Prior Authorization : Grant and Expiration Dates

Backdating

Backdating an initial PA request or SOI to a date prior to ForwardHealth's initial receipt of the request may be allowed in limited circumstances.

A request for backdating may be approved if all of the following conditions are met:

• The provider specifically requests backdating in writing on the PA or SOI request.
• The request includes clinical justification for beginning the service before PA or SOI was granted.
• The request is received by ForwardHealth within 14 calendar days of the start of the provision of services.

Backdating for Nurses in Independent Practice

Backdating a PA request to a date prior to ForwardHealth's initial receipt of the request may be allowed in limited circumstances.

Each nurse is solely responsible for submitting PA requests in a timely manner. Failure to do so may result in denied PA requests.

Initial Requests

An initial PA request may be backdated up to 14 calendar days from the first date of receipt by ForwardHealth. For backdating to be authorized, both of the following criteria must be met:

• The provider specifically requests backdating in writing on the PA request.
• The request includes clinical justification for beginning the service before PA was granted.

Extraordinary Circumstances

In the following cases, a PA request may be backdated for more than 14 days:

• A court order or hearing decision requiring ForwardHealth coverage is attached to the PA request.
• The member is retroactively eligible. (Indicate in Element 21 of the PA/RF that the service was provided during a period of retroactive member enrollment. Indicate the actual date the service was provided in Element 15.)

Returned Requests

An initial PA request returned for additional information may be backdated 14 calendar days from the date it was initially received by ForwardHealth if the additional corrected information is returned with the original PA/RF.

Amendment Requests

PA amendment requests may be backdated 14 calendar days from the date of receipt by ForwardHealth if the request is for urgent situations in which medical necessity could not have been predicted.

Denied Requests

Once a PA request has been denied, that PA number can no longer be used. A new PA number must be used with a new request. A new request following a denial may be backdated to the original date the denied request was received by ForwardHealth when all of the following criteria are met:

• The earlier grant date is requested.
• The denied PA request is referred to in writing.
• The new PA request has information to justify approval.
• The request for reconsideration submitted with additional supporting documentation is received within 14 calendar days of the adjudication date on the original denied PA request.

Expiration Date

The expiration (end) date of an approved or modified PA request is the date through which services are prior authorized. PA requests are granted for varying periods of time. Expiration dates may vary and do not automatically expire at the end of the month or calendar year. In addition, providers may request a specific expiration date. Providers should carefully review all approved and modified PA requests and make note of the expiration dates.

Grant Date

The grant (start) date of an approved or modified PA request is the first date in which services are prior authorized and will be reimbursed under this PA number. On a PA request, providers may request a specific date that they intend services to begin. If no grant date is requested or the grant date is illegible, the grant date will typically be the date the PA request was reviewed by ForwardHealth.

Renewal Requests

To prevent a lapse in coverage or reimbursement for ongoing services, all renewal PA requests (that is, subsequent PA requests for ongoing services) must be received by ForwardHealth prior to the expiration date of the previous PA request. Each provider is solely responsible for the timely submission of PA request renewals. Renewal requests will not be backdated for continuation of ongoing services.

Private Duty Nursing Renewal Requests

For PDN services, the PAL is responsible for timely submission of PA request renewals.