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 
•    assess service coverage changes and resulting exception request volume increases, in a specific category of service, to support the delivery of quality and cost-effective health care services.   

The data and trendline demonstrates equal requests for Pharmacy and Medical services for this quarter, with one Pharmacy denial. CY25 Q2 data reveals Exception requests volumes are continuing to trend low each quarter, with this being the lowest quarter data since CY24 Q2.

Narrative Updated:  07/11/2025
 

• 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