New Hampshire Medicaid ABA authorization guidance 2026 clarifies that requests are reviewed individually under EPSDT and He-W 546. The April 14 notice identifies an individualized treatment plan, medical-necessity rationale, signed diagnostic evaluation, signed order or referral, requested quantity support, and a school-service duplication review. A missing full IEP alone cannot be the reason for denial.

Build the signed clinical packet

Lock the member, Medicaid product, requesting and rendering providers, diagnostic evaluator, diagnosis record, signature and date, ordering or referring professional, signed order, assessment, treatment plan, requested codes, quantity, duration, setting, and submission route. Confirm each professional is qualified for the function performed. The current He-W 546 rule and provider-specific instructions control; a checklist does not replace an individualized clinical explanation.

Explain medical necessity at the requested quantity

Connect the assessed condition and functional needs to measurable goals, selected procedures, frequency, intensity, duration, setting, caregiver work, data plan, generalization, transition, and risk of a lower amount. Avoid treating a diagnosis, standard package, school schedule, or historical authorization as the rationale. The decision record should show what was requested, what evidence supports it, what the reviewer approved, and the clinical consequence of any reduction.

Review school services without making the IEP a gate

For members receiving ABA through Medicaid to Schools, compare the requested service with relevant IEP services, goals, provider, setting, schedule, and funding route. New Hampshire allows the full IEP, relevant portions, or a rendering-provider attestation that medically unnecessary duplication is absent. It expressly says failure to include the IEP cannot itself cause denial. Request only the minimum necessary education record and preserve consent and access controls.

Preserve partial-denial and appeal evidence

When an MCO approves fewer hours based on medical necessity, the notice directs a partial-denial process so member appeal rights attach to the unapproved amount. After peer review, an unchanged adverse result still needs the denial or partial denial. If the provider and MCO agree to a different amount, the provider submits a new request. Keep the original request, peer-review chronology, revised request, notices, deadlines, and member communication distinct.

A fictional New Hampshire packet audit

Theo reviews 32 open ABA requests. Twenty-four contain signed diagnostic and referral records, an individualized plan, quantity rationale, school-service comparison when relevant, submission receipt, reviewer outcome, and appeal field. Completeness is 24 of 32, or 75%. Three evaluations are unsigned, two school attestations lack a service comparison, one order is stale, one quantity rationale is generic, and one partial approval lacks a notice.

Distinguish fee-for-service and MCO routes

The state notice applies across the program, yet the operational destination differs. Use the billing-manual portal and current plan instructions to confirm form, portal, attachments, deadlines, contacts, and appeal route. The fee-for-service authorization instructions are not automatically the MCO workflow. Record product and payer at intake, and obtain written clarification when a plan request conflicts with the state notice.

New Hampshire authorization checklist

For New Hampshire Medicaid ABA authorization guidance 2026, verify the April notice, He-W 546, current billing manual, member eligibility and product, diagnostic evaluation and signature, diagnosis, order or referral and signature, assessment, individualized treatment plan, requested codes and quantity, medical-necessity rationale, setting, school participation, IEP excerpt or attestation when used, nonduplication analysis, submission, receipt, determination, partial denial, peer review, new request, appeal rights, continuity action, and source recheck.

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