This measure is important because it tracks the exception requests reviewed by the Pharmacy, Clinical Integrity and Clinical Operations Units and will provide data to support a more efficient and improved clinical review of non-covered codes. The exception request process allows a Vermont Medicaid member, 18 years of age or older, to request coverage for non-covered services or items.

This measure tracks and monitors non-covered code request volumes, clinical category of exception requests, and the clinical review determination of exception requests.  Monitoring the request trends of non-covered codes will allow DVHA to consider code coverage in a timely approach, ensure access to services, and collaborate with the provider and member community to deliver quality, cost effective, and medically necessary health care services.

The data and trendline demonstrates that the majority of exceptions requests are received for medical non-covered codes, followed by pharmacy requests, and the smallest percentage of exception requests are associated with mental health requests. Data reveals the majority of exceptions requests are approved and that request volume by quarter is variable.

Narrative last updated:  11/03/22

• DVHA Exceptions Coordinator
• DVHA Clinical Services Team:  Pharmacy Unit, Clinical Integrity Unit & Clinical Operations Unit
• DVHA Chief Medical Officer
• DVHA Enrolled Providers
• DVHA Member Provider Services Unit
• DVHA Fiscal Agent, Gainwell