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MEDICAL SERVICES POLICY MANUAL,SECTION A

A 200 Health Care Coverage Periods

Services for the retroactive period are subject to the same restrictions as services for the current period (that includes, without limitation: utilization review, benefit limitations, medical necessity). Prior authorization cannot be a condition of payment for services received during the retroactive period. However, such services are subject to the same Utilization Review standards as all other services financed under the State’s Health Care (Medicaid) program. The State is not required nor obligated to pay for services which have been retroactively determined by Utilization Review to be unnecessary. For cases in which an applicant has made partial or full payment for services received during the retroactive period, the state will make payment to the servicing provider if: 1. The services were necessary and the applicant was eligible when the services were received; and 2. The provider is willing to refund the payment to the applicant and bill the State for the services.

A-211 Retroactive Eligibility-Long Term Services and Supports MS Manual 01/01/16 For Long Term Services and Supports (LTSS) retroactive eligibility is determined according to the guidelines for each Long Term Services and Supports eligibility group as described below: 1. Nursing Facility (NF) For any month that an individual was in an NF during the retroactive period, the eligibility determination for retroactive LTSS is the same as the eligibility determination for current eligibility. The caseworker will indicate the begin date of retroactive eligibility in the system in conjunction with current facility vendor payment. The caseworker should be aware that eligibility for retroactive Medicaid based on LTC criteria can only be determined for applicants who were institutionalized prior to the month of application. Applicants who first qualify for LTC in the month of application will have to be determinedeligible for retroactive Medicaid in another eligibility group. An ICF/IID case cannot be certified with an eligibility start date that precedes the decision date on the DCO-704 or the PASARR effective date.