(a)
(1)
(A) Subject to § 20-77-1707 for retrospective reviews, if the Department of Human Services has sufficient documentation to determine that some level of care other than the level that was claimed is medically necessary, then the department may recoup.
(B) However, the provider shall be entitled to file a second claim at the level that was medically necessary according to the department's explanation for recoupment.
(C) Alternatively, the department may recoup the difference between the amount previously paid and the amount that would be payable for the care deemed to be medically necessary.
(2)
(A) If the department does not have sufficient documentation to determine the level of care that was medically necessary, the department shall not recoup at that time, but shall request from the provider additional documentation the department needs to determine the level of care that was medically necessary.
(B) After receiving documentation requested under subdivision (a)(2)(A) of this section, the department shall review the documentation and determine whether to proceed with a recoupment and notice, subject to § 20-77-1707.
(3)
(A) No physician referral shall be required as a condition of payment for care that is determined to be medically necessary upon a review conducted under this section.
(B) A requirement for a referral from a primary care physician shall not be imposed retroactively.
(4)
(A) The recoupment notice from the department under subdivisions (a)(1) and (2) of this section shall explain the reason for the recoupment under § 20-77-1705 and shall include one (1) of the following statements:
(i) “In the reviewer's professional judgment, the documentation submitted establishes that the following care, treatment, or evaluation was medically necessary: _______.”; or
(ii) “In the reviewer's professional judgment, the documentation submitted does not establish that any care, service, or evaluation was medically necessary.”.
(B) For purposes of this subdivision (a)(4), “care” may include referrals to healthcare professionals.
(5) A provider's decision to file a second claim at the level of care approved by the reviewer or the department's decision to recoup rather than requiring a second claim does not waive the provider's or recipient's right to appeal the denial of the original claim if the provider disagrees with the department's determination.
(b)
(1) For concurrent or prior authorization, if the department has sufficient documentation to establish that some level of care other than the requested level is medically necessary, the department shall approve the request at the other level of care with proper notice.
(2)
(A) If the department does not have sufficient documentation to determine the level of care that is medically necessary, the department shall not deny the claim at that time but shall request from the provider the additional documentation the department needs to determine the level of care that is medically necessary.
(B) The department shall then:
(i) Review the request; and
(ii) If the department denies the request, explain the reason for the denial in accordance with subdivision (b)(4) of this section.
(3)
(A) No physician referral shall be required as a condition of payment for care that is determined to be medically necessary upon a review conducted under this section.
(B) A requirement for a referral from a primary care physician shall not be imposed retroactively.
(4)
(A) The denial notice from the department under subdivisions (b)(1) and (2) of this section shall explain the reason for the denial as required by § 20-77-1705 and shall include one (1) of the following statements:
(i) “In the reviewer's professional judgment, the documentation submitted establishes that the following care, treatment, or evaluation was medically necessary: _______.”; or
(ii) “In the reviewer's professional judgment, the documentation submitted does not establish that any care, service, or evaluation was medically necessary.”.
(B) For purposes of this subdivision (b)(4), “care” may include referrals to healthcare professionals.
(5) The department's decision to approve a request at another level of care under this subsection does not remove the provider's or recipient's right to appeal the denial of the original claim if the provider disagrees with the department's determination.
(c)
(1) Subsections (a) and (b) of this section apply only:
(A) In the absence of fraud or abuse; and
(B) If the care is furnished by a provider legally qualified and authorized to deliver the care.
(2) Nothing prevents the department from reviewing the claim for reasons unrelated to level of care and taking action that may be warranted by the review, subject to other provisions of law.