The Clinical Operations Unit (COU) staff determine the medical necessity of a service or product provided to its members using the prior authorization (PA) process. Medical necessity determinations are made using evidence-based clinical guidelines. PA decisions must be made within time frames specified in the Medicaid Rules and in Federal regulations.
There is variation in this data that is out of the control of the COU. This data heavily relies on Medicaid providers sending sufficient clinical information so a complete clinical review and decision can be rendered.
The COU may have had extended review time due to:
- Decreased Administrative support due to illness
- In 2019, prior authorization requests averaged between 1000-1500 on a monthly basis
- As of 2020, there has been a decline of about 150 prior authorizations reviewed by the Clinical Operations Unit each month
- The SFY20 Q3 data reflects a decline due to the emergence and response to COVID-19 and the decline in prior authorization requests
This performance measure is important because it shows:
- Timely access to treatment/services for members
- Compliance with State and Federal Regulations
- The PA turnaround times are reported to the External Quality Review Board (EQRO) and to KPMG, an auditing service that monitors the COU’s regulatory compliance
- Providers understanding of required documentation
Last updated: 10/15/2020