Getting Approval for Long-Term Care Services

Some Medicaid-covered long-term services and supports require approval before services begin, change, or continue. This process is called service authorization.

What Is Service Authorization?

Service authorization is the process used to review requests for certain Medicaid-covered long-term services and supports.

A qualified clinical professional reviews each request to determine whether the service is medically necessary and appropriate based on your health needs, functional needs, and plan of care.

Examples of services that may require service authorization include:

Personal Care Services
Consumer Directed Personal Assistance Services (CDPAS)
Adult Day Health Care
Home-Delivered Meals
Private Duty Nursing
Medical Social Services
Other long-term care services covered by your plan

Which Plans Use Service Authorization?

The service authorization process applies to:

HomeFirst Managed Long-Term Care (MLTC)
Elderplan Plus Long-Term Care (HMO-POS D-SNP) for Medicaid-covered long-term services and supports

How Service Authorization Works

In most cases, your Care Management Team and providers work together to request the services you need.

Work With Your Care Management Team

Your Care Manager works with you, your caregivers, and your providers to understand your needs and develop a Person-Centered Service Plan (PCSP).
A Request Is Submitted

Your provider, Care Manager, or authorized representative submits a request for services along with supporting clinical information.

You may also request services yourself or appoint someone to act on your behalf.
We Review the Request

Qualified clinical staff reviews the request using Medicaid coverage requirements, clinical criteria, and information about your individual needs.

When a determination involves medical necessity, the review is performed by a qualified clinical professional with appropriate expertise.
We Notify You of the Decision
We send written notice of our decision to you and, when applicable, your provider or authorized representative.

If approved, the notice will explain:
- The service approved
- The amount, frequency, or duration of the serviceThe authorization period
If denied, reduced, suspended, or terminated, the notice will explain the reason for the decision and your appeal rights.

Need an Urgent Decision?

If waiting for a standard review could seriously jeopardize your life, health, or ability to attain, maintain, or regain maximum function, you or your provider may request an expedited review.

How Long Does a Decision Take?

Decision timeframes vary depending on the type of request.

Request Type	Standard Timeframe	Expedited Timeframe
Prior Authorization Request	Generally, within 3 business days after receiving all necessary information, but no later than 14 calendar days after receiving the request	Generally, within 72 hours
Concurrent Review Request	Generally, within 1 business day after receiving all necessary information, but no later than 14 calendar days after receiving the request	Generally, within 72 hours
Expedited Service Authorization Request	N/A	Generally, within 72 hours

Find Service Authorization Requirements for Your Plan

Authorization requirements vary by plan. Select your plan below to view services that require service authorization.

HomeFirst Managed Long-Term Care (MLTC) →

Elderplan Plus Long-Term Care (HMO-POS D-SNP) →

What If a Service Is Denied, Reduced, or Stopped?

If we deny a request for services, reduce the amount of services you receive, or stop a service you are currently receiving, you have rights and options available to you.

Appeals, Fair Hearings & ICAN →

Need Help?

If you have questions about service authorization or whether a service requires approval, Member Services and your Care Management Team can help.