Health Care Responsibility Act

Pinellas County Prior Authorization Requests

Prior Authorization Requirements for all elective clinical services and non-emergency admissions provided in healthcare settings outside of Pinellas County for certified indigent residents.

Policy:

Pinellas County Human Services Department requires prior written authorization for all elective and non emergency admissions or services provided at hospitals located outside of Pinellas County for certified residents who qualify as an indigent patient under Florida Statutes Chapter 154 Part IV.

Procedure:

An elective service or non emergency admission is defined as a clinical service that is scheduled and does not present an imminent danger to the patient. These elective services and/or non emergency admission will be paid for by the Pinellas County Human Services Department provided prior approval and written authorization from the Pinellas County Human Services Health Care Administrator is obtained. The prior approval process is used to verify eligibility and facilitate appropriate utilization of these elective clinical services and /or non emergency admissions. Patients are required to meet eligibility criteria as outlined in FL Administrative Code Chapter 59H-1.007. The following must be submitted by the requesting hospital at least 60 days prior to the date of elective service/admission:

Requirements:

• Completed Health Care Assistance application (AHCA Form 5220-0002) with supporting documentation (see Chapter 5 of HCRA Handbook), including proof of:
  • Pinellas County residency
  • Income
  • U.S. Citizenship
  • Assets
• Letter from physician who will perform clinical services stating
  • ICD10 Code(s)
  • Clinical Service Requested which corresponding Procedure (CPT) Code(s)
  • Statement of Medical Necessity and Justification
  • Name and Credentials of physician, along with contact information

Elective and Non-Emergency Services:

Pursuant to FL Admin. Code 59H-1.0065, Pinellas County shall not be required to pay for elective or non-emergency admissions or services at an out-of-county hospital for a qualified indigent when one of the following conditions exist: a) If the county of residence provides funding for such services and the services are available at a hospital located within the resident county; or (b) The out-of-county hospital has not obtained prior written authorization and approval for such hospital admission or service, provided that the resident county has established written procedures to authorize and approve such admissions or services.

Prior Authorizations Decisions:

Decisions regarding authorization requests will be provided in writing by the PCHS Health Care Administrator within 60 days of receipt. Failure to comply with PCHS’ prior written authorization requirements shall result in an administrative denial for payment.

Requests for prior approval and written authorization must be submitted to:

Karen Yatchum
Health Care Administrator
Pinellas County Human Services
440 Court Street – 2nd Floor
Clearwater, FL 33756
(727) 464-5045
kyatchum@pinellas.gov