Children and Youth with Special Health Care Needs Program Provider Manual
Prior Authorization
The CYSHCN Program has limited financial resources. Prior authorization of services allows the Program to ensure efficient utilization of these resources through appropriate planning and budgeting.
Medically necessary services/equipment that are directly related to the participant’s eligible condition will be considered for CYSHCN coverage. To ensure there is adequate documentation of medical necessity and that participants receive the least costly medically appropriate services/equipment certain services/equipment require prior authorization. It is the responsibility of the provider to obtain prior authorization from CYSHCN for services/equipment requiring prior authorization. Neither CYSHCN nor the participant/family will be responsible for payment of a service when the provider fails to complete the CYSHCN prior authorization process.
Prior approval must be obtained through the Service Coordinator and must be requested by the provider in writing on business letterhead and include:
- A detailed description of the service/equipment being requested including justification of medical necessity and
- An itemized statement of charges.
Requests for prior authorization shall be submitted no later than five (5) business days prior to the anticipated date of service. Verification of prior authorization must be obtained by the provider before the date of service in order for CYSHCN to consider reimbursement.
The CYSHCN Reimbursement Rate Schedule provides a comprehensive list of services and prior authorization requirements.