DCS Comprehensive Health Plan

Prior Authorization

Statement/Purpose

This policy outlines the Department of Child Safety Comprehensive Health Plan (DCS CHP) utilization management activities to determine the medical necessity of services that require Prior Authorization

Definitions

Calendar Days: Includes every day of the week including weekends and holidays.

Expedited authorization request: A request for expedited review of a service (that is not a medication) where following the standard timeframes for making an authorization determination could seriously jeopardize the member’s life of health or ability to maintain, or regain maximum function.

Prior Authorization (PA): The process by which authorization requests are submitted with clinical documentation supporting the medical necessity for the services requested.

Service Authorization Request: A request by the member/Health Care Decision Maker (HCDM), and Designated Representative (DR) or a provider for a physical or behavioral health service for the member which requires Prior Authorization (PA) by the Contractor.

Policy

DCS CHP, through its contracted MCO, requires Prior Authorization (PA) to verify member eligibility and facilitate the appropriate utilization of non-routine services, including:

• Health and dental services;

• Non-formulary medications;

• Non-emergent/elective hospitalizations; and

• Durable medical equipment.

Health care providers obtain prior authorization from DCS CHP’s contracted MCO before providing clinical services, procedures, non-emergency or elective hospitalizations, including expedited (urgent) requests. Non-compliance with prior authorization policies and procedures may result in denial or delay of reimbursement.

DCS CHP covers emergency medical (physical and behavioral health) services, including crisis intervention services, without PA.

Prior to the issuance of a determination on a service authorization, all attempts are made to obtain any lacking clinical information necessary to provide clarification or render the decision.

Members and providers are notified of PA determinations within the standard and expedited timeframes required by AHCCCS and set forth in federal and state law and regulations.

In the event of a denial, the provider who requested the service has the option to request a peer to peer discussion with the MCO Medical Director. The provider is allowed 10 business days to request a peer to peer.

Approval of a PA request does not guarantee payment.

Clinical staff are Arizona licensed with appropriate training to apply medical criteria to make PA decisions. Decision makers in the PA process are not incentivized, nor make decisions based solely on setting, diagnosis, type of illness or condition of the member, to approve, deny or reduce, limit duration or scope of service or discontinue medically necessary services to any member.

Procedure

Services that require PA for DCS CHP members can be found on the Mercy Care DCS CHP provider website: Prior Authorization look-up

Providers requesting services submit completed PA request forms and clinical documentation supporting the medical necessity for the service requested, via telephone, mail, web or fax. PA request forms are accessible via the health plan website.

PA requests are reviewed and may be approved, or pended for further information by licensed clinical staff.

Factors considered when making PA determinations include:

• Member eligibility;

• Medical necessity;

• Over-utilization and cost;

• Exposure or risk for the member;

• Extensive clinical and/or care management interventions; and

• Services that are paid and managed by another program.

Services performed without PA are reviewed retrospectively for medical necessity and payment.

If on appeal a decision is reversed, authorization or provision of services are addressed promptly or as expeditiously as the member’s condition requires.

The requesting provider and the specialist/provider selected to perform the service must be registered with AHCCCS and DCS CHP. If the provider is not AHCCCS registered, DCS CHP and its contracted MCO assist the provider with the AHCCCS registration process.

Initial specialist visits do not require PA from DCS CHP except for orthodontists.

Emergency services do not require PA.

If a PA request and documentation does not substantiate medical necessity, the request may be pended for further documentation, or may be denied by the Medical Director and/or Chief Medical Officer (CMO). Some medications that require authorization are determined utilizing standardized criteria. (See HS-MM-05 Prescription Medication Services).

In the event that a PA is denied, the provider is notified and informed of an option to request a peer to peer discussion with the Medical Director and/or Chief Medical Officer. Once an NOA is issued the provider is afforded 10 calendar days for a peer to peer.

Only the contracted MCO CMO, Medical Directors and/or DCS CHP Chief Medical Officers may deny a PA request or reduce, suspend, or terminate services. Medical Directors and Chief Medical Officers have the appropriate clinical expertise to render decisions for skilled and non-skilled services within her/his scope of practice.

If a request has potential for denial, the Medical Directors and/or Chief Medical Officers may consult with the requesting physician prior to the decision, and may reconsider the decision if additional documentation is provided.

The Medical Directors and/or Chief Medical Officers may consult with community-based specialists, as an external physician review, before a denial is finalized.

Dental Health Prior Authorizations/Predeterminations (PA)

All dental services requiring PA must be submitted for approval prior to delivery of the service.

If PA is not obtained and the service is completed, the claim is reviewed retrospectively for medical necessity.

Dental health PA determinations are made in writing prior to the delivery of service.

For emergency procedures, services are performed and the provider is instructed to submit the claim with documentation for Retrospective Review.

Providers request services utilizing an ADA Dental Claim Form and submit all appropriate supporting documentation and/or x-rays in accordance with AHCCCS guidelines. Providers have the option to submit PAs via fax, postal mail and electronically. (See DCS CHP Policy HS-CH-06 Dental and Orthodontic).

If on appeal a decision is reversed, authorization or provision of services are addressed promptly or as expeditiously as the member’s condition requires.

Transplant Services

Consideration for coverage of transplants begins with a Request for Transplant Evaluation by the member’s PCP and/or specialist(s) treating the condition necessitating the transplant. (See DCS CHP Policy HS-MM-11, Transplant Services).

If the member is evaluated for transplant while hospitalized, no authorization is needed. The evaluation is included in the DRG payment.

Each request is reviewed on a case-by-case basis; authorizations and processes follow AHCCCS Medical Procedures Manual (AMPM), Chapter 300, Policy 310-DD, and are coordinated with the AHCCCS Transplant Coordinator. If on appeal a decision is reversed, authorization or provision of services are addressed promptly or as expeditiously as the member’s condition requires.

All transplant cases are reviewed with the Medical Director and/or Chief Medical Officer and reported at the Medical Management (MM) and the Quality Management/Performance Improvement (QM/PI) Committee Meetings.

Timeframes for Processing

Providers and/or members are notified of PA determinations within the standard and expedited timeframes required by AHCCCS and set forth in federal and state law and regulations as follows:

• Urgent or expedited PA requests that do not involve medications are processed within 72 hours, with a possible extension of up to 14 calendar days if the member or provider requests the extension and the delay is in the member’s best interest.

• Routine or standard PA requests that do not involve medications are processed within 14 calendar days or a Notice of Extension (NOE) may be sent which allows an additional 14 calendar days for a decision to be made (See DCS CHP Policy HS-MM-09, Notice of Adverse Benefit Determination (NOA) and Notice of Extension (NOE).

• Expedited requests are evaluated to determine if they meet the criteria for Expedited Authorization Requests. If they do not meet the criteria, these requests may be treated as a standard request after provider outreach to confirm the urgency, allow the provider to supply additional supporting information to support urgency, and notification of the change of the request to standard authorization.

PA requests for medications are processed within 24 hours from receipt and a decision is provided by telephone, fax or electronically. If the request lacks sufficient information to render a decision, a request for additional information is sent no later than 24 hours from receipt, with a final decision no later than seven working days from the initial date of the request. At least a 4-day supply of covered outpatient prescription drugs is provided to members in emergent situations.

Denied PA decisions are conveyed to the prescribing provider. A Notice of Adverse Determination (NOA) letter is sent to the member and/or custodial agency representative.

Authorization Guidelines (aka Prior Authorization Guidelines)

Relevant criteria and guidelines are applied to determine medical necessity, including but not limited to:

• Criteria required by applicable state or federal regulatory agency (AHCCCS);

• Applicable MCG care guidelines as the primary decision support for most medical and behavioral health diagnosis and conditions, ASAM and LOCUS to complement MCG criteria for behavioral health diagnosis and conditions;

• Aetna Clinical Policy Bulletins (CPBs);

• Aetna Clinical Policy Review Unit;

• Consensus of relevant health care professionals;

• Hayes;

• Practice Guidelines from the American Academy of Pediatrics (and other National Academies and Colleges);

• Pediatric RED BOOK; and

• Other relevant national guidelines.

PA Guidelines are reviewed at least annually, or more frequently when new medical information is made available, and published on the website. Changes to the PA guidelines are communicated to providers 30 days prior to the change, through the provider manual, provider newsletters. Updated guidelines are posted on the website.

Reporting

Changes to PA guidelines and applied rationale for decision-making are discussed, documented, and reported to the DCS CHP MM Committee.

Monitoring

PA requests are monitored to ensure that all requests are processed within the established timeframes for standard and expedited requests. Should a deficiency be determined, staff training and education is initiated and a follow-up review is completed to ensure the effectiveness of the training.

Medicare or Third-Party Payer

PA determinations are not conducted differently just because DCS CHP is a secondary payer. The PA process is followed, including the timelines for decisions; however, DCS CHP may only be responsible for payment of co-pays and deductibles