Md. Code Regs. 10.09.02.06

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.09.02.06 - Preauthorization Requirements

A. The following procedures or services require preauthorization:

(1) Cosmetic surgery;

(2) Contact lens evaluation and fitting;

(3) Lipectomy and panniculectomy;

(4) Transplantations of vital organs;

(5) Services rendered to an inpatient before one preoperative day;

(6) Surgical procedures for the treatment of obesity;

(7) Surgical procedures for the purpose of gender reassignment; and

(8) Elective services from a noncontiguous state.

B. Services which have been determined by Medicare to be ineffective, unsafe, or without proven clinical value are generally presumed to be not medically necessary, but will be preauthorized if the provider can satisfactorily document medical necessity in a particular case. These services are found in the Medicare Carriers Manual, Part 3, Claims Process, Chapter II, Coverage Issues Appendix.

C. Physicians dispensing or prescribing eyeglasses shall comply with the requirements of COMAR 10.09.14.

D. The Department will preauthorize services when the provider submits to the Department adequate documentation demonstrating that the service to be preauthorized is medically necessary.

E. Preauthorization normally required by the Program is waived when the service is covered and approved by Medicare. Non-Medicare claims require preauthorization according to §§A-D of this regulation.

F. Physicians rendering mental health services shall comply with the preauthorization requirements of COMAR 10.09.70.07A.

Md. Code Regs. 10.09.02.06

Existing regulations repealed and new Regulations .06 adopted effective December 8, 1976 (3:25 Md. R. 1467)
Regulations .06 amended effective July 1, 1979 (6:13 Md. R. 1126)
Regulations .06 amended as an emergency provision effective July 1, 1997 (24:18 Md. R. 1286) (Emergency provisions are temporary and not printed in COMAR)
Regulation .06A amended effective June 20, 1983 (10:12 Md. R. 1072); February 9, 1987 (14:3 Md. R. 273); December 16, 1996 (23:25 Md. R. 1785); December 29, 1997 (24:26 Md. R. 1757)
Regulation .06A, D amended as an emergency provision effective July 1, 2006 (33:15 Md. R. 1273); amended permanently effective September 11, 2006 (33:18 Md. R. 1505)
Regulation .06E adopted effective April 4, 1980 (7:7 Md. R. 708)
Regulation .06F adopted effective December 29, 1997 (24:26 Md. R. 1757); amended effective 43:20 Md. R. 1109, eff. 10/10/2016; amended effective 44:17 Md. R. 834, eff. 8/28/2017