Clinical Services Team: Clinical Operations Unit

# of imminent harm codes reviewed for prior authorization

101Oct 2021

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Notes on Methodology

Partners
  • DVHA Data Unit
  • DVHA Chief Medical Officer
  • Gainwell Technologies
  • Provider Member Relations Unit
  • DVHA enrolled providers and vendors
Story Behind the Curve

This performance measure is important because it measures the total number of imminent harm codes reviewed for prior authorization. 

Beginning in 2019, this is a newly identified set of codes that requires prior authorization for all Medicaid members, whether or not they are attributed to the ACO.  Imminent harm is defined as a situation in which an action causes, or is likely to cause serious injury, harm, impairment, or death to a beneficiary.  Imminent harm is not restricted to services that are committed.  It can also apply to services that are omitted.  The harm that results does not need to occur within a certain timeframe.  It may occur on a pathway that can predictably and within reason result in harm to the member.  The risk of imminent harm can also be cumulative over time.  Vulnerable populations are at highest risk for imminent harm.

The data is showing the three categories of service reflected in the imminent harm codes and the total volumes of prior authorization requests for three years.  The trend lines show an increase in DME purchases and surgical requests holding steady from previous quarters. This trend line will serve to inform DVHA of all requests for imminent harm codes of service and identify specific volumes of utilization. This current scorecard measure captures volume data. In the future, developing a measure to demonstrate impact to determine if Medicaid members are better served with such review of services is planned.

Narrative last updated:  10/15/2021

Scorecard Result Container Indicator Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy