How To Do A Prior Authorization For Medicaid

Why Does My Health Insurance Company Need A Prior Authorization

The prior authorization process gives your health insurance company a chance to review how necessary a medical treatment or medication may be in treating your condition.

For example, some brand-name medications are very costly. During their review, your health insurance company may decide a generic or another lower-cost alternative may work just as well in treating your medical condition.

Clinical Reviewers Who Make Medical Necessity Decisions

At least once a year, a review is completed to make sure all clinical reviewers follow the same process in clinical case reviews. Financial rewards are not offered to doctors, nurses or other clinical staff responsible for making a utilization review decision. In addition, utilization review policy and criteria do not allow decisions that may result in members not receiving all medically necessary services.

Emergency Room And Post Stabilization Services Never Require Prior Authorization

MHS Health Wisconsins Medical Management department hours of operation are 8 a.m. to 5 p.m. Monday-Friday . After normal business hours, NurseWise staff is available to answer questions and intake requests for prior authorization. Emergent and post-stabilization services do not require prior authorization. Urgent/emergent admissions require notification within one business day following the admit date.

We will process most routine authorizations within five business days. If we need additional clinical information or the case needs to be reviewed by the Medical Director it may take up to 14 calendar days to be notified of the determination. Authorization determinations may be communicated to the provider by fax, phone, secure email, or secure web portal.

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Medicare Medicaid And The Prior Authorization Process

Need to submit a prior authorization request for a patient on Medicare or Medicaid? With an electronic solution, the process is the same regardless of your patient’s coverage type.

When it comes to the differences between three of the most common types of health coverage commercial, Medicare and Medicaid confusion is common.

Questions range from How do these problems affect prescription coverage? to What do these differences mean for completing prior authorization requests? Confusion is amplified by the fact that not all healthcare staff members manage PA requests every day.

Heres the good news: An electronic PA solution streamlines the PA process for every request, regardless of a patients coverage type.

How To Get Prior Authorization For Medical Care

Have you ever tried to make an appointment to get a medical test, arrange for a treatment, or fill a prescription from your dermatologist only to find out that you need prior authorization?

When some patients hear these two words, they dont know what to do next. The following explains what you need to know.

Your health insurance provider may require you to get prior authorization before you fill a prescription or get other medical care.

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Prior Authorization Process And Criteria

The Georgia Department of Community Health establishes the guidelines for drugs requiring a Prior Authorization in the Georgia Medicaid Fee-for-Service/PeachCare for Kids® Outpatient Pharmacy Program. To view the summary of guidelines for coverage, please select the drug or drug category from the list below.

If the drug cannot be located by name or if you are unsure of the drug category in which the drug is located, please see the attached Prior Authorization Cross Reference document for assistance.

Submit Supporting Documentation To An Existing Authorization

Use one of the following cover sheets when submitting supporting documents to an already existing authorization: For example, when responding to a pend for additional information, or an existing approved authorization requires a billing code or NPI update.

• Checking status through our IVR starts on slide 22.

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Timeframe For Prior Authorization Decision

In most cases, your provider should submit a prior authorization request five business days before the desired start date of the service.

The timeframes required to provide a decision in response to a prior authorization request is listed below, for different types of prior authorization requests:

Physical Health Services, Supplies, Equipment, Behavioral Health Services, Clinician Administered Drugs

Chip Prior Authorization Procedures And Requirements

Demographic and Clinical Information

• To ensure that the medical necessity review of a prior authorization request can be timely processed for determination, the following information must be included with each prior authorization request:
• Member information and
• Provider information (Rendering provider name, NPI, TIN and
• Physician signature/Physician order and
• Specification and description of service, supply, equipment, or CAD procedural/service code and description and
• Pertinent diagnosis/conditions that relate to the need for the service and
• Objective clinical information necessary to support medical necessity for the requested service and
• Start and end date of service and
• Frequency and duration

Incomplete Prior Authorization Requests

• If a prior authorization request does not include the demographic and/or clinical information necessary to complete the medical necessity review of the request, two phone call attempts are completed to obtain the missing documentation/information.
• If the required information is not received as required in the request, the prior authorization request is forwarded to a Medical Director for determination, based on the clinical information available.

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How Often Is Prior Authorization Used And What Is Its Impact

There is little information about how often prior authorization is used and for what treatments, how often authorization is denied, or how reviews affect patient care and costs.

A 2021 KFF Issue Brief found that most Medicare Advantage enrollees are in plans that require prior authorization for some services. In addition, 84% of Medicare Advantage enrollees are in plans that apply prior authorization to a mental health service.

A recent report from the U.S. Department of Health and Human Services Office of the Inspector General found 13% of prior authorization denials by Medicare Advantage plans were for benefits that should otherwise have been covered under Medicare. The OIG cited use of clinical guidelines not contained in Medicare coverage rules as one reason for the improper denials, as well as managed care plans requesting additional unnecessary documentation. The OIG recommended and HHS agreed that the Centers for Medicare and Medicaid Services should take a closer look at the appropriateness of clinical criteria used by Medicare Advantage plans in making coverage determinations.

Who Needs To Get Prior Authorization

What requires prior authorization can vary from one insurance provider to another. It can also vary from plan to plan, year to year, or state to state.

For example, you may be treating a skin condition with a medication that isnt working as well as youd like. During your last dermatology appointment, your dermatologist wrote a prescription for a different medication. When you tried to fill the new prescription, your pharmacist told you that you need prior authorization, even though you never needed this for the other medication.

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Determine If A Code Or Service Requires Prior Authorization

Use our provider billing guides and fee schedules to review policy and find out whether a code or service requires prior authorization.

National Correct Coding Initiative

HCA’s authorization services do not consider National Correct Coding Initiative guidelines when processing a request. Make sure your office checks the NCCI guidelines prior to submission.

Important: Inadvertently approved authorizations do not guarantee claims payment.

For questions about NCCI please refer to The National Correct Coding Initiative in Medicaid.

How Does The Prior Authorization Process Work

Typically, within 5-10 business days of receiving the prior authorization request, your insurance company will either:

• Approve your request
• Deny your request
• Ask for more information
• Recommend you try an alternative thats less costly, but equally effective, before your original request is approved

These responses are based on input from clinical pharmacists and medical doctors who review the requests at the health insurance company.

If youre unhappy with your prior authorization response, you or your health care provider can ask for a review of the decision.

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Completing A Pa Request For Any Plan

The less time spent managing PA, the faster patients get the medications they need, and integrated ePA solutions within EHRs can allow providers to submit PA requests at the point of prescribing. This results in patients receiving their medications an average of 13.2 days sooner, compared to requests started at the pharmacy.CoverMyMeds data on file, 2019

When using an ePA solutionlike CoverMyMeds to submit and manage prescription PA workload, the process for completing a medication PA request is the same for commercial or government plans.

Many Part D and Medicaid plans have transitioned to an ePA format meaning staff receive electronic determinations, often in real-time. By modernizing the process, plans with ePA capabilities are helping decrease administrative waste and save providers time.

A recent rule finalized by the Centers for Medicare & Medicaid Services , “Medicare Program Secure Electronic Prior Authorization for Medicare Part D is aimed at further streamlining the Medicare Part D PA process and improving the sharing of data between payers and providers.

Its expected that both state and federal policy makers continue to advance not only PA but other patient access issues, such as price transparency. Innovators in the market will continue advancing toward interoperability, data liquidity and transparency in order to empower clinical and prescription decision support and access for patients to their needed medications.

What Types Of Medical Treatments And Medications May Need Prior Authorization

• Medications that may be unsafe when combined with other medications
• Medical treatments that have lower-cost, but equally effective, alternatives available
• Medical treatments and medications that should only be used for certain health conditions
• Medical treatments and medications that are often misused or abused
• Drugs often used for cosmetic purposes

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S For Getting Prior Authorization

While each insurance provider may use slightly different steps, here is what typically happens during the prior authorization process.

When your medical care requires prior authorization

Medicaid Prior Authorization Procedures And Requirements

Standard Prior Authorization Request – Incomplete or Insufficient Documentation

• Medicaid prior authorization requests must contain all Essential Information
• Essential Information is prescribed in HHSCs UMCM, Chapter 3.22, II. A., and includes all elements below.
• Member name, Medicaid ID number and date of birth
• Requesting and rendering/servicing provider name, National Provider Identifier , and Tax Identification Number
• Service requested – Current Procedural Terminology , Healthcare Common Procedure
• Service requested start and end date
• Quantity of service units requested

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Get Important News & Updates

Sign up for email and/or text notices of Medicaid and other FSSA news, reminders, and other important information. When registering your email, check the category on the drop-down list to receive notices of Medicaid updates check other areas of interest on the drop-down list to receive notices for other types of FSSA updates.

Prior Authorization Of Health

Superior members have access to all Medicaid and CHIP covered benefits that are medically necessary health-care services. Some of these services need to be reviewed before the service is provided to make sure the service is appropriate and medically necessary. This review is called prior authorization, and is made by doctors, nurses and other health-care professionals. If a prior authorization request cannot be approved based on medical necessity, you will receive a letter with the reason why the prior authorization request was not approved. This is called an adverse determination . You can ask Superior to review the prior authorization request again. This is called an appeal of the adverse determination.

A list of the Medicaid and CHIP covered services that require prior authorization may be found by visiting:

Health-care providers are responsible for submitting prior authorization requests. These requests can be submitted by phone, fax or online, using Superiors Secure Provider Portal. Your provider can also get more information by visiting Superiors Medicaid and CHIP Prior Authorization Requirements webpage.

Review the information below to learn more about which services may need prior authorization approval before the service is provided. If you have any questions, please call Member Services :

• CHIP: 1-800-783-5386
• STAR+PLUS: 1-877-277-9772

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Prenatal And Delivery Notification

• Notification of Pregnancy form within 30 days of members first prenatal visit
• Note: Providers are eligible for a $50 incentive for each NOP form submitted through the Secure Provider Portal. Enter your Tax ID Number in field labeled “OB Provider’s ID #)

Prior Authorization And Pre

CMS runs a variety of programs that support efforts to safeguard beneficiaries access to medically necessary items and services while reducing improper Medicare billing and payments. Through prior authorization and pre-claim review initiatives, CMS helps ensure compliance with Medicare rules.

Prior authorization and pre-claim review are similar, but differ in the timing of the review and when services can begin. Under prior authorization, the provider or supplier submits the prior authorization request and receives the decision before services are rendered. Under pre-claim review, the provider or supplier submits the pre-claim review request and receives the decision prior to claim submission however, the provider or supplier can render services before submitting the request.

A provider or supplier submits either the prior authorization request or pre-claim review request with all supporting medical documentation for provisional affirmation of coverage for the item or service to their Medicare Administrator Contractor . The MAC reviews the request and sends the provider or supplier an affirmed or non-affirmed decision.

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Prior Authorization Status Information

Learn how the high-level displayed on the IHCP Provider Healthcare Portal and reported in 278 transactions and by the Interactive Voice Response system translate to the working statuses associated with each standard response. Providers should refer to their PA notification letters for additional information regarding the more detailed working status of a PA request.

Submitting Requests For Prior Approval

The preferred method to submit prior approval requests is online using the NCTracks Provider Portal. However, providers can also submit paper forms via mail or fax. PA forms are available on NCTracks.

All requests for PA must be submitted according to DMA clinical coverage policies and published procedures.

Providers must request reauthorization of a service before the end of the current authorization period for services to continue. The date that the request is submitted affects payment authorization for services that are denied, reduced or terminated.

Providers must request authorization of a continuing services 10 calendar days before the end of the current authorization period for authorization to continue without interruption for 10 calendar days after the date an adverse decision notice is mailed to the Medicaid beneficiary or to the beneficiary’s legal guardian and copied to the provider.

Some requests are submitted for review to a specific utilization review contractor, as described on the Prior Approval Fact Sheet on NCTracks.

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Idaho Medicaid Pharmacy Program

The goal of the Idaho Medicaid Pharmacy Program is to provide quality care to Medicaid participants with the most effective drug at the right price. Magellan Medicaid Administration, Inc. is the Idaho Medicaid Pharmacy Benefit Management contractor.

Idaho Medicaid Pharmacy call centerCall: 208-364-1829 OR toll free 866-827-9967 Fax: 800-327-5541

• For prior authorization status inquiries, call Magellan Medicaid Administration Pharmacy Support Center at 800-922-3987

Prior authorization faxMagellan Medicaid Administration Pharmacy Support CenterProvider line: 800-922-3987 Participant line: 888-773-9466

• Drug coverage and payment information
• Eligibility issues or inquiries

Genetic Testing For Brca

Criteria

BRCA screening is allowed in the following instances: Members is over the age of 18 and Have at least one of the following criteria:

o Personal history of any of the following:

Breast cancer diagnosis at or before age 45. Breast cancer diagnosis at or before age 50 with any of the following: An additional breast cancer primary 1 or more close blood relative with breast cancer at any age 1 or more close blood relative with pancreatic cancer 1 or more close blood relative with prostate cancer with a Gleason score 7.

o Family history of any of the following:

First or second degree blood relative who meet any of the above criteria. Third degree blood relative who has breast cancer and/or ovarian cancer and who has 2 or more close blood relatives with breast cancer and/or ovarian cancer. 1 or more family member with a known potentially harmful mutation In the BRCAl or BRCA2 gene.

*Close blood relative includes first, second,and third degree relatives on the same side of the family.

**Breast cancer diagnosis includes invasive and ductal carcinoma in situ.

Prior Authorization Contact

Cochlear implants may be covered for:Adult Criteria

Pediatric Criteria

Documentation Must Include

• A completed Cochlear Implant Compliance Criteria form
• Hearing tests indicating hearing loss that fits within the above criteria
• Medical records

Replacements Components of the Cochlear Implant may be replaced no more than once in a five-year period and only if:

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