Prior Authorization (PA) Process
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Presentation Transcript
Prior Authorization (PA) Process MO HealthNet Pharmacy Team January 18, 2023
Methods to Complete a PA with MHD Transparent Approval at Point of Sale Based on paid claims history and Smart PA criteria CyberAccess Prescription Pad Providers can log-in to check if a PA is needed and submit a request if indicated Phone Call to the Pharmacy Helpdesk 800-392-8030 Fax PA form to the Pharmacy Helpdesk 573-636-6470 2
Current Fax PA Process PA Form is filled out completely and accurately Can be hand-written or electronic PA Form is faxed to the Pharmacy Helpdesk Fax number is at the top of all PA forms 573-636-6470 Response will be sent back via fax once reviewed Request for more information Information about criteria requirements Final decision based on available information 3
Barriers to Timely PA Processing Form is not filled out completely or accurately Incorrect PA form is used Hand writing is illegible Use of Third Party ePA (i.e. CoverMyMeds) Duplicate faxes and split faxes Requested documentation not submitted with PA form 4
Examples 5
Examples 6
Example ADHD Stimulant for 4yo Day 1: Fax contains general PA form for Focalin XR 5mg. Helpdesk faxes provider for Child ADHD form, progress notes and positive parent rating scale and teacher rating scale, then will refer to state staff as pt is 4 years Day 2: Fax contains ADHD for Child Under 6 form for Focalin XR 5mg. Helpdesk faxes provider again. Day 3: Fax contains positive teacher/parent scale, progress note lacking s/s and IEP note. Helpdesk faxes provider again. Day 28: Fax contains general PA form for Quillivant XR. Day 32: Fax contains general PA form for Quillivant XR. Day 34: Fax contains general PA form for Quillivant XR, positive rating scales and IEP. Attached progress notes still lacking s/s. Day 35: Fax contains IEP, + scales, and ADHD Evaluation form. Dx of ADHD confirmed on page 39 and S/S listed on page 41. Review with state staff begins as patient is 4y. 7
Examples 8
Checking the Status of a PA Please don t re-fax the same documents if no response is received in a given time. You can call the Pharmacy Helpdesk to ask about the status of a fax after 24 hours. 800-392-8030 For urgent requests start with call to Pharmacy Helpdesk instead of fax 9
Making the PA Process Easier Specific PA forms Tailored to a specific class of medications List approval criteria on the form List out all other documentation that is needed for the review Pharmacy Edit page is updated weekly https://dss.mo.gov/mhd/cs/pharmacy/pages/clinedit.htm Provider blasts about upcoming changes https://dss.mo.gov/mhd/providers/ 10
MO HealthNets Recommendations Check CyberAccess to see if PA is needed Use correct PA form Send in all requested documentation in one fax Respond to requests for clarification or additional documentation 11
Seeking Suggestions from Providers What can MO HealthNet do to make the PA process easier for providers? What parts of the PA process currently work for providers? What parts don t work? 12
