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Medicaid - Prior Authorization Guidance

Prior Authorization Guidance Updated – May 5, 2022

  • Effective July 1, 2022, Medicaid Fee-for-Service (FFS) and Managed Care Organizations (MCOs) may require prior authorization (PA) requirements for SUD residential and inpatient treatment services, including ASAM Levels 3.1, 3.5, 3.7 and 4.0 will be reinstated. This includes provider types 02, 03, 06, 26, 30 and any hospital setting that provides SUD treatment.
  • All other behavioral health and SUD services continue to be waived.
  • FFS and MCOs may require PA for all inpatient and outpatient Medicaid services provided by Kentucky Medicaid enrolled inpatient hospital providers (Provider Type 01) except for admissions with a COVID diagnosis, effective May 1, 2022.
  • FFS and MCOs may require PA, for provider type 93, Rehabilitation Distinct Part Unit, effective May 1, 2022.
  • FFS and MCOs may require PA, for provider type 12, Skilled Nursing Facilities, effective May 1, 2022.
  • FFS and MCOs may require a PA for an outpatient service/procedure at other outpatient facilities or other Medicaid service based on their Utilization Management program, except for individuals with a COVID diagnosis. Please refer to the FFS or MCO’s specific PA guidelines.
  • PA remains in place for all pharmacy benefits and products listed on the physician administered drug lists, except for medication assisted treatment (MAT) products (i.e. Sublocade).
  • To facilitate provider payment, requirements for prior authorization of non-Kentucky Medicaid enrolled providers will remain in place.
  • FFS and MCOs will continue to monitor for fraud, waste, and abuse (FWA) activity.

 

 Kentucky Department of Medicaid Services