This performance measure is important because prior authorization (PA) determinations of medical necessity are expected to adhere to specified completion timeframes outlined in Medicaid Rules and Federal Guidelines.

Medical necessity determinations are made using evidence-based clinical guidelines.  Reaching a goal of 100% is heavily dependent on prior authorization request volumes, receipt of all required clinical documentation from requesting provider, adequate staffing, and accurate data analysis.

In analyzing the trendline it became apparent there was an issue with the data. Requests for additional documentation from providers and resulting change to informational status in the system was not being captured correctly.  The decisions were being delayed in an effort to gain more information, which in turn usually benefits members. The Clinical Operations Unit determined it was most accurate to calculate the actual determination time after all necessary information was submitted. This new shift in capturing the data has resulted in a higher percentage of determinations meeting the specified timelines.  Additionally, the removal of Pharmacy J code prior authorization data included in the required captured data has contributed to improved % results. Previously, the Clinical Operations Unit was responsible for the necessary data entry of Pharmacy J codes into MMIS to ensure payment.  The clinical determination of these requests is conducted by a DVHA vendor and the process was contributing to an erroneous inflated turnaround time.  The change in the CMS required turnaround timeframe in conjunction with the removal of Pharmacy J-code data entry of prior authorizations and recent data entry system refinements has resulted in a more accurate percentage which is close to the 100 % target for this measure. Additionally, less than half of the total monthly prior authorization requests received require a request for additional clinical information to determine medical necessity and complete the prior authorization request.  New strategies are being explored to reduce this volume and improve % results.    

Narrative last updated: 02/28/23

•    DVHA Chief Medical Officer (CMO)
•    DVHA Data Unit
•    DVHA Member and Provider Services Unit
•    DVHA enrolled Providers and Vendors
•    DVHA Fiscal Agent

As of August 2022, the COU has implemented the following strategies in an effort to improve performance on this measure:

• 3 business day PA turnaround timeframe changed to 7 calendar day PA turnaround timeframe to align with CMS requirements
• Worked with DVHA data team to implement new data reporting specification for this measure
• Identified the data entry processing of Pharmacy J-codes into MMIS by the COU was being attributed to the PA turnaround timeframe erroneously and removed that category of service from the performance measure data specifications
• Developed new scorecard measure and data specifications to report this performance measure
• Addressed staffing resources by filling administrative assistant position