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Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 33 - Under the MO HealthNet Program, certain covered services and equipment require approval from the DSS, MO HealthNet Division, prior to provision of the service as a condition of reimbursement. Prior authorization is used to promote the most effective and appropriate use of available services and to determine in conjunction with the ordering provider, the medical necessity of the service. Providers are required to seek prior authorization for certain specified services before delivery of the services. In addition to services that are available through the traditional MO HealthNet Program, expanded services are available to children 20 years of age and under through the Healthy Children and Youth (HCY) Program. Some expanded services also require prior authorization. Certain services require prior authorization only when provided in a specific place or when they exceed certain limits. The Pharmacy and Clinical Services Unit of the MO HealthNet Division operates a toll-free hotline for providers to request overrides on drug products with restricted access due to clinical or fiscal edits and prior authorization. The hot- line staff operate an internet web portal-based system to process requests for drug products, which have been denied through the point-of-service claims processing system. The Unit is also responsible for responding to requests through the Exception Process for essential medical items or services, including insulin pumps and supplies, which are not typically reimbursed through the MO HealthNet Program. The MCOs have written policies and procedures for prior authorization of non- emergency services and the time frames in which authorizations will be processed (approved or denied) and providers and members are notified. The policies and procedures include the requirement to not exceed 14 calendar days following the receipt of the request of service to provide approval or denial. MO HealthNet Managed Care Delivery System 7.2.5 The MCOs have written policies and procedures for prior authorization of non- emergency services and the time frames in which authorizations will be processed (approved or denied) and providers and members are notified. The policies and procedures include the requirement to not exceed 14 calendar days following the receipt of the request of service to provide approval or denial