atch. II, Exh 3, p. 8.  (back)
  41. Fla. Contract, Atch. II, Exh. 3, p. 8.  (back)
  42. Fla. Contract, Atch. II, Exh. 3, p. 8.  (back)

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