Clinical Services Team: Clinical Operations Unit

% of initial prior authorization requests that have a decision rendered within 3 days of receiving all necessary information

74.7%SFQ1 2021

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  • Chief Medical Officer (CMO)
Story Behind the Curve

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.

The 3-day goal for a decision to be rendered is based on CMS rule. Reaching this goal is heavily dependent on having adequate staffing and prior authorization volumes.

SFY20 Q4 rate reflects multiple factors impacting the % determination.

The COU experienced extended review time due to:

Prior Authorization request volumes have been declining each month throughout 2020, as expected with the ACO attribution and due to the lifting of PA requirements in response to COVID.

The SFY20 Q4 % is 57.69 and increase from all previous quarters.

The 28-day turnaround % for SFY20 Q4 is 94.41%.  This data point seems to be the most accurate measure of this information.  There are several “statuses” of a prior authorization based on whether the necessary documentation is received to complete a prior authorization.  Due to this factor and other influences, such as volumes and staffing, the 28-day turnaround provides a more accurate reflection of outcomes.

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

Last updated:  10/15/2020

  • Q4 demonstrates a % increase and the highest % in all four quarters
  • COU fully operating and utilizing OnBase electronic system with proficiency and efficiency including refinements to the workflow and systems process
  • Appropriate staffing within the COU
  • Daily monitoring and prioritization of Prior Authorization requests accordingly
  • % of Prior Authorization requests closed out within 28 days equal to 94.41%.
Scorecard Result Container Indicator Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy