Updates to Beneficiary Notices of Adverse Determination for Prior Approvals

The format and content of Notices of Adverse Benefit Determinations for Prior Approvals (PAs) is changing. On June 28, 2020, updates will be made to the NCTracks system to implement new, State-designed Notices of Adverse Benefit Determination. The updated format will now provide decision information for each service requested. Previously, only a single decision statement was communicated for all services in a PA request. 

The new detailed service information includes the following items:

• Listing of each service requested, approved and denied;
• All requested Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes on the PA request;
• Listing of each service voided or approved at a reduced amount than what was originally requested;
• Specific reason for each service not approved and the supporting State policy information for the decision; 
• For re-authorization requests, the previously approved service(s) information;
• For recipients under the age of 21, the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) criteria rationale for each service not approved as requested.

Notices of Adverse Benefit Determination (denial, reduction or modified approvals) will be sent to both the requesting provider and the recipient via USPS. The provider notice is sent via regular mail and the recipient notice is sent via certified mail.

M20149-2-R-2109-R-2109.1