Prior authorizations — Retrospective reviews

Checkout our iOS App for a better way to browser and research.

If the Department of Human Services requires a provider to justify the medical necessity of a service through prior authorization, the department shall not later take the position that the services were not medically necessary, unless the retrospective review establishes that:

  1. (1) The previous authorization was based upon misrepresentation by act or omission;

  2. (2) The services billed were not provided; or

  3. (3) An unexpected change occurred that rendered the prior-authorized care not medically necessary.


Download our app to see the most-to-date content.