MedicaidPrior AuthHigh impact
Child HCBS Authorizations and Reminder of State Billing and Claiming Requirements
Healthfirst·Pediatrics·Provider Update
Effective date
Apr 4, 2022
We identified it
Jun 20, 2026
Summary
Effective April 4, 2022, Medicaid Managed Care Plans must deny HCBS claims for children in the Children's Waiver program if they cannot verify K1 Recipient Restriction/Exemption codes or if no Authorization and Care Manager Notification Form was received. Claims may also be denied if billed units don't match the authorized frequency, scope, and duration.
Action Required
Immediately: Billing team must verify K1 Recipient Restriction/Exemption codes are present for all children receiving HCBS services before submitting claims to Medicaid MCPs. Ensure Authorization and Care Manager Notification Forms are obtained and on file before billing. Verify billed units match the frequency, scope, and duration documented on authorization forms. Claims will be denied without proper verification of Children's Waiver eligibility and authorization documentation.